MEDICAL-SURGICAL POINTS TO REMEMBER

CARDIOVASCULAR SYSTEM

• Cardiovascular disease is the leading cause of death among Americans.
• Take blood pressures correctly
• Give client 5 minutes rest.
• Take blood pressure while client is lying, sitting, and standing.
• Ask client if he/she has recently smoked, drank a beverage containing caffeine or was emotionally upset. If so, repeat blood pressure in 30 minutes.

• Rarely, the heart may lie on the right side instead of the left, this is called Dextrocardia.
• Valves control the direction of the blood flow through the heart. Flow is unidirectional.
• When the atria contract, the atrioventricular valves swing open, allowing the blood to flow down into the ventricles.
• When the ventricles contract the valves snap shut preventing blood from flowing back up into the atria. Semilunar valves open allowing blood to eject during ventricular contraction.
• If the SA node fails to generate an impulse, the AV node takes over, generating a slower rate. If the AV node fails to generate an impulse, the Bundle of His takes over, generating an even slower rate. If the Bundle of His fails to generate an impulse, the Purkinje fibers take over and generate an even slower rate.
• Damaged areas of the heart may also stimulate contractions and produce arrhythmias.
• Rapid, short-term control of blood pressure is achieved by cardiac and vascular reflexes that are initiated by stretch receptors (baroreceptors) in the walls of the carotid sinus and the aortic arch.
• Many clients with angina or MIs benefit from involvement in a structured cardiac rehabilitation program to assist clients to increase their activity level in a monitored environment.
• Current research suggests that life style and personal habits are closely related to cardiac changes once attributed to aging.
• The elderly are less able to physically adapt to stressful physical and emotional conditions, because their hearts do three things less quickly: the myocardium contracts less easily, the left ventricle ejects blood less quickly, and the heart is slower to conduct the impulse for a heartbeat.
• Because different enzymes are released into the blood at varying periods after a myocardial infarction, it is important to evaluate enzyme levels in relation to the onset of the physical symptoms such as chest pain.
• Clients who are in postoperative recovery, on bed rest, obese, taking oral contraceptives or had knee or hip surgery should be monitored closely for thrombophlebitis.

RESPIRATORY

• Oxygen is essential for life. So, before all else, keep airways open and ease breathing.
• Clients with chronic lung disease use more oxygen and energy to breathe; this can create a vicious cycle in which the client works harder, and continually requires more oxygen and more energy.
• Nursing interventions for clients with lung disease should include pacing of activities, because clients have little reserve for exertion.
• Quality of life for clients can be significantly improved if you teach clients diaphragmatic breathing and pursed-lip breathing.
• Clients with asthma must understand the different types of inhalers and when to use each type. Some are rescue inhalers for acute dyspnea; others are maintenance drugs.

• A finger oximeter reading is simply one element of an assessment; it's not the whole picture.
• Cyanosis is determined by oxygenation and hemoglobin content; anemic clients may be severely hypoxemic and never turn blue; polycythemic clients may be cyanotic with adequate tissue oxygenation.
• Control of pulmonary TB is a serious public health issue.
• If a client is in respiratory distress, start out by administering oxygen by non-rebreather mask at 10-15 LPM until the client's condition is clarified or stabilizes.
• When caring for a client with a chest tube, you must know whether the client has a leak from the lung. Only when you know there is no leak, should you apply an occlusive dressing.

• When caring for a client on a ventilator, if an alarm sounds, first, assess the client. See if the alarm resets or if the cause is obvious. If the alarm continues to sound and the client develops distress, disconnect the client from the ventilator, use a manual resuscitation bag and page or call the respiratory therapist immediately.
• To maximize therapeutic effect of inhalers, the key is technique. It is critical to teach clients the right technique and test how well they use the inhaler.
• Smoking cessation is critical to reduce the risk and severity of lung disease. Second-hand smoke hurts children most.
• Best treatment of pulmonary embolus is prevention by using intermittent compression stockings (with anticoagulants in extra-high risk clients) to prevent clots in deep veins.
• TB clients need intensive community follow up to ensure that they continue with pharmacological treatment once discharged from the hospital. Clients who stop therapy too soon are the source for the more deadly multi-drug resistant forms of TB.

NEUROLOGICAL SYSTEM

• In Multiple Sclerosis, early changes tend to be in vision and motor sensation; late changes tend to be in cognition and bowel control.
• Peripheral nerves can regenerate, but nerves in the spinal cord cannot regenerate.
• During a seizure, do not force anything into the client's mouth.
• A major problem often associated with a left CVA is an alteration in communication.
• Clients with CVAs are at high risk for aspiration. These clients must be evaluated to determine if dysphagia is present.
• The rate, rhythm and depth of a client's respirations are more sensitive indicators of intracranial pressure than blood pressure and pulse.
• When caring for a comatose client, remember that the hearing is the last sense to be lost.
• A CVA can result in a loss of memory, emotional lability and a decreased attention span.
• Communication difficulties in a CVA client usually indicate involvement of the dominant hemisphere, usually left, and is associated with right sided hemiplegia or hemiparesis.
• The client with myasthenia gravis will have more severe muscle weakness in the morning due to the fact that muscles weaken with activity and regain strength with rest.

EYE

·             Anything that dilates the pupil obstructs the canal of Schlemm, increases intraocular pressure.

·             Color blindness is caused by a deficiency in one or more types of cones and is caused by a sex-linked recessive gene.

·             Destruction of either the right or left optic nerve tract results in blindness in the respective side of both eyes

·             When mydriatics are instilled, caution clients that vision will be blurred for up to two hours

·             Following eye surgery teach client to avoid, for six weeks, activities that can increase IOP

·         Stooping

·         Bending from the waist

·         Heavy lifting

·         Excessive fluid intake

·         Emotional upsets

·         Constrictive clothing around neck

·         Straining with bowel movement (or straining at stool)

·             Teach client proper administration of eyedrops

·             Provide sunglasses for photophobia

·             Assist with activities of daily living as required

·             When clients wear eye patches, they lose depth perception. Remember that this loss presents a safety risk.

·             Systemic disorders that can change ocular status include diabetes mellitus, atherosclerosis, Graves' disease (hyperthyroidism), AIDS, leukemia, lupus erythematosus, rheumatoid arthritis sickle cell disease.

Ear

·             Changes in barometric pressure will affect persons with ear disorders

·             Hearing loss

·         can be partial or total

·         can affect one or both ears

·         can occur in low, medium or high frequencies

·         AMA formula for hearing loss: hearing is impaired 1.5% for every decibel that the pure tone average exceeds 25 decibels (dB)

·         A hearing loss of 22.5% usually affects social functionality and requires a hearing aid

·         Noise exposure is the major cause of hearing loss in the United States

·           Ask client how he/she communicates: lip-reading, sign language, body gestures, or writing

·           To gain the client's attention, raise your hand or touch the client's arm

·           When talking with client, speak slowly and face him/her

·           Speak toward the client's good ear

·           If the client wears a hearing aid, allow him/her to show you how it's inserted

·           Speaking louder to a hearing impaired client does not increase his/her chances of hearing

·           Communicate the client's hearing loss to other staff members

·           Ototoxic drugs include:

·         Aminoglycosides

·         Antimyobacterials

·         Thiazides

·         Loop diuretics

·         Antineoplastics

·           Tell clients taking ototoxic drugs to report any signs of dizziness, loss of balance, tinnitus, or hearing loss

GASTRO-INTESTINAL

·             Most obstructions occur in the small bowel.

·             Most large bowel obstructions are caused by cancer.

·             Onset of cirrhosis is insidious with symptoms such as anorexia, weight loss, malaise, altered bowel habits, nausea and vomiting.

·             Management of cirrhosis is directed towards avoiding complications. This is achieved by maintaining fluid, electrolyte and nutritional balance.

·             A client with esophageal varices must be monitored for bleeding (e.g., melena stools, hematemesis, and tachycardia.

·             The rupture of esophageal varices is life threatening and associated with a high mortality rate.

·             Pancreatitis is often associated with excessive alcohol ingestion.

·             Pancreatic cancer is an insidious disease that often goes undetected until its later stages.

·             Diverticula are most common in the sigmoid colon.

·             Clients with diverticulosis are often asymptomatic.

·             A deficiency in dietary fiber is associated with diverticulitis.

·             Colostomies: an ascending colostomy drains liquid feces, is difficult to train and requires daily irrigation; a descending colostomy drains solid feces and can be controlled.

·             Frequent liquid stools can be indicative of a fecal impaction or intestinal obstruction.

·             Bowel sounds tend to be hyperactive in the early phases of an intestinal obstruction.

GENITO-URINARY

·             After a urinary catheter is removed, the client may have some burning on urination, frequency and dribbling. These symptoms should subside.

·             After a TUR (transurethral resection), tell the client that, because the three-way foley catheter has a large diameter, he will continuously feel the urge to void.

·             After prostatic surgery, it is normal for the client's urine to be blood tinged and for him to pass blood clots and tissue debris.

·             Because the prostate gland receives a rich blood supply, it is important to observe the client undergoing a prostatectomy for bleeding and shock.

·             Breast cancer starts with the alteration of a single cell and takes a minimum of two years to become palpable.

·             At the time of diagnosis, about 1/2 of clients with breast cancer have regional or distant metastasis.

ENDOCRINE

• About Insulin

·             In the Pancreas's islets of Langerhans, beta cells secrete insulin-the islet-cell hormone of major physiological importance; without sufficient insulin, the body develops diabetes mellitus.

·             Currently, researchers are exploring a number of new delivery systems for insulin.

·             Oral inhalation of insulin may become a viable alternative to injections.

·             Transdermal patches of insulin may someday replace the injections.

·             Still another prospect is an implanted insulin delivery system, possibly in combination with a glucose sensor to create an "artificial pancreas."

·             Exercise that increases the body's metabolic rate decreases blood sugar and increases insulin sensitivity. Watch for signs of hypoglycemia.

·             Illness can disrupt metabolic control and raise blood sugar, requiring an increase in insulin.

·             Insulin-dependent clients should be well controlled for at least one week prior to any surgery. Special care should be taken to monitor blood glucose during and after surgery and adjust insulin accordingly.

• About the Thyroid

·             Following neck surgery, potentially life-threatening complications such as laryngeal edema and tracheal obstruction can occur. Observe for respiratory distress.

·             Following thyroid surgery, many clients suffer transient hypocalcemia. Check for signs of tetany for about three days after surgery.

·             Thyroid surgery can cause a thyroid storm.

About the Parathyroid

·           Positive Chvostek's sign: contraction of facial muscle occurs when light tap is given over facial nerve in front of ear.

·           Positive Trousseau's sign: carpopedal spasm results from inflating blood pressure cuff above client's systolic pressure.

ORTHO

·        After hip replacements, pulmonary embolism may occur even without thrombosis in foot or leg.

·        Patients should sit in a straight, high chair; use a raised toilet seat; and never cross their legs.

·        In hip or knee replacement, patients will need assistive devices for walking until muscle tone strengthens and they can walk without pain.

·        After an amputation, the home must be assessed for any modifications needed to ensure safety.

·        The management of soft tissue injury can be remembered by RICE: Rest, Ice, Compression and Elevation.

·        Some clients will need transportation to continue rehabilitation.

·        Amputee support groups can help patients and family.

·        After Arthroscopy, outpatient rehab may be prescribed depending on procedure; physician may prescribe knee immobilizer.

·        External Fixator - If possible, prepare the client preoperatively to reduce anxiety. Device looks clumsy, but patient should be reassured that discomfort is minimal.

·        After a hip pinning or femoral-head prosthesis, caution client not to force hip into more than 90 degree of flexion, into adduction or internal rotation.

·        Caution clients with a new prosthesis not to use any substances such as lotions, powders etc. unless prescribed by the doctor.

·       Osteoporosis cannot be detected by conventional x-ray

·        Foods high in calcium include milk, yogurt, turnip greens, cottage cheese, sardines, and spinach.

·        When performing a musculoskeletal assessment on a client with Paget's Disease, note the size and shape of the skull. The skulls of these clients will be soft, thick and enlarged.

·        Clients at high risk for acute osteomyelitis are: elderly, diabetics, and clients with peripheral vascular disease.

·        When clients receive corticosteroids long-term, evaluate them continually for side effects.

·        Immunosuppressed clients should avoid contact with persons who have infections.

·        Steroids may mask the signs of infections, so client should promptly report slightest change in temperature or symptoms.

·        Photosensitive clients should avoid the sun, limit outdoor activities during peak sun hours and wear sun block.

ONCOLOGY

·        Radiation has local effects; chemotherapy is more systemic.

·        Only certified nurses may administer chemotherapeutic agents.

·        Ionizing radiation will damage both normal and cancerous cells, and cause side effects.

·        Clients who receive external radiation are not radioactive at any time.

·        Clients receiving internal radiation are not radioactive: the implant or injection is.

·        If the source of radiation is metabolized, the client's secretions and excretions may be radioactive for a time, based on the half-life of the isotope.

CPR

• Early defibrillation is the key to successful resuscitation for many adults.
• Continually reassess during CPR to see if the client regains a pulse or begins breathing. Reassess to see that the chest moves and pulses are palpable during CPR.

SHOCK

• In shock, the first hour of treatment is most critical. Early detection is key.
• There are different ways to categorize shock. Basically, shock presents three potential problems:

·         Not enough fluid in the blood vessels OR

·         Fluid has moved outside the vessels, so cannot be pumped to the organs OR

·         Heart cannot pump fluid that is present

Shock and Temperature

• In septic shock, the skin and body temperature may increase. In other shock states, body and skin temperature will decrease.

Shock and Heart Signs

·        Early stages of shock activate the sympathetic nervous system. So in early stages, the client will not always be hypotensive.

·        Bradycardia is a very late sign in shock.

·        Another late sign is cardiac arrhythmia (other than sinus tachycardia). Arrhythmias reflect less perfusion of the coronary arteries and myocarditis.

·        As the myocardium receives less perfusion, heart pumps less.

·        Because less blood perfuses the brain, level of consciousness drops.

Shock and Urinary Output

• Average adult urinary output is 0.5 to 1.0 ml/kg/hr. Less than 35 ml/hour reflects decreased renal blood flow. Acute renal failure can result.

Shock and Respiration

• As blood flow to lungs decreases, less gas exchange will occur.
• When tissues receive less oxygen, they produce more lactate and metabolic acidosis sets in. Metabolic acidosis increases risk of cardiac arrhythmias.
• For a client in shock, body cells receive less oxygen and nutrients. Thus treatment aims at increasing both available oxygen and volume of blood in vessels (unless the heart has failed).
• Medications can improve tone of blood vessels (inotropes) or treat the cause of shock (corticosteroids, antibiotics).
• When treating a trauma client, you must quickly assess ABCs. After you know the client is breathing and has a pulse, vital signs can wait while you stop any bleeding and start other interventions (such as starting IVS). Don't rely only on the vital sign numbers.

Head and Spine Injury

• If client has head injury, the most important assessment is level of consciousness; next is pupil response to light. Changes in vitals are very late sign.
• With trauma clients, assume spine is injured until proven otherwise. While you open the airway, you must keep cervical spine immobile.

Viral Infections

• Viruses are parasites that cannot reproduce or meet own metabolic needs.
• Skin cells react to virus with swelling, "vesiculation," or proliferation, sometimes warts.
• Most viruses are associated with rashes (characteristic of each disorder, such as chicken pox, rubella, roseola)

SOURCE: NCSBN