Medical-Surgical Nursing: Deep Vein Thrombosis

Focus Topic: Medical-Surgical Nursing

 

Medical-Surgical Nursing

 

Definition: This refers to thrombus formation (blood clot) in one or more deep veins in the body, commonly in the lower extremities or groin. Blood clots are dangerous because they can break off and travel to different parts of the body such as the lungs. Signs and Symptoms: Edema or swelling in the extremity. The affected area is warm, edematous, tender, and reddened. Positive Homan’s sign (dorsiflexion causes extreme pain).

Diagnostics: Ultrasound of the affected extremity, Doppler, CT scan, or x-ray. Lab work such as PTT, PT, and INR will need to be obtained.

Complications: Pulmonary embolism, leg ulcerations, and venous insufficiency.

Drug Therapy: Anticoagulants such as Lovenox, heparin, Xeralto, Coumadin, or Arixtra. Anti-inflammatory medications such as Toradol to control inflammation and pain. Fibrinolytic medications may also be needed.

Nursing Care: Once the ultrasound confirms there is a DVT, the patient is immediately started on an anticoagulant. It is important to teach the patient about the risk of bleeding. Due to the increased risk of bleeding, patients should be careful when shaving. Instruct patients to use an electric razor. Because there is also an increased risk of bruising, instruct patients to use caution when walking. For any invasive procedures, anticoagulants must be stopped for 48 hours prior to any procedures. Elevate the affected extremity. Apply a warm compress to the site to decrease inflammation. If there is a blood clot in an upper extremity, make sure to put a “restricted extremity” armband on that extremity. No blood pressure or labs must be taken from that arm. Complete bed rest is ordered. If there is a blood clot in a lower extremity, do not apply sequential compression devices (SCDs) or thromboembolic deterrent devices (TEDs) on the affected leg. Continue to monitor clotting factors.

Surgical procedures such as venous thrombectomy may need to be performed.

Medical-Surgical Nursing: Peripheral Artery Disease

Definition: In this condition, there is a decrease in the blood flow and oxygenation to the extremities caused by atherosclerosis.

Signs and Symptoms: Bilateral leg pain, darkening of the skin, tingling, cyanosis, weak pulse, and poor circulation to the lower extremities.

Diagnostics: Ultrasound and angiography. Clotting factors and CBC also need to be obtained (paying close attention for signs of infection).

Complications: Necrosis, infection, and ulcerations. In advanced stages, amputation of the extremity is necessary.

Drug Therapy: Anticoagulants, antihyperlipidemics, antiplatelet, and antihypertensives are needed.

Nursing Care:
Control cholesterol levels and blood pressure, along with diabetes management, if needed, with the ordered medications. Maintain a low-fat/sodium diet. Administer skin care or wound care if ulcers are present. Avoid applying extreme temperatures to the extremity. Assess pulses, use Doppler stethoscope if unable to palpate. If the patient is a smoker, offer smoking cessation. Provide comfort.

Surgical procedures such as peripheral endarterectomy (removal of plaque in the artery), bypass graft, or amputation, may be required, depending on the severity. Nonsurgical measures such as angioplasty or stent may be placed to open up the artery walls and allow better blood flow. If surgery is needed, provide preoperative and postoperative instructions.

Medical-Surgical Nursing: Chronic Venous Insufficiency

Definition: Insufficient blood flow to the veins in the legs, causing ulcers or cellulitis.

Signs and Symptoms: Redness, edema, itching, flaking, ulcerations, pain, and skin that appears tough and dry.

Diagnostics: Obtain an ultrasound to rule out DVT.

Complications: Ulcerations.

Drug Therapy: Antibiotics are commonly administered.

Nursing Care: Dressing changes and wound care for the affected site. Administer antibiotics as ordered. Decrease risks of clots. Elevate extremity. SCDs are applied to increase blood flow, but use precaution when applying to the affected extremities. Assess pulses.

Medical-Surgical Nursing: Endocarditis

Definition: Endocarditis is infection and inflammation of the valves and endocardium of the heart. It is caused by bacterial infection or vegetation.

Signs and Symptoms: Fever, chills, weakness, fatigue, weight loss, murmurs, Janeway lesion (flat red spots on the palms and soles, Osler’s nodes on hands/feet, and red blotches on the skin).

Diagnostics: EKG, echocardiogram, CBC, and blood cultures.

Complications: Embolism and heart failure.

Drug Therapy: Aggressive antibiotic therapy.

Nursing Care: Assess for complications such as emboli. Administer long-term antibiotics and educate the patients on their use. Ensure cardiac monitoring. Bed rest is ordered. Continue to monitor for signs of heart failure. Patients who are IV drug users are at the highest risk of endocarditis, and the risks of using drugs should be taught to the patient. Patients should avoid exercise or strenuous activity.

Medical-Surgical Nursing: Pericarditis

Definition: Pericarditis is infection and inflammation of the pericardium of the heart.

Signs and Symptoms: Chest pain, respiration changes, fever, shortness of breath, and signs of heart failure.

Diagnostics: EKG, CBC, WBC, chest x-ray, and increased C-reactive protein (CRP).

Complications: Fluid in the pericardium that is left untreated can lead to cardiac tamponade. Signs of cardiac tamponade are muffled heart sounds, increased heart rate and respirations, and jugular vein distension.

Drug Therapy: Nonsteroidal anti-inflammatory (NSAIDs), corticosteroids, antibiotics, cardiac glycoside (Digoxin), and, possibly, a diuretic.

Nursing Care: Provide comfort and monitor for levels of pain and anxiety. Administer medications as ordered. Assess and monitor for complications.

Medical-Surgical Nursing: Cardiac Valve Disorders

Hang in there! We are almost through cardiac disorders. Last, but not least, we will discuss valve disorders of the heart. You will be responsible for knowing the five main diseases, but will not need to go into too much detail. These disorders are caused by infective endocarditis, ischemia, or congenital heart disease. Diagnostic testing, such as an echocardiogram, EKG, or stress test, is used to distinguish the valve disorders. Explanations of the five main disorders of the mitral valve and aortic valves are listed here:

1. Mitral valve stenosis: Calcification of the left atrium of the heart is the most common of the valve disorders. Causes pulmonary congestion. Symptoms are shortness of breath, fatigue, cardiac murmur, palpitations, and emboli. Medications such as diuretics, antibiotics, and anticoagulants are given.

2. Mitral valve regurgitation: Blood flow is forced into the left atrium of the heart. Causes pulmonary edema, abnormal pulse, and symptoms of heart failure. Medications such as diuretics, antibiotics, ACE inhibitors, cardiac glycoside (Digoxin), and anticoagulants are given.

3. Mitral valve prolapse: A prolapse occurs in the left atrium of the heart. Symptoms are heart murmurs, chest pain, and arrhythmias. Antibiotics and beta-blockers are commonly administered.

4. Aortic valve stenosis: Calcification of the aortic valve. Symptoms are dizziness, vertigo, angina, shortness of breath, fatigue, and murmurs. Rheumatic heart disease can cause stenosis; it is important to treat the underlying cause. Medications such as antibiotics, cardiac glycosides, beta-blockers, and diuretics may be administered.

5. Aortic valve regurgitation: Blood flow is forced back into the aortic valve. Shortness of breath is usually the first symptom. Diuretics are often administered to relieve symptoms of fluid overload.

Nursing Care: Monitor for complications. Monitor vital signs. Ensure continuous cardiac monitoring. Administer medications as ordered. Surgical procedures such as open heart surgery for valve replacement or cardiac catheterization may be needed. Limit activity.

Medical-Surgical Nursing: Cardiac Arrhythmias

You will be required to know the various cardiac arrhythmias. Some examples of the common rhythms seen are included in Appendix C. I will explain the most common arrhythmias here:

  • Normal sinus rhythm: Regular and heart rate is 60 to 100 bpm.
  • Atrial fibrillation: No “P” waves. Controlled rate of 60 to 100 bpm or can be uncontrolled with a rate greater than 100 bpm. Patients are at risk for clots and need to be put on anticoagulants to prevent thrombosis. Medications such as Coumadin or Xeralto can be given. Also, patients receive an ablation to treat A-fib.
  • Sinus bradycardia: Heart rate below 60 bpm. Hold all blood pressure medication when the pulse is less than 60 bpm. If the heart rate does not increase, a pacemaker may be needed.
  • Sinus tachycardia: A heart rate greater than 100 bpm. Medications such as Lopressor may be given.
  • Ventricular fibrillation: Very rapid and disorganized. Patient is unresponsive. Initiate CPR. Defibrillation is needed.

Medical-Surgical Nursing: RESPIRATORY DISORDERS

Assessing a Patient With Respiratory Disorders

Review the anatomy and physiology of the lungs in your textbook. Obtain a health history from the patient. Assess both any new symptoms and chronic disorders the patient may have. Obtain a set of vital signs and oxygen (O2) level. If saturation levels are below 92%, oxygen may be administered to the patient through a nasal cannula at 2 L. Any patients who are experiencing shortness of breath or any change in respirations are considered emergencies and must be seen immediately. Remember that maintaining an airway is always important and takes priority!

Respiratory Diagnostics

Lab Work: CBC, CMP, ProBNP, blood cultures, and D-dimer are typically assessed.

Chest x-ray

Pulse Oximetry: Measured by placing a sensor on the finger. Normal range is anything above 95% to 100%. If nail polish or acrylic nails are present on a female patient, this may affect the reading and must be removed.

Arterial Blood Gases: Refer to the chart in the previous chapter for values.

Sputum Cultures: Sputum taken from the patient and tested for specific organisms.

Pulmonary Function Tests (PFTs): Measure lung volume and airflow.

Bronchoscopy: Procedure in which the bronchi are observed and the upper airway, including the larynx, trachea, and bronchi, is visualized.

Computed Tomography Angiogram (CTA) of the Chest: Visualization of the chest for any congestion, fluid, masses, or blood clots.

Pulmonary Angiogram: Dye is injected into the pulmonary arteries to determine whether a pulmonary embolism is present.

Mantoux Skin Test: Purified protein derivative (PPD) is used to diagnose tuberculosis. A positive reaction to the PPD test is noted when a patient has been exposed to Mycobacterium tuberculosis; results are available in 48 to 72 hours.

Lung Biopsy: Obtaining a tissue sample from the lung to diagnose disorders such as lung cancer.

Thoracentesis: Removal of fluid from the pleural cavity. Lung (V/Q) Scan: Dye is injected and is used to determine whether there are any defects in blood perfusion in the lungs. It is used to diagnose pulmonary embolism.

Medical-Surgical Nursing: Asthma

Definition: Chronic inflammation and muscle contractions of the lungs that are often caused by triggers or allergens. Triggers can be stress, food, medications, exercise, infections, mold, or dust.

Signs and Symptoms: Wheezing, chest tightness, cough, increased mucus secretions, diminished lung sounds, decreased oxygen saturation levels, anxiety, and use of accessory muscles to breathe.

Diagnostics: Pulse oximetry, symptoms, PFTs, ABGs, and allergy skin testing.

Complications: Status asthmaticus and respiratory distress.

Drug Therapy: Beta2-adrenergic agonists such as albuterol. Albuterol is administered as first-line treatment, because it is fast acting, and is termed a rescue inhaler. Inhaled corticosteroids, oral anti-inflammatories, and leukotriene modifiers (Singulair) are ordered. Long-term corticosteroids are administered to control asthma, and bronchodilators such as Serevent, anticholinergics such as Atrovent, and expectorants such as Mucinex may be used. Oxygen may be administered.

Nursing Care: For patients experiencing acute shortness of breath and wheezing, assess oxygenation and respiratory status immediately. Monitor oxygen levels and administer oxygen as needed. Obtain ABGs and other labs. Place patient on strict bed rest. Common side effects of inhalers are tremors, nervousness, and increased heart rate; and patients need to be educated about medications. Avoid the use of fragrance, flowers, and other triggers while in the hospital. Monitor activity level. Patients should sit in high Fowler’s position to facilitate better breathing. Peak flow meters are often given to patients to allow them to measure the highest airflow during a forced expiration. The results help measure the severity of asthma.

Medical-Surgical Nursing: Hypoxia

Definition: Decreased oxygen levels caused by heart failure, ischemia, respiratory disorders, or anemia.

Signs and Symptoms: Restlessness, shortness of breath, low oxygen levels, anxiety, increased heart rate, and altered mental status.

Diagnostics: ABGs and oxygen saturation levels.

Complications: Chronic hypoxia or respiratory distress.

Drug Therapy: Treat the underlying cause. Administer oxygen through a mask or nasal cannula. Bilevel positive airway pressure (BiPAP) therapy may be needed.

Nursing Care: Monitor oxygen levels. Encourage deep breathing and cough. Place patients in high Fowler’s position. Administer chest physiotherapy and oxygen therapy as ordered. Monitor for complications.

Medical-Surgical Nursing: Chronic Obstructive Pulmonary Disorder (COPD)

Definition: A progressive and chronic obstruction of airflow, this condition encompasses chronic bronchitis, emphysema, and other disorders. Smoking is the most common cause. Patients are often admitted to the hospital for COPD exacerbations.

Signs and Symptoms: Shortness of breath, hypoxia, cough, diminished breath sounds, barrel chest, fatigue, anxiety, and anorexia.

Diagnostics: Oxygen levels, ABGs (respiratory acidosis), chest x-ray, and PFTs.

Complications: Pneumonia, GERD, acute respiratory failure, and cor pulmonale (right-sided heart failure).

Drug Therapy: Bronchodilators, corticosteroids, antibiotics, expectorants, and oxygen therapy. Nebulizers and steroids such as Solumedrol or prednisone are given as first-line treatments.

Nursing Care: Maintain oxygen saturation levels. Administer medications as ordered. A respiratory therapist will also assess the patient frequently. Chest physiotherapy is performed to help break up secretions. Teach the patient to conserve energy, and schedule periods of rest. Smoking cessation assistance should be provided. Monitor glucose levels, as steroids tend to increase blood glucose levels. Observe for and prevent complications that may arise.

Medical-Surgical Nursing: Pneumonia

Definition: Pneumonia is inflammation of the lung tissues and alveoli. Pneumonia can be caused by infection, aspiration of fluid or food, and accumulation of fluid. It can be viral or bacterial (Streptococcus pneumoniae, Mycoplasma pneumoniae, or Staphylococcus aureus).

Signs and Symptoms: Fever, cough, chest pain, chest tightness, increased secretions, chills, diminished breath sounds, wheezing, crackles, and hypoxia.

Diagnostics: Labs, chest x-ray, PFTs, ABGs, blood cultures, and sputum culture. Antibiotics are often administered once a sputum culture is obtained. Chest x-ray will show pleural effusion or infiltrates when pneumonia is present.

Complications: Respiratory failure and sepsis

Drug Therapy: Antibiotics, bronchodilators, analgesics, steroids, and antipyretics.

Nursing Care: Oxygen therapy. Monitor vital signs, and closely monitor the patient’s temperature. Patients should be placed in high Fowler’s position to facilitate breathing. Nebulizer treatments are administered. Monitor lab work, including WBC and glucose levels. Place sterile specimen cup at bedside for patient to use for sputum culture. The first sputum of the morning is best. Maintain nutrition and hydration. When the patient is treated for pneumonia and no longer exhibits symptoms, a pneumonia vaccine is administered to prevent further cases.

Medical-Surgical Nursing: Pleural Effusion

Definition: This is the accumulation of fluid in the pleural space of the chest. Pleural effusion is often caused by CHF, pneumonia, TB, pulmonary emboli, or lung cancer.

Signs and Symptoms: Pulmonary congestion, chest pain, crackles, edema, shortness of breath, and decreased breath sounds.

Diagnostics: Chest x-ray, CT of the chest, and culture of pleural fluid.

Complications: If left untreated, respiratory distress or worsening of symptoms.

Drug Therapy: Diuretics are used to remove fluid from the lungs. Antipyretics are used if a fever is present.

Nursing Care: Monitor respiratory status. Administer oxygen as needed. Administer medications as ordered. A thoracentesis or chest tube may be placed to remove fluid from the lungs. Assess chest tube or thoracentesis site. Assess lung sounds throughout the shift, monitoring for any changes.

Medical-Surgical Nursing: Pulmonary Edema

Definition: Pulmonary edema is accumulation of fluid in the lungs. It can be caused by heart failure or fluid overload.

Signs and Symptoms: Shortness of breath, crackles heard on auscultation, edema, restlessness, cough, tachycardia, and wet breath sounds.

Diagnostics: Chest x-ray and ProBNP to assess for heart failure and fluid overload.

Complications: Respiratory distress.

Drug Therapy: Diuretics, oxygen therapy, patients may require BiPAP, vasodilators, and mechanical ventilation in severe cases.

Nursing Care: Assess vital signs and oxygen. Maintain a patent airway. Place patients in high Fowler’s position. Complete bed rest is ordered. Administer medications as ordered. Cardiac monitoring may be ordered. Continue to monitor potassium. Fluid restriction will be needed. Monitor strict intake and output.

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Medical-Surgical Nursing: Tuberculosis

Definition: TB is an infectious disease spread by the organism Mycobacterium tuberculosis, transferred through respiratory droplets. Signs and Symptoms: Fatigue, anorexia, cough, chest pain, night sweats, chills, crackles, and hemoptysis.

Diagnostics: Chest x-ray, Mantoux test, QuantiFERON-TB (QFT) blood test, and acid-fast bacilli (AFBs). AFBs are sputum cultures that test positive when a patient has active tuberculosis. Three sputum cultures need to test positive to make a diagnosis of TB. If the tests are positive, a chest x-ray is done to confirm the results. The patient is then immediately placed on treatment and airborne precautions. Sputum culture is checked every 2 weeks until negative.

Complications: Pneumonia and worsening of infection.

Drug Therapy: Broad-spectrum antibiotics are administered to patients diagnosed with TB: (a) isoniazid (INH), (b) rifampin (Rifadin), (c) pyrazinamide (PZA), (d) rifabutin (Mycobutin), and (e) ethambutol (Myambutol). Refer to Chapter 5 for further details on these medications, including common side effects. Antipyretics are administered to control temperatures.

Nursing Care: Once a patient exhibits symptoms of TB, he or she is placed in a negative pressure room and droplet precautions are applied. An N95 mask must be worn at all times when in contact with the patient. N95 masks are worn at all times when in contact with the patient. Patients are placed in a negative pressure room and placed on droplet precautions. Medications are usually taken for 6 to 12 months with the sputum culture checked every 2 to 4 weeks. Provide adequate nutrition and hydration. Monitor vital signs and temperature. Provide periods of rest and limit activity. Visitors may be prohibited, especially children, while patients are on droplet precautions. Adhere to strict hand-washing guidelines and standard precautions.

Influenza

Definition: Commonly known as the “flu,” influenza is an infectious disease caused by the influenza virus.

Signs and Symptoms: Fever, chills, cough, fatigue, body aches, headache, and nasal congestion.

Diagnostics: Nasal swab to test for influenza A or influenza B.

Complications: If left untreated, symptoms can worsen, leading to pneumonia, and for patients who are immunocompromised, further complications can arise.

Drug Therapy: Antivirals such as oseltamivir (Tamiflu) or zanamivir (Relenza). M2 inhibitors such as amantadine (Symmetrel) and rimantadine (Flumadine) are also used to treat the flu.

Nursing Care: Patients who present with symptoms of the flu are placed on airborne precautions and should wear a mask when exposed to others to prevent infection. A mask must be worn when taking care of these patients. To prevent infection, flu vaccines are administered yearly. Monitor vital signs and temperature. Administer antivirals as ordered.

Medical-Surgical Nursing: Ebola

Definition: This infection is caused by the Ebola virus, which has caused recurring outbreaks of disease in western African countries. Ebola is spread through bodily secretions (mucus, sweat, tears, etc.). According to the World Health Organization, in 2013, the largest outbreak occurred and is an ongoing epidemic. Cases in the United States began to appear, and Ebola precautions were put in place immediately.

Signs and Symptoms: The development of symptoms or incubation period is 2 to 21 days. Symptoms are flulike initially but quickly escalate to include fevers, cough, severe headache, joint pain, chest pain, hypotension, shortness of breath, bleeding, hemoptysis, and bloody stools.

Diagnostics: Lab work and ELISA test.

Complications: Respiratory distress, sepsis, and death.

Drug Therapy: Antivirals such as Ribavirin are used to treat Ebola. Antipyretics are used to control temperatures. Administer intravenous fluids to hydrate patient.

Nursing Care: Patients who exhibit symptoms of Ebola are placed in an isolation room immediately. Protective wear is put on at once, and the CDC must be called for further instructions. These patients must stay in the isolated area until further instructions from the CDC. It is important to ask patients who present with symptoms of Ebola if they have traveled out of the country recently.

Medical-Surgical Nursing: Pulmonary Embolism

Definition: This is a blockage in the pulmonary artery caused by a blood clot. It often occurs when a clot that is formed elsewhere in the body travels to the lungs. This is an emergent situation!

Signs and Symptoms: Shortness of breath, cough, blood-tinged sputum, chest pain, crackles, anxiety, and increased respirations.

Diagnostics: CTA of the chest, D-dimer, V/Q scan, and clotting factors.

Complications: Sudden death if the clot is large and left untreated.

Drug Therapy: Anticoagulants are administered. Patients are often put on a continuous heparin drip with frequent monitoring of PTT, PT, and INR levels. Thrombolytics may be administered. Medications to decrease anxiety may also be given.

Nursing Care: Patients who present with symptoms of a PE must be seen and diagnosed immediately. Maintain airway and vital signs. Administer anticoagulants once a diagnosis is made. Ensure strict bed rest and administer oxygen therapy. Adequate hydration and nutrition is needed.

Medical-Surgical Nursing: Acute Respiratory Distress Syndrome (ARDS)

Definition: Acute respiratory distress syndrome is increased fluid in the interstitial space and alveoli of the lungs causing respiratory acidosis. ARDS is caused by pneumonia, chest injury, shock, or embolism. This is considered an emergent situation, and the patient must be seen immediately.

Signs and Symptoms: Hypoxia, shortness of breath, fatigue, decreased oxygen levels, chest pain, increased heart rate, confusion, use of accessory muscles, and cyanosis. Patient appears to be in distress.

Diagnostics: Oxygen saturation level, chest x-ray, ABGs, and CT scan of the chest.

Complications: Pulmonary collapse, respiratory failure, and shock.

Drug Therapy: Antibiotics, oxygen therapy, IV hydration, vasopressors, pulmonary vasodilators, and diuretics may be needed. Always treat the underlying cause.

Nursing Care: Maintain a patent airway, and assess respiratory status. Maintain oxygenation. Patient may be placed on mechanical ventilation or need an endotracheal intubation to improve ventilation. Positive end-expiratory pressure (PEEP) is used to improve ventilation as well. These patients are often placed in the ICU and are closely monitored. Administer medications as ordered.

Medical-Surgical Nursing: Acute Respiratory Failure

Definition: This is the lack of oxygen to the lungs, which is most often due to the increase of fluid in the airspace. It causes a decrease in oxygen in the blood and an increase in carbon dioxide.

Signs and Symptoms: Cyanosis, tachycardia, decreased O2 levels, increased BP, confusion, and restlessness. Change in mental status is a first sign that there is a lack of oxygen.

Diagnostics: CT of the chest and ABGs.

Complications: Death can occur if left untreated.

Drug Therapy: Oxygen therapy, bronchodilators, corticosteroids, or mechanical ventilation may be needed.

Nursing Care:
This is an emergent situation, and patients must be seen at once. Maintain a patent airway and O2 saturation levels. Patient may be placed on PEEP or intubated. Once off the ventilator, assess patient’s O2 levels. Maintain adequate hydration and nutrition. Provide rest, and place restrictions on strenuous activity.
Continue to closely monitor vital signs and signs of infection.

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