Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+, Exams of Nursing

Download Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ and more Exams Nursing in PDF only on Docsity! Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Kaplan→ Med Surg 1, 2 & Comprehensive Rationales Med Surg 1A Topics 1. Cushing’s Syndrome (2 questions) → hypersecretion of ACTH (hormone that allows body to react to stress) ○ https://www.youtube.com/watch?v=ea1sXgd5ui8 ● Signs & Symptoms → fatigue, muscle weakness, weight gain, thinning extremities, thin & fragile skin, moon face & ruddy complexion, hirsutism, truncal obesity, broad purple striae, bruising, impaired wound healing, increased blood pressure & sodium, hypokalemia, hyperglycemia, buffalo hump, DM ● Treatment → restore hormone balance by radiation, drug therapy or adrenalectomy (removal of one or both adrenal glands) ● Nursing Considerations → Frequently monitor VS (especially BP), monitor labs for electrolyte changes, monitor daily weight, check for signs of infection, perform passive range of motion for those that have osteoporosis or are bedridden ○ Post-surgery nursing considerations → encourage Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ coughing & deep breathing, monitor for shock & HTN, administer cortisone as ordered ○ Diet → High in protein & potassium, but low in carbs & sodium, high calcium + vit. D 2. Hepatitis (3 questions) → inflammation of the liver that causes liver cell damage ○ https://www.youtube.com/watch?v=eocRM7MhF68 ○ Chronic hepatitis (> 6 months) can lead to cirrhosis of the liver ● Causes → bacteria, toxins or viruses , 6 viral types → A, B, C, D, E, G ● Hepatitis A & E → fecal to oral (shellfish from contaminated waters is a major source) ● Hep. A stages ○ Pre-icteric: malaise, N/V, anorexia ○ Icteric: jaundice, clay colored stool, tea colored urine ○ Convalescent: SX resolves ● Hepatitis B,C, D & G → parenteral drug abuse, sex, blood & body fluids, Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ ○ General anesthesia is usually administered ● Upper Tract cystoscopy ○ Pt. usually kept NPO for several hours before test ○ A sedative may be administered ○ Pt. can expect some burning on voiding, blood in urine, urinary frequency ○ Heat applications are helpful in relieving pain and relaxing muscles ● Nursing Care → monitor pt. with prostatic hyperplasia (enlarged prostate that can cause urine difficulty) for urine retention, suggest warm sitz baths and antispasmodic meds, monitor for s/s of UTI 4. Diabetes Mellitus (4 questions) → know setting priorities → Condition is characterized by a high level of glucose in the body ○ Signs & Symptoms → THE POLY’s (polyuria,polydipsia, polyphagia), weakness, dizziness, fatigue i. In Children → those above + enuresis (bed-wetting), unusual fatigue & irritability Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ ○ Type 1 → beta cells in pancreas are destroyed and produce no insulin i. Treatment → insulin injections, continuous infusion via pump & diet control ○ Type 2 → beta cells in pancreas secrete insulin, but the body is resistant to its effects i. Treatment → insulin, oral hypoglycemic injections & diet control ○ Diet Management → monitor total calories, carbs & timing of food ○ Diet Intake → meals with complex carbs, ↓ fat, ↑ fiber, some protein i. Time meals with peak effect of insulin ii. Provide extra snacks for unplanned physical activity iii. Substitute soft foods 6-8 times per day if you cannot stick with the usual meal plan iv. If vomiting, diarrhea or fever persist take in some liquids like ½ cup coke, juice, broth or 1 cup of gatorade to maintain caloric intake every ½ hour or hour Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ v. Report nausea, vomiting & diarrhea to HCp → extreme fluid loss = dangerous vi. Unable to retain fluids = hospitalization to prevent DKA ○ Patient Teachings → lose weight if obese, oral hypoglycemic agents, maintain healthy weight, s/s of hypoglycemia & hyperglycemia, self-monitoring of glucose, skin/foot care, importance of exercise ○ “Sick Day” Rules → guidelines for managing diabetes when ill → aimed at preventing DKA i. Take insulin or hypoglycemic agents as usual ii. Test blood glucose & urine ketones every 3-4 hrs → report elevated levels to MD iii. If you take insulin, you may need supplemental doses every 3-4 hours ○ Dawn Phenomena → early morning glucose levels are elevated caused by nocturnal release of growth hormone ○ Somogyi Effect → fall in blood glucose during the night with ↑ morning glucose levels → caused by 5. Thermal Injury (4 questions) Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ ○ Treatment → calamine lotion to soothe itching & pain, Acyclovir, corticosteroids to reduce inflammation, vaccination to prevent or modify the disease course ● Nursing considerations: minimize pain & prevent complications, analgesics, apply compresses (wet dressings to skin lesions & cold compresses to ruptured vesicles), administer systemic corticosteroids to diminish severity, prevent spread- contagious to anyone who has not had chickenpox or is immunocompromised 7. Hernia (2 questions → know Umbilical Hernia) → protrusion of intestines through a weakness in the umbilical ring, muscle & fascia Types of Hernias ● https://www.youtube.com/watch?v=3wUrJGDgGO4 ● Umbilical → Hernia occurring at the naval ; more common in women who are obese or multiparous ○ S/S → bulging protrusion at the umbilicus → pain, discomfort at site ○ Treatment → Size of fascial ring less than 2 cm = none; larger = surgery → laparascope Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ ○ Nursing Care → do not use a belly band or tape a silver dollar to the area, keep pressure dressing in place until sutures are healed, sponge-bath child until the dressing is removed & keep diapers folded below the dressing ● Hiatal → opening in diaphragm through which esophagus passes ○ S/S: heartburn, full after meals, GI bleed and N/V (severe) ● Inguinal → Protrusion of the hernia sac containing the intestine of the inguinal opening 8. Incentive Spirometer → Breathing device used to maximize lung expansion by opening closed alveoli and mobilize secretions → facilitates tissue oxygenation!, prevents atelectasis ● Nursing considerations: instruct client to breath in and exhale normally, seal lips around mouthpiece, inhale slowly and deeply, holding breath for at least 3 seconds while keeping ball or cylinder elevate, exhale, take several normal breaths and repeat 4-5 to,es; client Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ should cough after procedure to facilitate secretion removal 9. NG Tube Insertion → Tube from nose into stomach inserted to instill medication ,food, fluids, to remove stomach contents, to obtain specimen for laboratory analysis ● Insertion: ○ Measure distance from tip of nose to earlobe plus the distance from the earlobe to the bottom of the xiphoid process, mark the distance on the tube with tape Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ 11. Thyroid Disorders (5 questions → know Grave’s disease & Hypothyroid) → ○ Hyperthyroidism → hypersecretion of thyroid gland (Graves Disease) i. S/S → hyperthermia, HTN, tachycardia, heat intolerance, diaphoresis, increased appetite, irritability, muscle fatigue, hyperactivity, sleep deprivation, hyperreflexia ii. Treatment → radioactive ablation, complete or partial removal, anti-thyroid meds 1. Radioactive precautions: flush toilet twice, use gloves, put clothes in radioactive sealed bag, don’t hand wash clothes (machine wash only x 2 on hot) iii. Nursing Care → monitor for thyroid storm, heart failure, cardiac dysrhythmias, quiet environment with little stimulus iv. Patient Education → high protein, carb, vitamin & mineral diet, cool clothes, balance rest & activity, may need hormone replacement therapy ○ Thyroid Storm → hyperpyrexia (fever), cardiac Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ dysrhythmias & altered mental status → hypothermic blanket, O2 & meds to suppress thyroid ○ Hypothyroidism → low secretion or cellular resistance to thyroid hormone i. S/S → weakness, fatigue, unexplained weight gain, constipation, edema, slow pulse rate, decreased libido, infertility ii. Treatment → gradual thyroid replacement with levothyroxine iii. Nursing Care → high-bulk(protein), low-calorie diet & encourage activity ○ Myxedema → patients w/ hypothyroidism i. non-pitting edema in periorbital area & hands/feet caused by severe or long standing hypothyroidism → patient must continue meds for hypothyroidism to prevent this! Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ 12. Immobility Hazards → know hazardous things if patient is immobile ● Includes pressure ulcers, osteoporosis, hypercalcemia, negative nitrogen balance, increased cardiac workload, orthostatic hypotension, stasis of respiratory secretions, boredom, depression ● Nursing considerations: turn frequently, provide good skin care, give high-protein diet with small-frequent feedings, rise from bed slowly, turn, cough,and deep breathe. ROM exercises at least 3x each or as much as pt. can tolerate, high protein diet, vitamin A and C ● Tx: enoxaparin → prevents DVT 13. Diabetes Insipidus → results from a deficiency in circulating ADH (vasopressin) → results from dysfunction of the pituitary gland ○ Signs & Symptoms → extreme polyuria, polydipsia (especially cold, iced drinks), nocturia, ↑ plasma osmolality, urine specific gravity 1.001-1.005, fatigue, dehydration → weight loss, poor skin turgor, dry mucous membranes, constipation, muscle weakness, tachycardia Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ caused by viral infections, toxins, bile stasis or obstruction ○ Signs & Symptoms → indigestion, gas, constipation, N/V, esophageal varices, hematemesis, hemorrhage, ascites, anemia, edema in extremities, JAUNDICE, pruritus, DARK URINE, CLAY-COLORED STOOLS, palma erythemia ○ Treatment → must treat what is causing the cirrhosis! i. Lactalose → for ammonia ii. If ascites → paracentesis iii. Shunts to relieve portal hypertension Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ iv. Liver transplant v. Diet: high carb, high protein ○ Nursing Care → HIGH PROTEIN DIET (high carb in early stages, but in late stages restrict fiber, protein, fat & sodium) & give supplemental vitamins i. Check skin, gums, stool & emesis regularly for bleeding ii. Apply pressure to injection sites iii. Assess fluid retention → daily weight iv. Avoid using soap when bathing patient to prevent skin breakdown v. LABS: low H & H 17. Allergy → hypersensitivity caused by exposure to an allergen, a true allergy will cause production of IgE antibodies ○ Allergic reaction is caused by large amounts of histamine being dispersed throughout the circulatory system → causes vasodilation & edema of the tissues ○ Signs & Symptoms → SOB, wheezing, inflamed airways, itching, congestion, erythema Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ ○ Common allergens → PCN, radiopaque dyes, aspirin, blood components, Toxins (snake, bee, wasp, hornet), food (berries, milk, chocolate, eggs, shellfish, seafood, wheat, nuts) & latex i. High risk populations for latex allergy → spina bifida kids, urogenital abnormalities, spinal cord injuries, multiple surgeries, health-care workers ii. Why spina bifida kids? https://www.ifglobal.org/en/37- temp-news/9-latex-allergies ○ Nursing Care → obtain detailed history, establish airway, administer epinephrine or diphenhydramine in the event of a reaction i. Latex allergy → avoid condoms, balloons, gloves, catheters, brown ace bandages, elastic pressure stockings ii. Do not give d5 LR → causes a reaction ○ Client Education → use of inhaler & epi pen, paint walls, toys should be wood, plastic or metal, remove rugs, move bed away from forced air vent ○ Allergic Rhinitis → allergic rxn that results in watery rhinorrhea, nasal obstruction, sneezing, nasal pruritus Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ i. Before procedure → obtain baseline vitals, breath sounds, weight, glucose & electrolyte levels ii. During procedure → infuse 1-2 L of fluid into cavity by gravity using sterile technique, leave fluid in for 20 minutes & then remove it by gravity iii. After procedure → take vital signs, check for respiratory distress, pain or discomfort, assess dressing around catheter for wetness iv. Complications → peritonitis (fever, abd pain & cloudy dialysis drainage, swelling, tenderness, redness or purulent secretions at site), abdominal pain, insufficient return of fluid v. Nursing Care → instruct patient to consume high protein & fiber diet ○ Hemodialysis → removal of excess fluids & wastes by circulating patient’s blood through a semi-permeable membrane that acts as an artificial kidney i. Done through a mature AV shunt, fistula or graft (4- 6 weeks old) → created by surgical anastomosis of an artery & a vein (usually radial artery & cephalic vein) Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ 1. Complications → air embolism, blood leaks, blockage/clotting, contamination & exsanguination ii. Nursing Considerations → check thrill & bruit every 8 hours, do not use that site for BP or blood specimens, assess site for infection, instruct patient to not lift anything heavy on that side or sleep on top of it, monitor closely for hypotension, N/V, malaise, HA, dizziness & muscle cramps 19. Cholecystectomy (2 questions) → surgical removal of the gallbladder to restore biliary flow, can be done either laparoscopic or traditional (T-tube) ○ Before surgery → keep on clear liquids/NPO 24 hours before, assess respiratory status ○ After laparoscopic surgery → monitor wounds & dressings, anesthesia related nausea/vomiting, keep in Semi-Fowlers position, encourage early ambulation, apply heat to right shoulder to alleviate any pain caused by phrenic irritation ○ https://www.youtube.com/watch?v=ffoKThdqo4I Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ ○ After traditional surgery → Low Fowler’s position, splint the affected side, assess drainage from T tube & position (make sure it is level with abdomen) watch for signs of post cholecystectomy syndrome (fever, abd pain, jaundice) ○ https://www.youtube.com/watch?v=sFtRwDUTavo ○ Patient Education → Encourage client to walk, instruct them that they will need assistance for the first 24-48 hrs after surgery, report any elevated temperatures, apply heat pad, sit-up in bed & that they should return to normal activities within one week ○ Diet: avoids spicey foods and fatty foods 20. Kidney Transplant → Transplantation of a donor kidney from a live donor or a cadaver, attractive alternative to dialysis or ESRD ○ Symptoms of Rejection → oliguria (little urine), edema, fever, hypertension, weight gain, tenderness over kidney ○ Nursing Interventions → monitor I & O’s, monitor K+ labs, and observe for signs of bleeding, report output of less Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ v=2ZEWz_Ps7vo iii. Nursing Care → apply hip protector pads in patients at risk for falls, monitor for hypovolemic shock post surgery, use compression stockings/ICD’s or anti- coagulants to prevent DVT’s, encourage patient to keep moving by using trapeze, administer pain meds, monitor hydration/nutrition/urine output, access the 6 P’s (pain, paresthesia, pallor, paralysis, pulse, poikilothermia (unable to regulate temp.) ○ Skull Fracture → results from direct impact, signs & symptoms may not be evident immediately i. Signs & Symptoms → ecchymosis behind ears, over mastoid process (Battle’s sign) or around eyes (raccoon eyes), CSF leakage from nose or ears, cranial nerve injury manifestations 1. Complications → brain abscess, meningitis, increased ICP 22. Lyme Disease → Inflammatory disorder caused by a spirochete (Borrelia burgdorferi) → spread to humans by deer tick bites Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ ○ Symptoms → flat, flu-like sx, slightly raised red lesions (bulls-eye pattern); fever; fatigue, chills; muscle pain; progresses to joint pain, persistent fatigue, headache, and stiff neck ○ Diagnostic Tests → blood tests to identify the bacteria → anti-body titers, ELISA, Western Blot i. Lumbar puncture to test CSF for the bacteria ii. RBC → anemia, WBC, ↑ sedimentation rate ○ Treatment → antibiotic therapy(3-4 weeks) → Doxycycline, Ceftriaxone, Azithromyocin, Amoxicillin; Analgesics & Anti-pyretics → reduce inflammation & fever, NSAIDs → treat arthritic symptoms ○ Patient Teaching → medication may be required up to 1 month → stress importance of maintaining consistent schedule of NSAIDs; provide education on transmission and prevention (wear long sleeves & pants outside in summer & early fall), use insect repellent, 23.Osteomyelitis → Infection of the bone from a soft tissue infection, bone surgery, trauma or blood-borne infection caused by Staphylococcus aureus Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ ○ Carried by blood from primary site of infection (upper respiratory infections (URIs), otitis media, and tonsillitis). ○ Often a chronic problem → can get sepsis ○ Symptoms → fever, chills, malaise, septicemia, throbbing and deep pain & swelling over the infected area Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ client’s verbalization of feelings, communicate nurses understanding & acceptance ○ Techniques → silence, general leads or broad openings, clarification & reflection Nurse-Patient Relationship Stages ● Pre-Interaction → review patient data ● Orientation → introduction to patient - use verbal & non- verbal skills ● Working → team building phase between you, patient & health care team ● Termination → discharge planning, nurse is no longer needed 26. Ileostomy (2 questions → know how to care for one) → surgical passage through abdominal wall (R lower quadrant) into the ileum → drains GI contents when rest of GI system cannot function properly ○ Drainage → liquid stool containing proteolytic enzymes & bile salts ○ Nursing Care → empty the bag when ⅓-½ full, change the bag every 3-7 days during inactive time (before Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ meals or at bedtime), check skin for irritation ○ Patient Education → be cautious of high fiber & high cellulose foods (popcorn, peanuts, coconut, chinese veggies, shrimp, rice, bran, corn, peas) → may cause diarrhea i. No enteric coated meds, laxatives or enemas ii. Always report an increase or decrease in drainage to HCP Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ 27. Anaphylaxis (2 questions) → serious, immediate multiple system response (vasogenic shock) to an antigen-antibody reaction upon exposure (rarely the first time) ○ Signs & Symptoms → feelings of impending doom/fright, weakness, sweating, sneezing, pruritus, urticaria (hives), angioedema, cardiovascular changes, respiratory discomforts & dyspnea ○ Treatment → immediate injection of epinephrine ( you may repeat every 5-20 minutes) ○ Nursing Care → maintain a patent airway is the most important thing i. Start CPR if patient goes into arrest ii. Monitor for hypotension & shock (maintain volume with volume expanders) iii. Monitor I&O, O2 & suction 28. Addison Disease (3 questions - know Addisonian Crisis) → deficiency in adrenocortical hormones ○ Addisonian Crisis → acute adrenocortical insufficiency caused by stress, surgery, trauma or infections i. Signs & Symptoms → classic shock symptoms Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ lesions…. Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Crust → dried residue of serum,pus or blood on skin surface Erosion → loss of superficial epidermis, depressed, moist area Fissure → linear crack in skin, may extend to dermis Scales → flakes, dead epithelium Ulcer → skin loss extending past epidermis, necrotic tissue loss, bleeding & scarring possible Cyst → encapsulated fluid-filled or semi-solid mass in subcutaneous tissue or dermis Macule → flat with nonpalpable skin color change Papule → elevated, palpable, solid mass Vesicle → circumscribed, elevated, palpable mass containing serous fluid Wheel → elevated mass with transient border, vary in size & color (fluid in the dermis) Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Pressure Ulcers → assess for redness, warmth, induration or hardness, swelling & signs of infection ● Stage 1 → area of skin with observable pressure related changes ● Stage 2 → superficial partial thickness wound that involves the epidermis & dermis ● Stage 3 → full-thickness wound with tissue damage or necrosis of subcutaneous tissue ● Stage 4 → full-thickness skin loss with extensive damage, destruction or necrosis to muscle, bone or supporting structures ○ Treatment → debridement of necrotic tissue, provide a moist wound-healing environment & good nutrition (protein, vitamin C & vitamin A) ● Pruritus → severe, intense itching, tingling & burning Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ ○ Causes → rubbing, scratching, allergies, hyperbilirubinemia ○ Treatment → remove causative agent, corticosteroid, anti- histamines ○ Nursing Care → soothing tepid baths, short nails & mittens ● Psoriasis → chronic, noninfectious inflammatory disease of the skin ○ Signs & Symptoms → thick, itchy, silvery-white scales with symmetrical distribution → common areas are scalp, knees, sacrum, elbows & behind ears ○ Nursing Considerations → oil or coal tar bath, topical steroids, soft brush, anti-metabolites, UV light 30. SIADH → Syndrome of Inappropriate Antidiuretic Hormone → excessive amounts of antidiuretic hormone that results in water imbalance causing water intoxication caused by fluid retention ○ Signs & Symptoms → decreased LOC (cerebral edema, ↑ ICP, HA, irritability, delirium), seizures, coma, sodium less than 120 ○ Treatment → treat the underlying cause! Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ ii. Meticulous skin care & monitor duration of morning sickness iii. Tell pt to take hot showers before bedtime & eat a balanced diet iv. Apply splints carefully & observe for pressure ulcers v. Make sure pt understands the chronic nature of RA & that it will require lifestyle changes 33. Amputation (2 questions) → Surgical removal of a part of the body ○ Complications : phantom limb pain, infection, & hip contracture ○ Nursing Considerations : ROM to prevent contracture of hip, place Pt prone for 20-30 min q3-4hrs; do not elevate residual limb on a pillow after the immediate postoperative period; after the pressure dressing & drains are removed, inspect the wound for inflammation; dressing changed daily until sutures are removed; residual limb wrapped with an elastic bandage to shape the residual limb and keep the dressing in place; observe for symptoms of inadequate tissue Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ perfusion. 34. Kidney: Nephrectomy → Removal of kidney because of tumor, infection, anomalies, advanced kidney cancer that is refractory to chemo. ○ Nursing Considerations → position client in lateral recumbent position, patient will have drains and indwelling catheter, check urine output closely (color, consistency, output → blood in urine is not normal, report to doctor), administer analgesics as prescribed, encouraged to cough and deep breathe, use incentive spirometer, splint incision to help with coughing and encourage early ambulation. i. Four Types of nephrectomy that are performed: 1. Partial Nephrectomy: portion of kidney is removed 2. Simple Nephrectomy: entire kidney is removed 3. Radical Nephrectomy: entire kidney, adrenal gland, and surrounding fat tissue are removed. Patients are placed in a side-lying position during surgery. A 7-inch flank incision just below the diaphragm is needed to perform an open Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ radical nephrectomy. This involves removal of the 12th rib. 4. Nephroureterectomy: entire kidney, surrounding fat tissue, and entire ureter are removed. 35. Colonoscopy : direct visualization of the colon with a fiberoptic colonoscope ○ Purpose: Aids the diagnosis of inflammatory and ulcerative bowel disease, pinpoints lower GI bleeding, detects lower GI abnormalities including, polyps, hemorrhoids, and abscesses. Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ pureed or soft diet easier to swallow than regular. Assess neurovascular function of upper and lower extremities and neurological function using the Glasgow coma scale. Monitor respiratory function. Hematoma formation and edema can occlude the airway. Have tracheostomy tray by room door and suction in room ready to use. Assess dressing for serosanguineous drainage indicating spinal fluid leak, also noted with the client reporting headache. Hoarseness and inability to cough effectively might represent damage to the recurrent laryngeal nerve, inability to cough could lead to atelectasis and pneumonia ii. Client Education: wear collar as directed, avoid twisting or bending or flexing or extending or rotating neck, avoid sitting or standing for over 30 minutes. ○ Lumbar → removal of one or more vertebral laminae plus osteocytes and herniated nucleus pulposus through an incision. Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ i. Postoperative nursing care: checking for fever and hypotension, checking dressing, performing neurovascular (circulation, movement, and sensation) assessment, client should wear antiembolic stockings, log roll every 2 hours by two people, when out of bed, back should be kept straight 38. Cast Care: ○ Immediate cast care: avoid covering cast until dry, handle with palms, not fingertips (plaster cast). Avoid resting cast on hard surfaces or sharp edges. Keep affected limb elevated above heart on soft surface until dry. Observe for blueness or paleness, pain, numbness on affected area. ○ Intermediate care: encourage client to perform prescribed exercises, report any break in cast or foul odor, inform client to not scratch skin underneath cast and avoid putting anything underneath cast. ○ Types of Casts: i. Non-plaster or fiberglass cast: Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ 1. Consist of open-weave, nonabsorbent fabric impregnated with cool water-activated hardeners. Used for nondisplaced fracture and long-term wear. ii. Plaster cast: 1. Rolls of plaster are wet with cool water and smoothed onto body; a crystallizing reaction occurs and heat is given off. ○ Complications: Pressure ulcers, Disuse syndrome, Compartment syndrome and delayed union or nonunion of fractures 39. Urinary Calculi → (urolithiasis [kidney stone disease]) calcifications in urinary system, commonly called stones; formed in any part of the urinary tract, usually kidney (nephrolithiasis), and can migrate within tract; may be composed of one type of crystal or a combination, calcium being most common; others oxalate, struvite, uric acid, cystine, xanthine. Important to collect stones to determine composition and appropriate treatment. ○ Indications S/S : sharp, severe, sudden pain depending on Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ iii. Treatment: Antibiotic therapy, Pyridium, Vaginal estrogen therapy, increased fluids, and increased vitamin C and cranberry juice intake. iv. Pt. teaching: females void following intercourse, avoidance of douche or powders, bladder cath care, clean properly after defecation (wipe front to back). ○ Children: i. Indications S/S: Hematuria, enuresis, fever, foul- smelling urine, poor appetite, painful urination ii. Parent instructions: administration of prescribed antibiotics, encourage child to drink clear liquids, instruct parents of good perineal hygiene, avoid tight clothing or diapers, encourage child to void frequently. ○ Cystitis → Bladder inflammation i. S/S: burning or pain on urination, urinary frequency, urinary urgency, bladder spasms. ii. Treatment: Symptomatic, organism-specific antibiotic iii. Nursing considerations: Monitor urination for frequency and amount, assess urine for cloudiness Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ and hematuria, obtain specimen for analysis and culture and sensitivity, iv. Client Education: increase fluid intake to dilute urine, use heating pad on lower abdomen for bladder spasms, take meds as directed. ○ Pyelonephritis: Inflammation of the kidney caused by bacterial infection, UTI, pregnancy, tumors, or urinary obstruction. i. S/S: chills, fever, malaise, flank pain, costovertebral angle tenderness ii. Nursing care: bed rest during acute phase, administer and teach about antibiotics, encourage fluids. 41. HIV/AIDS (3 questions) ○ HIV (Human Immunodeficiency Virus) i. Virus that causes immunodeficiency that can lead to AIDS 1. Transmitted: via blood and body fluids 2. S/S: early stage: asymptomatic, later as immune system Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ deteriorates...opportunistic infections. 3. Medical Treatment: antiretroviral medications, organism-specific medications, chemotherapy, antidepressants, nutritional support, symptomatic. 4. Nursing Considerations: user personal protective equipment to prevent infection, supportive care depending on presence of opportunistic infections. 5. Client and Public Education: Practice safe sex. ○ AIDS: i. Syndrome distinguished by serious deficits in cellular immune function; causes opportunistic such as Pneumocystis jiroveci pneumonia, Candida albicans stomatitis and esophagitis, cytomegalovirus, Kaposi sarcoma. 1. Pneumocystis jiroveci Pneumonia is the most common opportunistic infection of AIDS a. Indications: Gradually worsening chest tightness, SOB, persistent, dry, Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ snacks, monitoring child’s weight and height, encouraging child to participate in activities with other children, providing anticipatory guidance to the family because child has potentially fatal disease. 42. Chronic Kidney Disease (2 questions) → know a lot of nursing judgment and concepts ○ Irreversible, progressive reduction of functional kidney tissue resulting in inability of kidneys to excrete wastes, concentrate urine, and conserve electrolytes. i. Indications S/S: anemia, acidosis, azotemia, fluid retention, hypertension, hypocalcemia, anorexia, N/V, constipation, impaired insulin action. ii. Interventions: to slow progression, control blood pressure and make fluid and dietary adjustments. Dialysis or transplantation may be done when these measures are no longer effective. iii. Nursing interventions: Monitor fluid status, encourage nutrition by decreasing nausea, vomiting and Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ stomatitis, and other GI symptoms, teach appropriate diet (low protein, low potassium, low sodium), manage constipation, teach to balance rest and activity, encourage good skin care with emphasis on moisturizing, teach coping skills to client and fam, teach dialysis-related procedures, explain transplantation process and subsequent potential issues and care. Important to increase non- protein calories, such as fruit ice. iv. Diagnostic tests: 1. Urine specimen (reveals low specific gravity, hematuria, proteinuria) 2. Blood studies (reveal elevated BUN, creatinine, potassium) 3. Creatinine clearance test (measures glomerular filtration rate) 4. Ultrasonography of kidneys, renal scan, CT scan 43. Peptic Ulcer Disease (3 questions) ○ Excavation formed in mucosal wall of stomach, pylorus, duodenum. Caused by infections with Helicobacter Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ pylori (H. Pylori), a gram-negative bacterium. i. Indication: normal-hypersecretion of HCl, weight loss may occur, pain occurs 0.5-1 hour after a meal, vomiting, hemorrhage more likely occurs with duodenal ulcer. ii. Predisposing factors: ages 40-60, familial tendencies, chronic use of NSAIDs, alcohol ingestion, excessive smoking. iii. Diagnostic tests: noninvasive; include immunological tests of antibodies to H. pylori and urea breath tests. Invasive; endoscopy, gastric biopsy, and biopsy with bacterial culture for H. pylori. Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ presence of Helicobacter pylori or to rule out gastric carcinoma) or fluid samples. i. Preparation: verify informed consent has been obtained, maintain NPO at least 8 hours before procedure, teach client about numbness of throat due to local anesthetic applied to posterior pharynx. ii. Post Procedure: maintain NPO until gag reflex returns, observe for vomiting of blood, respiratory distress, inform client to expect sore throat for 3-4 days after procedure. ○ Description of Procedure: i. Patient is sedated ii. Lubricated endoscope is passed through the mouth and into the esophagus for visualization of the gastric wall and sphincters. iii. Endoscope is advanced to duodenum iv. Still and video images are taken, or images are shown on a monitor for continuous viewing during the procedure. v. Biopsy forceps are passed through the scope to Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ obtain any necessary tissue samples 46. Inflammatory Bowel Disease: Includes Crohn’s disease and ulcerative colitis ○ Indications: abdominal pain, diarrhea, fluid imbalance, weight loss. Diarrhea in Crohn’s disease is less severe than in ulcerative colitis. ○ Nursing Considerations: include high-protein, high- calorie, low-fat, low-fiber diet, may require TPN to rest the bowel, administer analgesics, anticholinergics, sulfonamides (gentamicin), Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ corticosteroids, antidiarrheals, and anti peristaltics, maintain fluid/electrolyte balance, monitor electrolytes, promote rest, relieve anxiety. i. Crohn’s Disease : Subacute and chronic inflammatory bowel disease involving segments of the terminal ileum and proximal colon; extends through all layers of the bowel wall; restricts absorption of nutrients. 1. Symptoms: colicky lower right quadrant pain not relieved by defecation, diarrhea, weight loss, low-grade fever, nutritional deficit, anemia, dehydrations; fistulas, anorectal fissure or fistula. 2. Treatment: medications→antidiarrheals, antispasmodics, anticholinergics, sulfonamides, steroids. 3. Diet: High calorie, high protein, parenteral nutrition used for bowel rest. NO cocoa, chocolate, citrus juices, cold or carbonated drinks, nuts seeds, popcorn or alcohol. 4. Nursing considerations: High-Protein, high- Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ arthroplasty, increases circulation to the area, prevents joint contracture, encourages early motion of joint; degrees of flexion and extension and amount to be increased over specified time frame determined by healthcare provider and physical therapist. ii. Nursing Considerations : Neurovascular assessment of affected extremity, administer pain meds as ordered, ensure proper alignment of extremity in devise, document degrees of flexion and contraction and time in device, allow client control over time in and out of device as possible. Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ iii. Client Education: rationale for use of machine, expected time in device, degrees of flexion and extension. 50. Pancreatitis →Inflammation of pancreas that can be acute or chronic. ○ Acute: mild inflammation with minimal discomfort to severe disease that is unresponsive to any medication, ending in death. This is caused by the premature activation of enzymes, particularly trypsin, which then self-digest the pancreas. The process of self-digestion is often triggered by the obstruction of the common bile duct by gallstones, causing bile to reflux back into the pancreatic duct, which stimulates the premature activation of the pancreatic enzyme (normally, activation begins later in the duodenum.) i. S/S: Severe, acute abdominal pain, back pain, abd distension, N/V, decreased intestinal motility, fever, jaundice, ALOC, Hypotension, ARF, Tachycardia, Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Respiratory distress, Hyperglycemia, Hypocalcemia. ii. Treatment: Parenteral nutrition, withhold oral intake so pancreatic enzymes are not stimulated. Nasogastric suction, Biliary drains and stents, surgery, and intravenous fluids after the initial crisis is over to restore electrolytes. 1. Meds: a. Histamine-2 (H2) antagonists. (cimetidine {Tagamet}, ranitidine {Zantac}), to decrease gastric acid production b. Analgesics for pain c. Antiemetics to prevent vomiting. iii. Nursing Care: 1. Record I & O hourly, and monitor electrolyte levels. 2. Patients with NG, good mouth and nose care and assess respiratory patterns regularly. 3. Administer pain meds 4. Watch for complications from parenteral nutrition (hypokalemia, overhydration, metabolic acidosis) and watch for signs of a Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ 5. Surgery (pancreaticojejunostomy, pancreaticoduodenectomy or the Whipple procedure, to relieve pain, restore proper drainage of pancreas and to reduce the frequency of attacks. 51. Intestinal Obstruction: Partial or complete blockage of lumen of large or small intestines; compression of the bowel lumen leading to blockage of passage through intestines. ○ Causes: May be mechanical (tumor, hernia, adhesions, intussusception, volvulus) or nonmechanical (paralytic ileus, abdominal infections, intestinal ischemia.) Manifestations depend on location of obstruction. ○ S/S: absence of bowel sounds, intermittent and severe abdominal pain and distension, vomiting, tympanitic and tender abdomen, obstipation (absence of stool or gas), obstruction of ileum causes fecal vomiting, nausea, abdominal tenderness, decreased bowel movements. ○ Treatment: NPO, insertion of NG or Intestinal tube for decompression, IV fluid and electrolyte replacement, Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ laxatives or enemas for fecal impaction, disimpaction, pain management, possible surgical intervention of colectomy possibly including temporary or permanent colostomy or ileostomy. ○ Complications: fluid volume deficit, bowel strangulation, necrosis, perforation, infection, nutritional deficiencies. ○ Nursing Considerations: maintenance of nasogastric tube (record amount and color of drainage) , monitoring for complications (metabolic acidosis/alkalosis), IV fluid replacement, postoperative care, monitor fluid and electrolyte levels, assist with ADLs, good oral and skin car, monitor vital signs (observe closely for signs of shock), Fowler's position to facilitate breathing, measure abdominal girth, administer antibiotics, pain and N/V management, auscultate for bowel sounds and watch for signs of returning peristalsis, ○ Client Education: Encourage high Fiber diet and plenty of fluids. ○ Diagnostic tests: i. Laboratory studies (electrolyte studies, complete Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ blood count), which reveal dehydration, loss of plasma volume, and sometimes infection ii. Abdominal x-ray, which show abnormal amounts of gas and/or fluid in the bowel. In large bowel obstruction, they show a distended colon. iii. Barium studies are contraindicated. 52. Hyperglycemic, Hyperosmolar, Nonketotic syndrome → know Hyperosmolar Nephrotic Syndrome is a complication of hyperglycemia, which also involves hyperosmolarity, minimal to absent ketosis, and altered sense of awareness. Occurs in type 2 diabetics over 50 years of age ○ Pathophysiology: i. Uncontrolled hyperglycemia causes the kidneys to excrete the excess glucose with water and electrolytes (osmotic diuresis). ii. Water then shifts from intracellular fluid space to extracellular fluid space, causing hypernatremia and increased osmolarity. 1. Indications: glucose levels greater than 800 Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ 1. Indications: returned to normal functioning while healing takes place. ○ Interventions: treat underlying cause, treat fluid and electrolyte imbalance, prevent infection, administer high caloric and low protein diet, possible dialysis ○ Nursing Interventions: maintain strict intake and output and compliance with fluid restriction/intake as ordered, daily weights, monitor vital signs closely, assist client with managing anorexia and eating appropriate foods, provide good skin care, monitor for infection, encourage rest, support dialysis if indicated. ○ Nephrotic syndrome: Minimal-change nephrotic syndrome (MCNS) most common in type of nephrotic syndrome in children; i. Indications: periorbital or ankle edema, larger than expected weight gain, decreased urinary output, pallor, fatigue, hyperalbuminuria, hypoalbuminemia, ascites, hypovolemia. ii. Treatment: restrict salt, corticosteroid therapy, immunosuppressive therapy iii. Nursing considerations: monitor I/O, daily weights, Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ test urine for albumin, measure abdominal girth, protect from upper respiratory infection, instruct parents about S/S to observe for at home, how to administer steroid therapy, and adverse effects. ○ Diagnostic tests: Urine specimen (reveals low specific gravity, hematuria, proteinuria), Blood studies (reveals elevated BUN, creatinine, potassium), Creatinine Clearance test (measures glomerular filtration rate), and Ultrasonography of kidneys, renal scan and CT scan. 54. Thyroidectomy → complete or partial excision of the thyroid gland ○ Purpose → corrects hyperthyroidism, removes breathing obstruction caused by goiter, treats thyroid cancer, treats hyperparathyroidism ○ After surgery → monitor respiratory status, ensure that incision drains properly, monitor pulse & temperature for indications of thyrotoxicosis or thyroid storm ( fever, tachycardia > 130, delirium, coma) i. Monitor for tetany → could indicate that Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ parathyroid glands were damaged during surgery which would cause hypocalcemia (Chovsteks & Trousseau’s sign) ii. Keep patient in Semi-Fowlers position, apply ice to reduce the swelling iii. Make sure to have suction, O2, trach set, IV calcium & suture removal kit at bedside iv. Ask patient to speak every 2 hours to check tone & hoarseness v. Emphasize importance of adhering to thyroid replacement therapy after discharge vi. Keep incisions clean & dry Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ ○ Preparation → Informed consent, encourage voiding, take vitals, measure abdominal girth & weigh client ○ During → take vitals Q15min ○ After → document amount, color & characteristics of drainage obtained, assess pressure dressing for drainage, keep patient in bed until vitals are stable Other topics from Vangie... 1. Lumbar puncture → tests CSF, normal should be clear, cloudy = infection, 2. Hypertensive crisis can’t find Kaplan rationale- Med Surg book pg.873 ❖ Emergency- BP are > 180/120 and BP must be lowered immediately to halt or prevent damage to target organs. Conditions that could cause hypertensive crisis are: pregnancy, acute MI, intracranial hemorrhage, and dissecting aortic aneurysm. ➢ TX: ICU- reduce mean blood pressure 20-25% 1st hour, a further reduction to a goal pressure of 160-100 over a period of 6 hours and a more gradual reduction over the next few days. Titrate hydrochloride (Cardene), Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ nitroprusside, (Nitropress) and fluids ➢ *Exceptions to this TX are: ischemic stroke, aortic dissection (lower BP sys 100, if pt. can tolerate) Urgency- no evidence of organ damage TX: anti- htn meds Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ 3. Pneumonia ❖ Inflammatory process that results into edema of the lung tissues and extravasation of fluid into alveoli causing hypoxia. ➢ S/SX: fever, leukocytosis, cough productive of rusted color, green, or whitish yellow sputum, dyspnea, pleuritic pain, tachycardia ➢ Nursing Intv: administer antibiotics, Q4H vitals, cough/deep breath Q2H, assess breath sounds, use incentive spirometer, encourage fluids 3,000ml/24 hours, semi fowler's position, O2 therapy Med Surg 2B Topics → 90 Test Questions 1. Pancreatic Cancer → Cancer of the pancreas can affect the head (75-80 %), body, or tail of the pancreas. The location of the cancer and whether pancreatic islet cells are functional influence the clinical picture. ○ S/SX → weight loss, Vague upper or mid-abdominal discomfort, abnormal glucose tolerance test Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ protecting them → Used for clients at increased risk for infection, such as immunosuppressed with neutrophil count under 500 Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ ➢ Nursing Intv: private rooms scrupulously cleaned; meticulous hand washing and use of personal protective equipment by all; restriction of visitors; no fresh fruit or vegetables; avoid invasive procedures, such as catheterization-unless essential, Air in rooms should be under positive pressure, All rooms should have own wash basin and toilet, which should be sanitized after each use, Supply of single use gloves, gowns, aprons, and masks must be kept in the room, keep door closed, Wear HEPA filter mask if neutropenia is severe.Provide low microbial diet; eliminate fresh salads and unpeeled fresh fruits or veggies and any uncooked foods, avoid any invasive procedure. Good Assessment: Monitor for any signs of infection, skin, no IM injections, breath sounds, temp, no rectal temps, change IV site frequently, shower daily with Dial soap preferably (antimicrobial soap) and CBC 4. Bell’s Palsy a. https://www.youtube.com/watch?v=aDkofQthvt0 ❖ Unilateral facial paralysis involving seventh cranial nerve; Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ usually temporary; indications include inability to close eye, decreased corneal reflex, increased lacrimation, drooping mouth, speech difficulty; eating difficulty; nursing interventions include protect head from cold and drafts, administer analgesics, assist with electrical stimulation, teach isometric exercises for facial muscles and also gentle massage and warm packs, prevent corneal abrasions ( artificial tears), sunglasses during the day, eye patch at night, reassure client that client has not had a stroke, provide emotional support for altered body image. ➢ TX: ■ Prednisone (to reduce edema), specific antiviral agents, electrotherapy may help prevent atrophy of facial muscles. ➢ Nursing Intv: ■ Apply moist heat to affected area (for pain), massage pt’s face with a gentle upward motion 2-3 times a day for 5-10min, apply fascial sling to improve lip alignment, provide frequent oral care, provide support. Provide thickened liquids due to difficulty swallowing Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ ■ S/SX: apprehension, restlessness,dizziness, confusion, fatigue, tachycardia, hyperpnea, dyspnea. Interventions: multiple pillows when lying down, medications, oxygen, relaxation, physical reconditioning. Orthopnea: breathing made difficult when in supine or prone position, and made easier when in a sitting or standing position. Can be caused by left ventricular failure or other cardiac or resp disorders. Pt sleeps w/ 3-5 pillows for comfort. 7. Bladder: Neurogenic 8.Bladder dysfunction related to a lower motor lesion of the spinal cord. AKA : flaccid (inability to get rid of urine) or spastic/reflexive (continually contracted/spasms) neurogenic bladder. Manifested by incontinence; frequency; urgency; a reflexive neurogenic bladder manifested by no control of micturition causing an over distention of bladder and incontinence; sensory neurogenic bladder manifests with poor bladder sensation, infrequent voiding and large residual Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ voiding; intermittent catheterization most common method of bladder management; important to determine bladder volume and amount of residual urine when deciding how often to catheterize client. a. TX: i. Focused on preventing complications such as infections, overdistention, kidney damage, & minimizing social and psychological effects of the disorder. ii. Medical management: anticholinergic drugs to decrease hyperactivity, Cholinergic to increase muscle tone. Muscle relaxants to decrease external sphincter tone, Desmopressin to treat nocturia, Botulinum to paralyze muscles of the external sphincter, Bladder retraining including voiding at certain times assuming body postures that make voiding possible, diet low in calcium, to avoid stone formation. iii. Surgical Management: TURP, Urinary catheterization, urethral dilation, external sphincterotomy, implant of artificial sphincter. Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+ b. Nursing Intv: Monitor for s&s of infection, encourage plenty of fluids, measure I&O, encourage mobility, refer to enterostomal for urinary diversion if needed, educate pt about condition c. S & S: Incontinence, frequency, urgency 9. Stroke (Cerebrovascular Accident) (6 questions) → know setting priorities, understanding concept, making nursing judgments, recognizing and recalling information ❖ Sudden disruption in blood supply to brain resulting in sudden loss of brain function that may be temporary or permanent; caused by thrombotic embolism, ischemia, or hemorrhage; indications include loss of movement, thought, memory, speech, or sensation; nursing responsibilities include encouraging the client to attain maximum independence, stimulating multiple senses, repeating directions and breaking down tasks into components, facing the client and speaking clearly slowly, giving the client time to respond, maintaining skin integrity and providing exercises (ROM and facial), self-care activities, and teaching Stating, antihypertensives, and platelet- Med Surg 1, 2 & Comprehensive Rationales LATEEST UPDATE ,100% CORRECT RATED/UPGRADED A+