ATI Capstone

Content Review:
Adult Medical
Surgical - Tips of
the Week

Helpful Med-Surg Tips!

Angina Precipitating Factors: 4 E’s

Exertion: physical activity and exercise

Eating

Emotional distress

Extreme temperatures: hot or cold weather

Arterial Occlusion: 4 P’s

Pain

Pulselessness or absent pulse

Pallor

Paresthesia

Congestive Heart Failure Treatment: MADD

DOG

Morphine

Aminophylline
Digoxin

Dopamine

Diuretics

Oxygen

Gasses: Monitor arterial blood gasses

Heart Murmur Causes: SPASM

Stenosis of a valve

Partial obstruction

Aneurysms

Septal defect

Mitral regurgitation

Heart Sounds: All People Enjoy the Movies

Aortic: 2nd right intercostal space

Pulmonic: 2nd left intercostal space

Erb’s Point: 3rd left intercostal space

Tricuspid: 4th left intercostal space

Mitral or Apex: 5th left intercostal space

Hypertension Care: DIURETIC

Daily weight

Intake and Output

Urine output
Response of blood pressure

Electrolytes

Take pulse

Ischemic episodes or TIAs

Complications: CVA, CAD, CHF, CRF

Shortness of Breath (SOB) Causes: 4As+4Ps

Airway obstruction

Angina

Anxiety

Asthma

Pneumonia

Pneumothorax

Pulmonary Edema

Pulmonary Embolus

Stroke Signs: FAST

Face

Arms

Speech

Time

Compartment Syndrome Signs and

Symptoms: 5 P’s
Pain

Pallor

Pulse declined or absent

Pressure increased

Paresthesia

Shock Signs and Symptoms: CHORD ITEM

Cold, clammy skin

Hypotension

Oliguria

Rapid, shallow breathing

Drowsiness, confusion

Irritability

Tachycardia

Elevated or reduced central venous pressure

Multi-organ damage

Hypoglycemia Signs: TIRED

Tachycardia

Irritability

Restlessness

Excessive hunger

Depression and diaphoresis

Hypocalcemia Signs and Symptoms: CATS

Convulsions

Arrhythmias

Tetany

Stridor and spasms

Hypokalemia Signs and Symptoms: 6 L’s

Lethargy

Leg cramps

Limp muscles

Low, shallow respirations

Lethal cardiac dysrhythmias

Lots of urine (polyuria)

Hypertension Complications: The 4 C’s

Coronary artery disease (CAD)

Congestive heart failure (CHF)

Chronic renal failure (CRF)

Cardiovascular accident (CVA): Brain attack or stroke

Traction Patient Care: TRACTION

Temperature of extremity is assessed for signs of infection

Ropes hang freely

Alignment of body and injured area

Circulation check (5 P’s)

Type and location of fracture

Increase fluid intake

Overhead trapeze

No weights on bed or floor

Cancer Early Warning Signs: CAUTION UP

Change in bowel or bladder

A lesion that does not heal

Unusual bleeding or discharge

Thickening or lump in breast or elsewhere

Indigestion or difficulty swallowing

Obvious changes in wart or mole

Nagging cough or persistent hoarseness

Unexplained weight loss

Pernicious Anemia

Leukemia Signs and Symptoms: ANT

Anemia and decreased hemoglobin

Neutropenia and increased risk of infection

Thrombocytopenia and increased risk of bleeding

Clients Who Require Dialysis: AEIOU (The

Vowels)
Acid base imbalance

Electrolyte imbalances

Intoxication

Overload of fluids

Uremic symptoms

Asthma Management: ASTHMA

Adrenergics: Albuterol and other bronchodilators

Steroids

Theophylline

Hydration: intravenous fluids

Mask: oxygen therapy

Antibiotics (for associated respiratory infections)

Hypoxia: RAT (signs of early) BED (signs of

late)

Restlessness

Anxiety

Tachycardia and tachypnea

Bradycardia

Extreme restlessness

Dyspnea

Pneumothorax Signs: P-THORAX

Pleuritic pain

Tracheal deviation

Hyperresonance

Onset sudden

Reduced breath sounds (and dyspnea)

Absent fremitus

X-ray shows collapsed lung

Transient Incontinence Causes: DIAPERS

Delirium

Infection

Atrophic urethra

Pharmaceuticals and psychological

Excess urine output

Restricted mobility

Stool impaction

Dealing with Constipation:

Constipation is difficult or infrequent passage of stools,

which may be hard and dry.

Causes include: irregular bowel habits, psychogenic factors,

inactivity, chronic laxative use or abuse, obstruction,
medications, and inadequate consumption of fiber and fluid.

Encouraging exercise and a diet high in fiber and promoting

adequate fluid intake may help alleviate symptoms.

Dealing with Dysphagia:

Dysphagia is an alteration in the client’s ability to swallow.

Causes include:

Obstruction

Inflammation

Edema

Certain neurological disorders

Modifying the texture of foods and the consistency of liquids

may enable the client to achieve proper nutrition.

Clients with dysphagia are at an increased risk of aspiration.

Place the client in an upright or high-Fowler’s position to
facilitate swallowing.

Provide oral care prior to eating to enhance the client’s sense

of taste.

Allow adequate time for eating, utilize adaptive eating

devices, and encourage small bites and thorough chewing.

Avoid thin liquids and sticky foods.

Dumping Syndrome:

Dumping Syndrome occurs as a complication of gastric

surgeries that inhibit the ability of the pyloric sphincter to
control the movement of food into the small intestine.

This “dumping” results in nausea, distention, cramping pains,

and diarrhea within 15 min after eating.

Weakness, dizziness, a rapid heartbeat, and hypoglycemia

may occur.

Small, frequent meals are indicated.

Consumption of protein and fat at each meal is indicated.

Avoid concentrated sugars.

Restrict lactose intake.

Consume liquids 1 hr before or after eating instead of with

meals (a dry diet).

Gastroesophageal Reflux Disease (GERD):

GERD leads to indigestion and heartburn from the backflow of

acidic gastric juices onto the mucosa of the lower esophagus.

Encourage weight loss for overweight clients.

Avoid large meals and bedtime snacks.

Avoid trigger foods such as citrus fruits and juices, spicy

foods, and carbonated beverages.

Avoid items that reduce lower esophageal sphincter (LES)

pressure, such as alcohol, caffeine, chocolate, fatty foods,
peppermint and spearmint flavors, and cigarette smoking.

Peptic Ulcer Disease (PUD):

PUD is characterized by an erosion of the mucosal layer of

the stomach or duodenum.

This may be caused by a bacterial infection with Helicobacter

pylori or the chronic use of non-steroidal anti-inflammatory
drugs (NSAIDs), such as aspirin and ibuprofen.

Avoid eating frequent meals and snacks, as they promote

increased gastric acid secretion.

Avoid alcohol, cigarette smoking, aspirin and other NSAIDs,

coffee, black pepper, spicy foods, and caffeine.

Lactose Intolerance:

Lactose intolerance results from an inadequate supply of

lactase, the enzyme that digests lactose.

Symptoms include distention, cramps, flatus, and diarrhea.

Clients should be encouraged to avoid or limit their intake of

foods high in lactose such as: milk, sour cream, cheese,
cream soups, coffee creamer, chocolate, ice cream, and
puddings.

Diverticulosis and Diverticulitis:

A high-fiber diet may prevent diverticulosis and

diverticulitis by producing stools that are easily passed and
thus decreasing pressure within the colon.

During acute diverticulitis, a low-fiber diet is prescribed in

order to reduce bowel stimulation.

Avoid foods with seeds or husks.

Clients require instruction regarding diet adjustment based on

the need for an acute intervention or preventive approach.

Cholecystitis:

Cholecystitis is characterized by inflammation of the

gallbladder. The gallbladder stores and releases bile that aids
in the digestion of fats.

Fat intake should be limited to reduce stimulation of the

gallbladder.

Other foods that may cause problems include coffee, broccoli,

cauliflower, Brussels sprouts, cabbage, onions, legumes, and
highly seasoned foods.

Otherwise, the diet is individualized to the client’s needs and

tolerance.

Acute Renal Failure (ARF):

ARF is an abrupt, rapid decline in renal function. It is usually

caused by trauma, sepsis, poor perfusion, or medications.
ARF can cause hyponatremia, hyperkalemia, hypocalcemia,
and hyperphosphatemia. Diet therapy for ARF is dependent
upon the phase of ARF and its underlying cause.

Pre-End Stage Renal Disease (pre-ESRD):

Pre-ESRD, or diminished renal reserve/renal insufficiency, is

a predialysis condition characterized by an increase in serum
creatinine.

Goals of nutritional therapy for pre-ESRD are to:

Help preserve remaining renal function by limiting the intake

of protein and phosphorus.

Control blood glucose levels and hypertension, which are

both risk factors.

Protein restriction is key for clients with pre-ESRD.

Slows the progression of renal disease.

Too little protein results in breakdown of body protein, so

protein intake must be carefully determined.

Restricting phosphorus intake slows the progression of renal

disease.

High levels of phosphorus contribute to calcium and

phosphorus deposits in the kidneys.

Dietary recommendations for pre-ESRD:

Limit meat intake.

Limit dairy products to ½ cup per day.

Limit high-phosphorus foods (peanut butter, dried peas and

beans, bran, cola, chocolate, beer, some whole grains).

Restrict sodium intake to maintain blood pressure.

Caution clients to use vitamin and mineral supplements ONLY

when recommended by their provider.

End Stage Renal Disease (ESRD):

ESRD, or chronic renal failure, occurs when the glomerular

filtration rate (GFR) is less than 25 mL/min, the serum
creatinine level steadily rises, or dialysis or transplantation is
required.

The goal of nutritional therapy is to maintain appropriate fluid

status, blood pressure, and blood chemistries.

A high-protein, low-phosphorus, low-potassium, low-sodium,

fluid-restricted diet is recommended.
Calcium and vitamin D are nutrients of concern.

Protein needs increase once dialysis is begun because

protein and amino acids are lost in the dialysate.

Fifty percent of protein intake should come from biologic

sources (eggs, milk, meat, fish, poultry, soy).

Adequate calories (35 cal/kg of body weight) should be

consumed to maintain body protein stores.

Phosphorus must be restricted.

The high protein requirement leads to an increase in

phosphorus intake.

Phosphate binders must be taken with all meals and snacks.

Vitamin D deficiency occurs because the kidneys are unable

to convert it to its active form.

This alters the metabolism of calcium, phosphorus, and

magnesium and leads to hyperphosphatemia, hypocalcemia,
and hypermagnesemia.

Calcium supplements will likely be required because foods

high in phosphorus (which are restricted) are also high in
calcium.

Potassium intake is dependent upon the client’s laboratory

values, which should be closely monitored.

Sodium and fluid allowances are determined by blood

pressure, weight, serum electrolyte levels, and urine output.

Achieving a well-balanced diet based on the above guidelines

is a difficult task. The National Renal Diet provides clients with
a list of appropriate food choices.

Nephrotic Syndrome:

Nephrotic syndrome results in serum proteins leaking into

the urine.

The goals of nutritional therapy are to minimize edema,

replace lost nutrients, and minimize permanent renal damage.

Dietary recommendations indicate sufficient protein and low-

sodium intake.

Nephrolithiasis (Kidney Stones):

Increasing fluid consumption is the primary intervention for

the treatment and prevention of the formation of renal calculi.
Excessive intake of protein, sodium, calcium, and oxalates
(rhubarb, spinach, beets) may increase the risk of stone
formation.

Test taking tips!

Prioritization

Prioritization includes clinical care coordination such as

clinical decision making, priority setting, organizational skills,
use of resources, time management, and evaluation of care.
Clinical decisions are made by completing a thorough
assessment which will help you make good judgments later
when you see a changing clinical condition. A poor initial
assessment can lead to missed findings later on.

Priority setting refers to addressing problems and prioritizing

care. It is critical for efficient care. The RN uses his/her
knowledge of pathophysiology when prioritizing interventions
with multiple clients.

Orders of prioritization:

1. Treat first any immediate threats to a patient’s survival or

safety.

Ex. obstructed airway, loss of consciousness, psychological

episode, or anxiety attack.

ABC's.

2. Next, treat actual problems. Ex. nausea, full bowel or

bladder, comfort measures.

3. Then, treat relatively urgent actual or potential problems

that the patient or family does not recognize. Ex. Monitoring
for post-op complications, anticipating teaching needs of a
patient that may be unaware of side effects of meds.

4. Lastly, treat actual or potential problems where help may be

needed in the future.

Ex. Teaching for self-care in the home.

Here are some great principles to help you as

you prioritize:

Systemic before local

Acute before chronic

Actual before potential

Listen don’t assume

Recognize first then apply clinical knowledge

Maslow’s Hierarchy of Needs:

Prioritize according to Maslow with physiological and safety

issues before psychological esteem issues.

Organizational skills:

Make effective and efficient use of time by combining nursing

activities like physical assessment and bath.

Use of resources:

Use other members of the health care team to help you when
necessary when turning and repositioning, lifting, or inserting
a catheter. Seeking help can make things safer and easier for
you and client.

Evaluation of care plan:

Evaluate the care plan for multiple clients and revise care as
need.

"Nurture your mind with great thoughts; to believe in the

heroic makes heroes."-Benjamin Disraeli