MED SURGE QUIZ #1

• air, water, food

• safety & security needs

• love/ belonging

• self confidence

• self- actualization (top goal)

Airway

Breathing

Circulation

• pallor

• difficulty w/ speech

• use of accessory muscles

• obstruction

• restlessness

• decreased pulse ox

• abnormal RR

• nasal flaring

• ICS retractions

• high BP (stroke?/rupture?)

• decreased BP (decreased perfusion → tissues & organs die)

• tachycardia

• diaphoresis

• blood clot

PT’S needs w/ highest priority

• ABC/safety

• basic survival needs

  • PT goes to the ER

Pt w/ medium & low priorities

• problems that require early resolution

• must handle B4 it becomes an emergency

  • ex: urinary retention

    • PT goes to urgent careN

PT’s problem does NOT need immediate attention

• PT can wait to see PCP

abrupt onset & usually short course

• whats going on right now

  • ex: broken arm

long period of time & continuing disease process

• ex: diabetes/arthritis

Teaching

Evaluation

Assessment (initial)

Advanced Intervention

Collaboration

Unstable PT’s

Planning

1. Right task

2. Right circumstances

3. Right person

4. Right supervision

5. Right direction/Communication

know what each person can do

PT should be stable & NOT require clinical judgement

• ex: UAP can move PT BUT if PT is unstable UAP should NOT ambulate

person has proper knowledge & skills to preform task

follow up & evaluate is required after each task

• was it done properly?

• have clear expectations

• ability to answer questions

• how should databe reported to the RN

• “can this task be delegated safely?”

• “is the task with the scope of practice of the individual?”

• “is there anything about the PT’s condition/environment which would stop individual from preforming the task delegated?”

• LPN/UAP refusal to accept delegation

• incomplete direction

• failure to confirm expectations

• failure to communicate

• potential for harm?

• complexity of task?

• problem-solving needed?

• unpredictability of outcome

• level of interaction w/ PT

• ALL MEDS

• admission assessment

• blood products

• care plan

• PT teaching

• UNSTABLE PT’s

• acute diseases

• vitals

• uncomplicated skills

• STABLE PT’S

• chronic disease

• oral/IM/SQ/patches/inhalers

• feeding

• hygiene

• basic skills

• STABLE PT’s

• chronic disease

• ambulation

• stable PT’S

• requirements within caregiver job description

• minimal potential for harm

• when adequate supervision is needed

• bed availability

• LOC

• PT acuity

• Age, gender, special needs

• staffing

• infectious disease

• attending physician

• RBC

• Hemoglobin

• Hematocrit

• WBC

• PLT

3.6-5.8 million/mm3

11.7 - 17.3g/dL

36% - 52%

4,500 - 11,000/ cubic mm3

150,000 - 450,000/uL

a blood test that can show if you have inflammation in your body

• <30mm/hr

3-8 min

measures how long it takes for a clot to form in a blood sample

• 11-13.5 seconds

• PT prep

• anxiety/pain

• education(what to expect/feel)

• postion

• lasts 5-10

• sedation

• sterile procedure

• apply pressure

• cover w/ sterile dressing

• check for infection

• pain relief

• wear bandage for 24 hrs

• NO tub/showers for 24 hrs

bone marrow is NOT producing enough blood cells

• decreased RBC, WBC, PLT

• hypoxia

• infection

• hemorrhage

• neuro assessment

• hand hygiene

• oral care

• avoid invasive procedure

• prevent immobility

• screen visitors for illness

• bleeding precautions

• increase fiber & fluid

increased in # of RBC

chronic myeloproliferation disorder arising from chromosomal mutation in stem cell

Increased…

• RBC

• WBC

• PLT

• Hemoglobin

• blood viscosity

• blood volume

• congestion of organs & tissues w/blood

predisposed to clotting

hypoxia stimulates erythropoietin in kidneys

• INCREASED RBC

  • body is trying to compensate to get more O2 around

• CVA

• MI

• PE

• headache

• dizziness

• dyspnea

• angina

• weakness

• intermittent claudication

• flushing of face

• L.upper abdominal pain

when NOT perfused properly → toxation might occur

• heart/brain/kidney must perfuse

• hydration therapy!!!!

  • give enough fluid to keep blood flowing

  • eval Pt I & O

• small frequent meals (decreased demand for O2

• reduce blood volume & viscosity

• decrease bone marrow activity

• ambulate (decrease clot formation)

decrease in PLT(<150,000)

• <50,000 → at risk for spontaneous bleed

• <5,000 → at risk for GI hemorrhage/ CNS bleed

• monitor signs of bleeding

• ID PT’s @ risk

• Monitor lab values

• check for bleeding (nose,mouth, urine, BM)

• PT teaching

• use electric razors

• NO Motrin/aspirin

• use smaller needles

decreased WBC

• ↓ neutrophils = ↓ immune response

• neutrophils are the primary phagocytic cell & are the body 1st line of defense

• classic signs of infection/inflammation may NOT occur

absolute neutrophil count (ANC)

• total WBC count * the % of neutrophils

@ risk for bacterial infection

MODERATE risk for bacterial infection

SEVERE risk for bacterial infection

Peripheral blood smear

• assess fro immature cells

Bone marrow biopsy

• teaching about preventing infection

• be alert for any complaints that might indicate infection

• blood cultures

• STRICT hand hygiene

• private room

• avoid fresh fruit & veg

100.4° F

• private room

• hand washing

• NO fresh fruit/veg/flowers

• NO sick visitors

• WBC overproduce

• WBC overcrowd bone marrow

  • therefore…RBC & PLT are not being made

the accumulation of immature cells due to loss of regulation in cell division

• no single causative agent

• combo of genetic & environmental influences

• inadequate production of normal bone marrow

• anemia

• thrombocytopenia (decrease PLT)

• decrease in # and function of WBC’s

• administer meds & monitor for side effects

• help PT develop coping strategies

• assess labs for effect of drugs

refer PT and family to survivor networks

Malignant

• caused by proliferation of abnormal multi nucleated cells located in lymph nodes

  • Reed-Sternberg Cells

malignant neoplasm of the immune system

• B & T cells

• enlarged cervical, axillary, inguinal nodes

• fever

• fatigue

• night sweats

• weight loss

• chills

-painless lymph nodes

enlargement may occur with s/s dependent on area of disease

• nodes biopsy

• xray

• bone marrow studies

isolated to one lymph node

at 2 or more sites

• same side

at both sides of diaphragm or spleen

started in lymphoma & spread to at least 1 body organ outside the lymphatic system

• localized radiation (stg 1)

• surgery

• combo of chemo w/localized radiation (stg 4)

• high dose combo of chemo w/radiation

• stem cell replacement

Razor → electric

Aspirin → NO

Needles → small gauge

Decrease needle sticks

Injury → prevent

cancer of the bone marrow

• destroys bone → bone breaks down

• neoplastic plasma cells infiltrate bone marrow & destroy bone

• neoplastic cells produce an excess amount of myeloma protein & cytokines which play a role in bone destruction

• skeletal pain

• symptoms develop slowly

• fatigue

• bone pain

• easy bruising

• bone fractures/degradation (@ risk for hypercalcemia)

OLD age

Calcium Elevated (hypercalcemia)

Renal failure

Anemia

Bone lytic lesions

• MAINTAIN ADEQUATE NUTRITION

  • flush out calcium/keep blood dilute so stones dont form

• Move PT carefully (avoid fractures)

• ambulation as tolerated

• pain management

• all functions carried out within a cell to maintain homeostasis

• response to extracellular signals

• the way each cells produces an intracellular response

• age

• sex

• race

• family medical HX

• alcohol

• tobacco

• diet

• sun exposure

• infectious disease

• chemicals

• radiation

NON CANCEROUS

• can often be removed

• in most cases do not reoccur

• cells DO NOT spread to other areas of body

  • ex: lipoma

ARE CANCEROUS

• can invade other ares of the body (metastasize)

skin and tissues lining internal organs

bone, connective, and supportive tissues

starts in blood

immune system

brain & spinal cord

PREVENTION IS KEY

• some cancers are related to viruses → can be prevented by vaccine

• 1/3 of all cancer are related to dietary factors & lack of physical activity

• identify risk factors & early detection

Change in bowel habits

A sore that does not heal

Unusual bleeding or discharge from body

Thickening or lump in breast/body

Indigestion or difficulty swallowing

Obvious change in wart or mole

Nagging cough

Biopsy is the only definitive means of diagnosing cancer

1. original tumor size & whether or not tumor has grown into nearby areas

2. whether or not cancer has spread to lymph nodes

3. whether or not cancer has spread to distant areas of the body

DESTROYS CANCER CELLS

administration of IV radioactive targeted substances

delivery of radiation from a source placed at some distance from the target site in the RT department