MedSurg I Exam 1 - Down & Dirty

olanjones's version from 2016-10-11 13:41

Normal Lab Values

Question Answer
Sodium135 – 145 mEq/L, Chief electrolyte of ECF (extracellular fluid)
Potassium3.5 – 5.0 mEq/L, Chief electrolyte of ICF (intracellular fluid)
Calcium8.5 – 10.5 mg/dL
Magnesium1.3 – 2.1 mEq/L
Phosphorus2.5 – 4.5 mg/dL
Fasting glucose60 – 100 mg/d
BUN8 – 20 mg/dL
Creatinine0.6 – 1.2 mg/dl
Albumin3.5 – 5.5 g/dL
White Blood Cell (WBC)4,500 – 10,500 per microliter
Red Blood Cell (RBC)4.2 – 5.4 million cells per microliter
Hematocrit37 – 50% (women 37-47%, men 40-50%)
Hemoglobin12 – 16.5 gm/dL (women 12-15, men 14-16.5)
Platelets150,000 – 450,000 platelets per microliter of blood
PT11.0 – 13.5 seconds, Coumadin Therapy will be Prolonged
PTT 25 – 35 seconds, Heparin Therapy will be Prolonged (up to 2.5 times longer)
INR (International Normalized Ratio) ≤ 1.1, Coumadin Therapy will be Prolonged (btwn 2-2.5 and 3.0-3.5 depending on goal)
pH7.35 – 7.45
HCO322 – 26 mEq/L
PaCO235 – 45 mmHg
PaO280 – 100 mmHg

Pre-op Meds

Question Answer
Sedatives & Amnesiacsbenzodiazepines / barbiturates = anxiety reduction
Antiocholinergicsscopalamine / atropine / gycopyrrolate = decrease secretions, prevent N&V, sedation, prevent bradycardia
Opioidsmorphine / fentanyl = Reduce anesthesia requirements & pain of preparation
Antiemeticsmetoclopramide / ondansetron = Increases gastric emptying, prevent N&V
Antibioticscefazolin = prevent postop infection (timed for peak bacteremia)
Rx for patient's co-existing conditionsbeta blockers (reduce HTN), H2 blockers (decrease HCl acid, increase pH, decrease gastric volume), insulin (stabilize blood glucose)


Question Answer
CranberryUse: Prevention of UTI , AE: GI upset/diarrhea in excessive amounts
GarlicUse: Decrease chol, AE: Increase bleed, Lower blood glucose (fish oil, Vit E can also increase bleed risk)
GingerUse: Treat N/V, AE: Increase bleed risk, Lower blood glucose
Ginkgo bilobaUse: Symptoms of claudication, AE: Increase stroke risk, Increase bleed risk, Affect blood glucose
GinsengUse: Improve mental performance, lower blood glucose, enhance immunity, AE: increase/decrease in BP, Increase bleed risk,
St. John's wortUse: Depression, AE: Interferes with drug metabolism, Increase SE if used with other antidepressants
Why are kava and valerian a surgical risk?Both herbs can cause excess sedation
When should herbs be discontinued?Ideally 2-3 weeks before surgery


Question Answer
CAP OrganismsStreptococcus pneumoniae, mycoplasma, haemophilus; respiratory viruses: chlamydia, legionella pneuomniae; oral anaerobes: moraxella catarrhalis, staph aureus, nocaria; enteric aerobic gram negative bacteria (Klebsiella); fungi: myobacterium TB
HAP Organismspseudomonas aeruginosa, enterobacter, e. coli, proteus, klebsiella, staph. aureus, strep pneumoniae, oral anaerobes
CAP & HAP Common Organisms Streptococcus pneumoniae, Klebsiella, Staphylococcus aureus

Antibiotic Tx for Pneumonia

Question Answer
the class of antibiotics most commonly used to treat a category 1 CAP is advanced generation macrolides
the drug of choice for treatment of pneumocystis carinii pneumonia is trimethoprim/sulfamethoxazole (Bactrim)
a group 3 HAP caused by pseudomonas aeruginosa is most likely to be treated with an aminoglycoside
Patient with MRSA has a group 3 HAP. Treatment would include the antibiotic: vancomycin
group 1 HAPs caused by enteric gram-negative bacilli, such as Klebsiella, are treated with acephalosporin


Question Answer
Classification: 0No TB exposure, no Hx of exposure; negative skin test
Classification: 1TB exposure, no infx.; negative skin test; hx of exposure
Classification: 2Latent TB infx.: no disease (significant rxn to skin test, neg. labs, neg. xray, no clinical evidence of TB)
Classification: 3 TB clinically active (TB infx); positive labs, sig. rxn to skin test, positive xray of disease)
Classification: 4TB but not clinically active (no current Dx, hx of previous episode, stable xray, rxn to skin test)
Classification: 5TB suspect (dx pending); person should not be in this class for >3months
Initial phase of drug therapy regimen, option 14-drug regimen consisting of INH, rifampin, pyrazinamide, ethambutol (daily for 56 doses & continuation phase includes INH/rifampin for 126 doses)
Option 2 INH, rifampin, pyrazinamide, ethambutol daily for 14 doses, then 2x wk for 12 doses; continue INH/rifampin for 2x/wk for 36 doses
Option 3INH, rifampin, pyrazinamide & ethambutol 3x/wkly for 24 doses, then INH/rifampin 3x/wk for 54 doses
Option 4INH, rifampin, ethambutol daily for 56 doses, then INH/rifampin daily for 217 doses
What is DOT?Direct Observational Therapy. Providing TB drugs directly to pts and watching as they swallow meds to ensure adherence.
Which TB drug is usually the only one used for LTBI?INH

Allergic Rhinitis & Sinusitis Rx

Question Answer
Nasal spraysdon't use >3days could cause rebound vasodilation & congestion
Nasal Spray drug namesbeclomethasone, budesonide, ciclesonide, flunisolide, FLUTICASONE (FLONASE), mometasone, triamcinolone
Mast Cell Stabilizer nasal spray namecromolyn spray
leukotriene receptor Antagonists LTRAszafirlukast, montelukast
anticholinergic nasal sprayipratropium bromide
antihistamines 1st generationazatadine, brompheniramine, chlorpheniramine, clemastine, dexchlorpheniramine, diphenhydramine, levocetirizine
antihistamines 2nd generationlortadine, cetirizine, fexofenadine, desloratadine
oral decongestantspseduoephedrine (Sudafed)
Topical nasal spray decongestantoxymetazoline, phenylephrine, azelastine

Lung Volumes

Question Answer
VTvolume of air inhaled and exhaled with each breath (Tidal Volume)
RVamount of air remaining in lungs after forced expiration (Residual Volume)
TLCmaximum amount of air lungs can contain (Total Lung Capacity)
VCmaximum amount of air that can be exhaled after maximum inhalation
FVCamount of air that can be quickly and forcefully exhaled after maximum inspiration
PEFRMaximum rate of airflow during forced expiration
FEV1amount of air exhaled in first second of forced vital capacity (Forced Expiratory Volume 1)

Classifications of Asthma

Question Answer
Sx no more frequent than 2x weeklymild, intermittent
sx more freq than 2x/wk, but <1x/D; exacerbations may affect activitymild, persistent
daily sx, exacerbations at least 2x/week and can last for daysmoderate persistent
continual sx, frequent exacerbations, limited physical activitysevere, persistent
asymptomatic with normal PEFR b/t exacerbations (exacerbations brief)mild, intermittent
daily use of inhaled SABAsmoderate, persistent
Nocturnal Sx 2x/monthmild, intermittent
nocturnal sx >2x/mmild, persistent
nocturnal sx >1x/weekmoderate persistent
nocturnal sx frequentsevere, persistent
FEV1/PEFR is at least 80% of predicted; PEFR variability is <20%mild, intermittent
FEV1/PEFR is at least 80% of predicted; PEFR variability is b/t 20-30%mild, persistent
FEV1/PEFR >60%, but <80% of predicted; PEFR variability >30%moderate, persistent
FEV1/PEFR is no greater than 60% of predicted; PEFR variability >30%severe, persistent

Oxygen Delivery Systems

Question Answer
provides highest oxygen concentrationsnon-rebreathing mask
may cause aspiration of condensed fluidtracheostomy collar
safest system to use in a patient with COPDventuri mask (can deliver precise concentrations of O2)
most comfortable and causes least restriction on activitiesnasal cannula (up to 6L)
used to give oxygen quickly for short timesimple face mask; 35-50% oxygen and rates of 6-12L/min, provides humidfication of inspired air
provides 40-60% oxygen concentrationpartial rebreathing mask; bag must stay inflated, pt. inspires about 1/3 of exhaled air that is rich in O2
invasive placement of catheter into tracheatranstracheal catheter
long-term O2 therapy at home, has built-in reservoir that ↑ O2 concentration, allowing patient to use a lower flow (30-50%Oxygen-conserving cannula; up to 8L/min; CF, pulmonary HTN

Respiratory Drug Class and Actions

Question Answer
albuterol nebulizerbeta-adrenergic agonist; quick-relief agent
oral prednisonesteroid anti-inflammatory; long-term control
triamcinolone inhalersteroid anti-inflammatory; long-term control
ipratropium in haleranticholinergic; quick relief agent
oral theophyllinemethylxanthine bronchodilator; long-term control
cromolyn inhalermast-cell stabilizer; long-term control
budesonide inhalersteroid anti-inflammatory; long-term control
IV aminophyllinemethylxanthine bronchodilator; quick-relief agent
formoterol inhalerbeta-adrenergic agonist; long-term control
zileutonleukotrine inhibitor; long-term control
metaproterenol inhalerbeta-adrenergic agonist; quick relief agent
beclomethasone inhalersteroid anti-inflammatory; long-term control
nedocromil inhalermast-cell stabilizer; long-term control
salmeterol inhalorbeta-adrenergic agonist; long-term control

Insulin Types

Question Answer
Rapid-acting: lispro, aspart, glulisineOnset 15 min, Peak 60-90 min, Duration 3-4 hours
Short-acting: regularOnset 30-60 min, Peak 2-3 hours, Duration 3-6 hours
Intermediate acting: NPH, LenteOnset 2-4 hours, Peak 4-10 hours, Durations10-16 hours
Long-acting: glargine, detemirOnset 1-2 hours, Peak None, Duration 24+ hours

Insulin Info

Question Answer
Mealtime insulin (bolus)Rapid (preferred, most like normal-body insulin response to food), Short (need to take 30-45 mins before food)
Background insulin (basal)Covers insulin needs btwn meals & at night; steadily released (less hypoglycemic risk), 24-hour control decreases DKA risk (DO NOT MIX with other insulin)
Combo therapyintermediate (NPH) mixed with a short-acting, control is not as precise so not used much anymore
Mixing insulin1. Inject air into NPH vial equal to dose, remove syringe. 2. Inject air into regular vial equal to dose and withdraw insulin. 3. Without adding more air to NPH vial, withdraw NPH insulin dose.
Vial StorageVial in use can be kept at room temp x 4 weeks, Store extra vials in fridge (heat/freeze make it unusable), Avoid sunlight exposure to vial, May keep in a cooler when traveling (DO NOT FREEZE)
Pre-filled syringe/Pen storageGood for 30 days in fridge, NPH should be stored upright with needle up, Roll in hands to warm prior to use
Sub-q insulin injection sites (fastest to slowest absorption)Abdomen (preferred), Arm, Thigh, Buttocks (admin at 45 or 90 degree angle, depending on adipose tissue present)
Important teaching points for insulin injectionDo not inject into site that will be exercised, Rotate injection site to avoid lipodystrophy (now recommended rotate within one site), Use smallest syringe for dose (improves accuracy), If using a pen must change needles between uses (if not dose may be inaccurate - possible remnants in old needle)
Nurses clean site w/ alcohol at hospital & Do not recap needles, differs for pt how?If self-admin insulin, pt may clean site w/ soap & water, and may recap needle
How do insulin pumps work?Delivers rapid or short-acting insulin 24/7, at a basal rate by continuous subQ infusion (bolus doses can be programmed by user for meals/exercise)
Insulin pump teachingChange site every 2 – 3 days (refilled & reprogram), Check insertion site for redness, Monitor glucose levels 4 to 6 times daily
Somogyi effectblood glucose drops at night due to maintenance insluin, body reacts with glucogenesis, producing rebound hyperglycemia. S/S HA, Night sweats, Nightmares. To dx: Check glucose btwn 0200-0400
Dawn effectcounter-reg hormones work to increase glucose levels in AM, those with DM may not have enough insulin present causing morning hyperglycemia

Oral Agents

Question Answer
Work in 3 waysReduce insulin resistance, Increase insulin production, Reduce hepatic glucose production
5 ClassesSulfonylureas, Meglitinides, Biguanides, alpha-Glucosidase inhibitors, Thiazolidinediones
SulfonylureasAction -> enhance pancreatic production of insulin (less chance of hypoglycemia & work best early on): Glyburide, Glucotrol, Micronase
Meglitinide Action -> enhance pancreatic production of insulin (even less chance of hypoglycemia. Take 30 to right before a meal, do not take if skipping meal): Prandin, Starlix
BiguanidesAction -> ↓ glucose production by the liver, increases insulin sensitivity. (Most common oral anti-hypoglycemic, often used in combo-tx) Glucophage (metformin)
alpha-Glucosidase inhibitorsAction -> ↓ absorption of carbohydrates by small intestine (Ineffective on hyperglycemia outside of meals, Take with 1st bite of meal): Precose, Glyset
ThiazolidinedionesAction -> Improve insulin sensitivity, transport, & utilization at target tissues (No hypoglycemic risk if used alone but increased risk if in combo tx; CAN CAUSE EDEMA - NO for CHF): Avandia


Question Answer
FPG (fasting plasma glucose)Preferred method, > 126 mg/dl fasting (no sugar for 8 hours). If impaired, signals the intermediate stage of prediabetes
RPG (random (casual) plasma glucose)> 200 mg/dl + symptoms (taken anytime w/o regard to food)
OGTT (2 hour oral glucose tolerance test)> 200 mg/dl using a glucose load of 75 g. If impaired, signals the intermediate stage of prediabetes but Can have false lows/highs depend on other factors
HgA1C (glycosylated hemoglobin)Not used an initial dx test, shows effectiveness of serum glucose control over past 120 days.
FPG guidelinesNormal=<100, Pre=100-125, Diabetic=126 or above
OGTT guidelinesNormal=<140, Pre=140-199, Diabetic=200 or above
HgA1C guidelinesIdeal level is ≤ 7% (ADA) or ≤ 6.5% (American College of endocrinology)



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