Oh, medical–surgical nursing! Fancy meeting you here! Let’s just say this is the most important course you will be taking in nursing school. I will not sugarcoat anything: It is also the most difficult, with tons of information packed into a semester. The Power-Point slides are miles long (okay, this is a little bit of an exaggeration, but it seemed like it). Medical–surgical nursing goes over most conditions and disorders that can occur in the body, including definition, symptoms, diagnostics, complications, drug therapy, and nursing care. I know you might hear from other students about the difficulty of the course, but put those negative thoughts behind you. You need to begin the course with a positive attitude; you are smart and can pass this class. It will take some work on your part, though; organization and studying are the two main components needed to pass this class. Here are a few tips to help you with this class:

  • Review the syllabus for the course. To be a step ahead, start reviewing the chapters. The med–surg book is huge! You will get an arm workout just from lugging this book around.
  • Review the materials before class, and become familiar with the material you will need to know for that week. You do not want to be that student who has the face of a deer in the headlights; it isn’t a cute look.
  • Listen in class! Even though you may have had a late night prior to your 8 a.m. class or you just don’t feel like being in class, try to pay attention. The professors often hint at what to expect on exams. This also means no texting or chatting, because you might miss something. I was not one to pay very close attention, and l was easily distracted in class. But, looking back, I wish I had paid closer attention; I think it would have helped me to know better what to expect on the exams. So, don’t follow in my footsteps. Pay close attention.
  • Do not study for the exams or quizzes the night before. The syllabus is there to let you know what to expect on exams and quizzes. Take your time in reviewing the material. You will need this information forever, as a nursing student and as a nurse. Also, remember the ABCs (airway, breathing, and circulation). If your exams include any questions for which airway or breathing may be the answer, always choose this answer. When answering prioritization questions (which patient to help first) always choose the answer that pertains to the patient who is experiencing respiratory distress or whose airway is compromised.
  • Plan your partying and social events for weeks when your workload is not too great. Never plan social events for the night before an exam. These exams are usually count for 20% to 25% of your grade and are very hard to recover from if you do poorly on just one. Party and celebrate after you pass!

Use this study guide along with your class notes and textbook. I will highlight the most frequently tested conditions and disorders. Use your syllabus as a study guide. You can create note cards based on the different sections of the syllabus. I know this class can be overwhelming, but take it one step at a time. At most schools, tutors and study groups are available if you need a little extra help. Attending study groups shows the instructors you are trying, and usually extra credit is given. The material learned in this class prepares you for the clinical portion of this course as well.

Your class grade is based on two components: exams and how well you apply the information in clinical. The class is knowledge based, where you learn to use critical thinking skills. The clinical portion is where you apply your skills and perform nursing care. The clinical portion will give you a better understanding of what nurses really do: the assessment, administering medication, and documentation. You may grasp the concepts a little more easily when you perform them hands on and see the disorders and conditions up close. It is really exciting and makes you feel, “Yes, finally, this is what nursing is all about.” Now take a deep breath: We are about to enter the world of med–surg. Hello, lab values.

Medical–Surgical Nursing: IMPORTANT LAB VALUES

Focus Topic: Medical–Surgical Nursing

 

Medical–Surgical Nursing

 

Lab values are used to help diagnose or help figure out what is going on with the patient by identifying key constiuents from a sample of either blood or urine. Sometimes a patient’s problem cannot be physically assessed (i.e., through examination techniques or visual observation). In these cases, both blood work and urine testing can help diagnose a condition or problem the patient may be having. I wanted to start with lab values because they are mentioned very frequently throughout this chapter and are used as a diagnostic aid for each condition. Here are the normal lab values for an adult:

Lab Values:

Red blood cell (RBC) count: 4.5 to 6.0 mm3/μL in men/4.0 to 5.0 mm3/μL in women
Hemoglobin (Hgb): 13 to 17 g/dL in men/12 to 15 g/dL in women
Hematocrit (HcT): 40% to 52% in men/36% to 47% in women
Platelets: 150 to 400 units/L
White blood cell (WBCs): 4.0 to 11.0 mm3/μL
Prothrombin time (PT): 10 to 14 seconds
Partial thromboplastin time (PTT): 25 to 35 seconds
International normalizing ratio (INR): 2 to 3
Creatine kinase: 25 to 200 U/L
Creatine kinase-MB (CK-MB): 0.4 ng/mL
Troponin: 0 to 0.4 ng/mL
Serum albumin: 3.5 to 5.0 g/dL
Blood urea nitrogen (BUN): 7 to 20 mg/dL
Creatinine (Cr): 0.5 to 1.3 mg/dL
Sodium (Na): 135 to 145 mEq/L
Potassium (K): 3.5 to 5.0 mEq/L
Magnesium (Mg): 1.5 to 2.6 mg/dL
Calcium (Ca): 8.6 to 10.4 mg/dL
Phosphorus (P): 2.7 to 4.5 mg/dL
Iron (Fe): 250 to 410 mcg/dL
Ammonia (NH3): 30 to 70 mcg/dL

Medical–Surgical Nursing: CARDIOVASCULAR DISORDERS

Assessing a Patient With a Cardiovascular Disorder

Focus Topic: Medical–Surgical Nursing

 

Medical–Surgical Nursing

 

To have a better understanding of the function of the heart and mechanisms of blood flow, review the structure of the heart in your anatomy and physiology textbook. Obtain a health history for any prior conditions, surgeries, or new onset of symptoms such as chest pain. Before conducting an assessment, obtain a set of vital signs and an electrocardiogram (EKG) to see the patient baseline heart rhythm. Patients who come into the hospital with chest pain are emergent cases and must be treated immediately.

Cardiac Diagnostics

Complete Blood Count (CBC): WBC, hemoglobin, hematocrit, platelets, etc.

Comprehensive Metabolic Panel (CMP): Electrolytes and renal function such as Na, K, BUN/Cr.

Cardiac Enzymes: Creatine kinase: 25 to 200 U/L, creatine kinase MB (CK-MB): 0.4 ng/mL, and troponin: 0 to 0.4 ng/mL. Used to determine if a patient is having a myocardial infarction (MI).

Clotting Factors: Prothrombin time (PT): 10 to 14 seconds, partial thromboplastin time (PTT): 25 to 35 seconds, International normalizing ratio (INR): 2 to 3.

Electrocardiogram (EKG): Along with labs, an EKG may be ordered to obtain the patient’s baseline cardiac rhythm. Abnormal EKGs can signify a heart attack or MI or other disorders. Professors love to include EKG strips on tests! Knowledge of the different cardiac rhythms is even tested on the NCLEX. A packet of cardiac strips will be provided in class; also refer to your textbook. I will not go into too much detail in this chapter. Refer to Appendix C for sample EKGs. I will explain the purpose of the EKG and its diagnostic use below:

  • EKGs measure electrical conduction of the heart, but do not reflect cardiac output.
  • The SA node in the heart controls heart rate and impulses of the heart. You can look at the SA node as being a person’s pacemaker.
  • Be able to recognize the various rhythms such as normal sinus rhythm, sinus tachycardia, sinus bradycardia, atrial flutter, atrial fibrillation, ventricular fibrillation, asystole, and heart blocks. Refer to your textbook for pictures of the various rhythms. Some of these rhythms are also very critical, and the patient must be assessed and seen immediately.
  • When a patient is in ventricular fibrillation, the number one treatment is defibrillation. CPR may also be administered per protocol. Defibrillation does not work on patients who are in asystole! CPR is administered immediately.
  • Patients with cardiac pacemakers will show a paced rhythm on the monitor. Pacemakers control the heart rhythm and are implanted in the chest wall. A shock is given if the HR is less than 50, depending on what the pacemaker is set to shock.
  • Patients with pacemakers are advised to use caution when receiving MRIs, but recent studies have shown it is safe.
  • Antidysrhythmic or anticoagulant medications should be administered to patients who suffer from dysrhythmias.

Echocardiogram: An ultrasound used to obtain valve function in the heart.

Stress Test: Using a treadmill to increase heart rate through exercising to see the patient’s cardiac response to activity.

Medical–Surgical Nursing: Hypertension

Focus Topic: Medical–Surgical Nursing

 

Medical–Surgical Nursing

 

Definition: Blood pressure is the force of blood exerted on the vessel walls measured in systolic and diastolic pressures. The systolic pressure represents the ejection of the blood from the heart into the arteries, and the diastolic pressure the heart at rest between beats. Blood pressure is measured using a sphygmomanometer (in simplest terms, a blood pressure cuff) or Dynamap (an electronic reading of BP). The most accurate way to obtain a BP is by manually taking the blood pressure with a cuff and stethoscope. Electronic measurements can be slightly off.

A normal blood pressure reading is anything less than 120/80 mmHg. According to the American Heart Association, anything above 120/80 to 140/80 mmHg is considered prehypertensive. Stage I hypertension is anything from 140/90 to 159/90 mmHg. Stage II hypertension is greater than 160 mmHg. Stage III, which is considered an emergency and must be treated immediately, is blood pressure that reads above 180 mmHg. A sustained hypertensive state can lead to stroke. Hypotension is the complete opposite: Anything below 100/80 mmHg is considered hypotensive. Hypotension can lead to dizziness or fainting. Report any abnormal findings to the physician immediately.

Signs and Symptoms:

Hypertension: Patients who are hypertensive may be asymptomatic and may be diagnosed during physical exams. When blood pressure remains elevated for a period of time, the patient may begin to feel symptoms of headache, increased heart rate, chest pain, sweating, vision changes, and edema. Hypertension is known as a “silent killer” when left untreated. Hypertension can lead to plaque buildup in the artery walls that can cause complications such as heart attacks or strokes if left untreated.

Hypotension: Patients who are hypotensive may experience dizziness, weakness, fatigue, sweating, or anxiety. On exam, the nurse or physician may obtain an orthostatic blood pressure reading to see if there is a rapid decrease in blood pressure when standing, a common problem. Orthostatic BP is first taken lying down, sitting upright, and then standing. If the numbers drastically change from the lying to the standing position—for example, say a patient’s supine BP is 125/80 mmHg and standing BP is 95/80 mmHg—the patient is considered to have orthostatic hypertension. Use safety measures with these patients due to the risk of falls and dizziness. Patients who are postsurgical or have GI bleeds can suffer from hypotension as well.

Diagnostics: Obtain blood pressure, cholesterol levels/lipid profile to see if there is buildup of plaque in the arteries, CBC, clotting factors PT/INR, BUN/Cr for kidney function and CMP.

Complications: A sustained elevated blood pressure can cause organ damage, coronary artery disease, stroke, retinal damage, heart attacks, and renal disease if left untreated. Patients with blood pressure sustained above 180 mmHg may need ICU treatment or more aggressive treatment to lower the blood pressure.

Drug Therapy:

  • Antihypertensive medications:

• Beta-blockers: These include atenolol (Tenormin), propranolol (Inderal), labetalol (Trandate), metoprolol (Lopressor/Toprol XL), carvedilol (Coreg), acebutolol (Sectral), and bisoprolol (Zebeta). Beta-blockers block epinephrine and decrease the heart rate and the heart’s demand for oxygen. Always obtain vital signs before administering. Do not administer if the patient is hypotensive or has a heart rate less than 60 bpm.

• Angiotensin-converting enzyme (ACE) inhibitors: These include captopril (Capoten), lisinopril (Zestril), enalapril (Vasotec), ramipril (Altace), quinapril (Accupril), benazepril (Lotensin), and fosinopril (Monopril). ACE inhibitors dilate the blood vessels and increase blood flow, decreasing blood pressure and the amount the heart has to work to pump blood.

• Calcium channel blockers (CCBs): These include amlodipine (Norvasc), diltiazem (Cardizem), verapamil (Calan), and nifedipine (Procardia). CCBs also dilate the blood vessels, which increases blood flow and decreases blood pressure.

• Angiotensin receptor blockers (ARBs): These include losartan (Cozaar), olmesartan (Benicar), valsartan (Diovan), telmisartan (Micardis), candesartan (Atacand), and irbesartan (Avapro). ARBs dilate the blood vessels to decrease blood pressure. They also promote excretion of sodium and water into the urine to decrease blood pressure.

• Thiazide diuretics/loop diuretics: Hydrochlorothiazide (HCTZ) and metolazone (Zaroxolyn) are thiazide diuretics. Loop diuretics are furosemide (Lasix), bumetanide (Bumex), and toresmide (Demadex). Diuretics help release fluid through the urine, decreasing both edema and blood pressure.

• Vasodilators: These are used in the hospital, not frequently given as a home med. Vasodilators inlcude apresoline (Hydralazine) and nipride (Nitroprusside), which is given intravenously to decrease blood pressure rapidly. It is important to closely monitor these patients.

• Antiadrenergics: The one most commonly administered is clonidine (Catapres), given orally to decrease blood pressure.

Nursing Care: Patient education is very important, and treating hypertension is the key to preventing further complications. Continuous monitoring of blood pressure and regular checkups are needed. Teach patients to maintain a low-sodium diet and regularly exercise to promote a healthy lifestyle. Antihypertensive medications can cause a decrease in blood pressure, and it is important to teach the patient signs of hypotension. These medications also have a side effect of a persistent dry cough; if these symptoms occur, speak to your physician, because a change in medication may be needed. Medications are often prescribed daily in the morning or twice a day.

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Medical–Surgical Nursing: Congestive Heart Failure

Focus Topic: Medical–Surgical Nursing

Definition: Congestive heart failure (CHF) is an accumulation of fluid around the heart and lungs that causes a decrease in cardiac output. CHF causes fluid overload, meaning too much fluid in the lungs. Heart failure can occur on either side of the heart, which is then termed right-sided heart failure or left-sided heart failure. Each side presents with different symptoms.

Signs and Symptoms:

Right-sided heart failure: Weight gain, ascites, nausea, edema in the upper and lower extremities, and jugular vein distension (bounding pulses).

Left-sided heart failure: Cough, dusky color skin, chest pain, shortness of breath, fatigue, weakness, crackles in the lungs, wheezes, palpitations, decreased oxygen saturation, anxiety, and difficulty breathing.

Diagnostics: A lab test called ProBNP (shows the amount of fluid accumulation in the body), as well as BUN/Cr, CBC, basic metabolic panel (paying close attention to potassium levels), and a chest x-ray are obtained, and a cardiac monitor may be placed on the patient.

Complications: Respiratory distress, pulmonary edema, renal failure, cardiogenic shock, hepatomegaly, cardiac arrhythmias, and death.

Drug Therapy: These patients must be admitted to the hospital immediately for intravenous diuretics. Diuretics decrease the amount of fluids in the body by excreting sodium and potassium. IV furosemide (Lasix) is often administered to patients with CHF in a hospital setting. Other diuretics such as spironolactone (Aldactone) are administered orally to treat patients who suffer from chronic CHF. ACE inhibitors and CCBs are also used to treat CHF.

Nebulizer treatments may be administered to facilitate breathing and help with congestion.

Nursing Care: Assess the patient’s respiratory status, oxygen saturation, and mentation, and listen to the lungs. If the patient is having difficulty breathing and you hear crackles in the lungs, the patient may be experiencing fluid overload, and an IV diuretic may be needed; call the doctor immediately. O2 may be placed on the patient to maintain oxygen saturation levels. Discontinue intravenous fluids, and monitor intake and output. Output should be documented every shift, to ensure that the fluid is being excreted properly. A fluid restriction may be ordered. Place the patient in high Fowler’s position at a 45° to 90° angle to facilitate breathing. Daily weights are needed to monitor the fluid overload. Elevate upper and lower extremities if edematous.

Medical–Surgical Nursing: Angina Pectoris

Focus Topic: Medical–Surgical Nursing

Definition: Severe chest pain caused by sclerosis of the arteries and myocardial ischemia. Do not confuse angina pectoris with an MI. Angina is chest pain that is relieved by medication, and there is no permanent damage to the myocardial tissue. Angina is caused by an imbalance of oxygen supply and demand. An MI involves actual cell death.

Signs and Symptoms: Chest pain, chest pressure, sweating, palpitations, dizziness, anxiety, and dyspnea.

Diagnostics: For patients with angina pectoris, an MI must first be ruled out. An EKG, cardiac enzymes, troponin levels, and a chest x-ray should be obtained.

Complications: Myocardial infarction and dysrhythmias.

Drug Therapy: Nitroglycerin, a vasodilator, is given sublingually and controls ischemic pain. Always wear gloves to administer nitro because it can cause severe hypotension. Assess the patient’s blood pressure before administering nitro. Give the first tablet sublingually; then, if the pain persists in 5 minutes, give another tablet. Continue to assess blood pressure. A total of three tablets can be given. Intravenous morphine sulfate is used to control pain if not relieved by nitroglycerin. Beta adrenergic receptors are given to decrease cardiac output. Anticoagulants are given to prevent pulmonary emboli. If angina persists, surgery may be needed. A percutaneous cardiac intervention (stent) or coronary bypass graft may be performed.

Storage of nitroglycerin is also important. It should be placed in a cool and dark place. Light can decrease its effectiveness. Gloves should be worn when administering nitroglycerin.

Nursing Care: When a patient presents with chest pain, it is important to distinguish whether the patient is having an MI or true angina through diagnostic testing. Once an MI is ruled out, treatment for angina is started. Administer oxygen to the patient. Place patient on strict bed rest. Continue to assess blood pressure, due to the risk of hypotension. Monitor vital signs frequently. If surgery is done, use surgical precautions. Patient education is important.

Medical–Surgical Nursing: Myocardial Infarction

Focus Topic: Medical–Surgical Nursing

Definition: Myocardial infarction (MI) occurs when ischemia of the ventricles causes a disruption of blood flow and oxygen to the heart. A patient presenting with an MI is considered an emergent situation.

Signs and Symptoms: Chest pain that radiates to the shoulder or back, nausea, vomiting, increased blood pressure, pulmonary edema, dizziness, anxiety, weakness, fatigue, shortness of breath, increased pulse, elevated ST on an EKG, and elevated troponins.

Diagnostics: EKG, CBC, CMP, PT/INR, BUN/Cr, cardiac enzymes, CK-MB, troponins, cardiac monitoring, and chest x-ray. CK rises within 4 to 6 hours of an MI, peaks in 24 to 72 hours, and last for 3 days. Troponin levels rise within 4 to 6 hours and remain high for 2 weeks. Lactate dehydrogenase increases in MI, and levels last for 3 days. If these labs are elevated, an MI must be ruled out immediately.

Complications: Cardiogenic shock, heart failure, pulmonary embolism, and death if left untreated.

Drug Therapy: An MI is a critical event, and drug therapy needs to be rapidly administered. Morphine/nitroglycerin is given to relieve pain. Oxygen is administered to maintain oxygen levels. Aspirin or clopidogrel (Plavix) is given as an anticoagulant. Antidysrhythmics are given to prevent fatal arrhythmias. Fibrinolytic therapy may be needed to prevent blood clots and dissolve plaque in the arteries, to increase perfusion and decrease ischemia to the heart. Fibrinolytic therapy is effective within 6 hours of an MI. Intravenous fluids are administered.

Nursing Care: An MI is considered an emergent situation; these patients are often placed in the ICU until stable. Administer medications as ordered. Administer oxygen to patient. Monitor vital signs closely. Patient is placed on continuous cardiac monitoring. Serial labs of troponin levels are performed. Keep patient calm and decrease anxiety. Patient activity is limited and patients are placed on strict bed rest. Lifestyle changes such as diet, exercise, smoking cessation, and regularly scheduled checkups are discussed.

These patients may require surgery such as percutaneous transluminal coronary angioplasty (PTCA), and coronary bypass graft or stent placement may be needed.

Medical–Surgical Nursing: Coronary Artery Disease

Focus Topic: Medical–Surgical Nursing

Definition: In coronary artery disease, plaque builds up on the blood vessel walls, leading to narrowing or blockage in the artery known as atherosclerosis. It is commonly caused by high cholesterol, smoking, a high-fat diet, and hypertension.

Signs and Symptoms: These include poor circulation, headache, dizziness, and angina, but patients may appear asymptomatic.

Diagnostics: These include CBC, CMP, PT/INR, cardiac enzymes, EKG, stress test, chest x-ray, cardiac angiography, and cardiac catheterization. Lipid profile total cholesterol should be less than 200. LDL is greater than 160 mg/dL, and HDL is less than 40 mg/dL.

Complications: Heart failure, dysrhythmias, MI, and death if left untreated.

Drug Therapy: Antilipidemic medications, such as atorvastatin (Lipitor) and simvastatin (Zocor), are administered to decrease cholesterol levels and calcium nitrates. Calcium channel blockers are also administered. Treat any underlying cause. Cardiac catheterization or stent placement may be needed to facilitate adequate blood flow. Coronary bypass surgery may be needed if sclerosis is severe.

Nursing Care: Administer medication as ordered. Patient teaching is performed to encourage maintenance of a healthy diet, regular exercise, and smoking cessation. Continue to monitor cholesterol levels. If surgery is needed, provide preoperative and postoperative teaching.

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FURTHER READING/STUDY:

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