Medical Surgical

• How to verify patient’s identity?

  1. Name
  2. Date of Birth
• How will the nurse will assess clients orientation status?

  • Ask Their Name
  • Location
  • Date
  • Current Situation(Current President)
• What are the Normal Vital Signs(Adult)

  • Heart Rate- 60-100bpm
  • Blood Pressure- 120/80mmHg
  • O2 Saturation- 95%-100% COPD Patients-88%
  • Temperature- 36.5- 37.2
  • Respiratory Rate- 12-20cpm
  • Pain Scale- Must Be Included(Subjective Data)
• What are the 5 areas of the heart need to auscultate?

  (ALL PEOPLE ENJOY TIME MAGAZINE)

  • Aortic
  • Pulmonic
  • Erb’s Point
  • Tricuspid
  • Mitral
• How to grade radial pulses?

  0- Pulse is Absent

  1+ -Diminished

  2+-Normal

  3+ -Full

  4+ -Bounding, Strong
• Normal Capillary Refill Time

  • 2-3 Seconds
• How to do assessment in Abdomen?

  -IAPP-

  • Inspect
  • Auscultate
  • Percuss
  • Palpate
• In what order will auscultate the abdomen?

  • Starts with Right Lower Quadrant and go clockwise
• Normal Range of Abdominal Gurgling sounds?


  • 5-30times per minute
• 1 oz

  -30ml

  8oz

  -1cup

  1tsp

  -5ml

  1tbsp

  -15ml

  1dram

  -5ml

  1kg

  -2.2lbs

  1lb

  -16oz
• When you see priority question you should immediately thinks of?

  • Maslow’s Hierarchy Of Needs
  • ABC’s
• Maslow’s Hierarchy Of Needs(Most Important to Least Important)

  • Physiological Needs
  • Safety and Security
  • Love and Belonging
  • Self-Esteem
  • Self- Actualization
• Infectious Agent

  • Fungi, Bacteria, Viruses, Parasites
• Reservoir

  • Where agents are found
  • Animals, Humans, Food and Water Sources, Environment
• Portal Of Exit

  • Where germs escape from
  • Anything EXCRETES from the Body
  • Openings in skin, saliva and mucus, stool, urine & blood, moisture & droplets
• Mode of Transmission

  • How agents travel
  • Superficial Contact, Sexual Contact, Aerolized or Droplet Particulates, underprepared food.
• Portal of Entry

  • How agents enter the body
  • Anything that ENTERS through Mouth, Eyes, Nose
• Susceptible Host

  • Whom agent travels to next
  • Anyone and Animals
• Infection Control

  1. Infectious Agent
  2. Reservoir
  3. Portal of Exit
  4. Mode of Transmission
  5. Portal of Entry
  6. Susceptible Host
• Stages of Infection

  1. Incubation- to grow and produce symptoms
  2. Prodromal- Early signs of illness(Contagious)
  3. Illness- Obvious symptoms
  4. Decline- Symptoms are improving but their immunity is down.
  5. Convalescence-Improvement
• PPE(Donning)

  1. Hand Hygiene
  2. Gown
  3. Mask
  4. Eye Googles/Face Shield
  5. Gloves
• PPE(Doffing)(Glogogo Maha)

  1. Gloves
  2. Googles/Faceshield
  3. Gown
  4. Mask
  5. Hand Hygiene
• Standard Precaution

  -General infection control

  
  

  Used For:

  • ALL PATIENTS

  Equipments:

  • Non Sterile Gloves
  • Googles
  • Surgical Mask
  • Face Shield
  • Gown
• Contact Precaution

  -Precautions taken to protect infection spread mostly by TOUCH/CONTACT

  Used For:

  • MRSA
  • C.Difficile
  • Drug- Resistant Organisms

  Equipments:

  • Gloves
  • Gown
• Droplet Precaution

  -Prevention of spreading infection by sneezing, coughing or talking. VISITORS SHOULD 3 FEET AWAY

  Used For:

  • Adenovirus(Children)
  • Pertussis
  • Rubella
  • Diptheria
  • Mumps
  • Bacterial Meningitis

  Equipments:

  • Surgical Mask
• Airborne Precaution

  -Infection that can spread thorugh particles that can stay in the air and travel

  Used For: (MTVC)

  • Measles (Rubeola)
  • Tuberculosis
  • Varicella (Chicken Pox) and Herpes Zoster (Shingles)
  • Covid-19

  Equipments:

  • Gown
  • Non Sterile Gloves
  • N95 Respirator
  • Negative Air Pressured Room
• Neutropenic Precaution

  -Reverse Isolation

  -Isolation type to protect patients with weak immune system from germs.

  Used For:

  • Pt’s with decreased WBC Count(Neutropenia)
  • Immunocompromised Patient
  • Cancer Patient
  • Chemotherapy Patient

  AVOID:

  • Fresh Flowers
  • Fresh or raw fruits/vegetable
  • Undercooked Meats
  • Standing Water
• Administration Of Blood Transfusion

  • Type and screen and a crossmatch are good for 72HOURS/3DAYS
  • Blood must be hung within 30MINUTES from the time blood is picked up from blood bank
  • Must be transfused within 4HOURS
• IV Therapy Complications

  Air Embolism

  Symptoms:

  • Tachycardia
  • Chest Pain
  • Hypotension
  • Decrease LOC
  • Cyanosis
  • Dyspnea or Cough

  Treatment:

  • Clamp the tubing
  • Turn the patient onto LEFT SIDE and place in TRENDELENBURG POSITION
  • Notify AP
• IV Therapy Complications

  Infiltration

  Symptoms:

  • Pain at the site
  • Swelling at the site
  • Coolness at the site
  • Numbness
  • No blood return

  Treatment:

  • Remove the IV
  • Elevate Extremity
  • Apply warm or cold compress
  • Avoid rubbing the area
• IV Therapy Complications

  Infection

  Symptoms:

  • Increase Heart Rate
  • Redness
  • Swelling
  • Chills and Fever
  • Malaise
  • Nausea and Vomitting

  Treatment:

  • Remove the IV
  • Obtain Cultures
  • Administration of Antibiotics
• IV Therapy Complications

  Circulatory Overload

  Symptoms:

  • Increased BP
  • Distented Neck Veins
  • Dyspnea
  • Wet Cough and Crackles

  Treatment:

  • KVO
  • Elevate Head of the Bed
  • Keep the patient warm
  • Notify AP
• IV Therapy Complications

  Phlebitis

  Symptoms:

  • Heat at the site
  • Redness at the site
  • Decrease flow of IV

  Treatment:

  • Remove IV
  • Notify AP
  • Restart IV on the opposite site
• IV Therapy Complications

  Hematoma

  Symptoms:

  • Blood at the site
  • Hard and painful lump
  • Ecchymosis

  Treatment:

  • Elevate Extremity
  • Apply pressure and ice
• Edema

  -Accumulation of excess fluid in the body tissues that can cause swelling of the skin

  Grading of Pitting Edema

  • +1 -Trace
  • +2 - Mild
  • +3 -Moderate
  • +4 -Severe
• Anasarca

  -Generalized Edema
• Decubitus Ulcers(Bed Sores)

  Stages of Bedsores

  • Type 1- Skin Intact with redness
  • Type 2- Skin not intact, patial thickness loss
  • Type 3-Skin not intact, full thickess loss
  • Type 4- Skin not intact, full thickness TISSUE loss
  • Deep Tissue Injury- Skin is intact but tissue beneath the surface is damage(Dark Red, Purple)
  • Unstageable- Cannot be determined due to eschar or slough covering the visibility of the wound
• Decubitus Ulcers(Bed Sores)

  Risk Factors: (AVOIDS PRESS)

  • Aging Skin
  • Vascular Disorders
  • Obesity
  • Immobility and Incontinence
  • Diabetes
  • Skin Friction
  • Poor Nutrition
  • Reduced RBC(Anemia)
  • Edema
  • Sensory Deficits
  • Sedation
• Decubitus Ulcers(Bed Sores)

  Nursing Considerations:

  • Relieve pressure (Pressure Relieving Devices)
  • Skin Hygiene
  • Proper Nutrition(Increased Protein, Adequate Hydration, Possible Enteral Nutrition
  • Reposition(Turn every 2 hours)
  • Monitor Bed Sores(Braden Scale)