Medical Surgical Review - Nursing 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, CHR, 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: TWITCHINGS
Tremors
Weakness
Irritable
Tachycardia
Cool skin
Hunger
Increased Pulse
Nervous
Gradual loss of vision
Sweating, moist, clammy skin
 
Hyperglycemia:  HANDTOWELS
Headache
Air hunger
Nausea and vomiting
Drowsy and dry skin
Thirst
Osmotic diuresis (polyuria)
Weak, rapid pulse
Eyes blurry
Lethargy
Sweet, fruity breath odor
 
Hypocalcaemia 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 Client 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
 
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
Pleuretic pain
Trachea deviation
Hyperresonance
Onset sudden
Reduced breath sounds (& 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.
 
Prioritization
Prioritization includes clinical care coordination such as clinical decision making, priority
setting, organizational skills, use of resources, time management, and evaluation of care.
Priority setting refers to addressing problems and prioritizing care. It is critical for efficient
care. The PN 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 client or family does not
recognize. Ex. Monitoring for post-op complications, anticipating discussion of side effects
of meds with the client and the family.
4. Lastly, treat actual or potential problems where help may be needed in the future.
Ex Reinforcement of 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 bathing and
dressing changes.
Use of resources:
Use other members of the healthcare 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.