Med Surg Exam 2-2024, Exams of Nursing

Download Med Surg Exam 2-2024 and more Exams Nursing in PDF only on Docsity! 1 Med Surg Exam 2-2024 Small Intestine ➢ Absorption of nutrients ➢ Folic acid ➢ Cobalamin ➢ Iron ➢ Fat-soluble vitamins ➢ Hormones and neurotransmitters ➢ Absorption of fat, carbohydrates, and proteins Abdominal Quadrants ➢ Right upper o Pylorous o Duodenum o Gallbladder o Liver ➢ Left upper o Stomach o Spleen ➢ Right lower o Cecum o Appendix ➢ Left lower o Sigmoid colon ➢ Midline o Urinary bladder o Uterus GI Focused Assessment Health History ➢ Current GI Symptoms ➢ Previous GI Problems ➢ Family History of GI Problems ➢ Medication Use: prescription and OTC ➢ Diet and Nutrition (Food Allergies) ➢ Use of Alcohol, street drugs, Caffeine ➢ Bowel Elimination Pattern ➢ Social/Cultural Factors GI Focused Assessment Physical ➢ Vital Signs ➢ Height and Weight ➢ Lab and diagnostic test results 2 ➢ Emesis, amount, color, consistency ➢ Stool, amount, color, consistency, odor. ➢ Oral Assessment ➢ Abdominal Assessment ➢ Rectal Assessment Factors affecting bowel elimination ➢ Age ➢ Diet ➢ Fluids ➢ Physical activity ➢ Personal habits ➢ Pain ➢ Pregnancy ➢ Surgery & anesthesia ➢ Medications Effects of Aging ➢ Mouth o Teeth loosen, reduced circulation to gums, teeth darken and fracture o Decreased output of salivary glands o Decreased stimulation of taste buds ➢ Stomach o Atrophy of gastric mucosa o Decreased secretion of hydrochloric acid o Decreased bile secretion ➢ Decreased muscle tone and strength Diagnostic Tests ➢ Lab tests o ➢ Bowel preparations o ➢ Colonoscopy o Provides direct visualization of the rectum, colon, entire large intestine, and distal small bowel. A flexible scope is inserted through the rectum and advanced to the cecum. o Useful in detecting lower GI disease. o Positioning: LT side with knees to chest o Anesthesia: Moderate sedation (Midazolam, fentanyl, and/or propofol) o Prep 5 ➢ Chronic inflammatory bowel disorder with a relapsing and remitting course. Once remission is achieved, the main aim of the management of Crohn's disease is maintenance of that remission. ➢ Assessment with clinical manifestations o Abdominal pain (RLQ) o Abdominal tenderness o Pain is relieved temporarily with defecation o Diarrhea ➢ Nursing Interventions o Diet: high- calorie, high protein o Weigh daily o Maintain calorie count o Monitor I&O Acute Inflammatory Disorders: Appendicitis ➢ Pathophysiology o The function of the appendix is not completely known, but it does regularly fill with and empty digested food. If untreated, necrosis, gangrene, and perforation follow. If the perforation is contained by the omentum, an appendiceal abscess results; if containment does not occur, generalized peritonitis results. ➢ Assessment with clinical manifestations o Periumbilical pain o Nauseous o Low- grade fever o Rovsing’s sign (Rebound tenderness) o Pain in the LLQ o McBurney’s point (pain elicited in the RLQ when firm pressure is applied) ➢ Diagnostic tests o CBC (elevated WBC) o CT o Urinalysis o Ultrasound ➢ Planning and implementation o Treatment: Appendectomy is the most common emergency abdominal surgery in the United States. ➢ Evaluation of outcomes o Acute pain related to the appendicitis. The patient should verbalize an adequate relief of pain along with the ability to realistically cope with the pain if it is not completely relieved. Diverticulitis ➢ Diverticula disorders increase with age. 6 ➢ Low fiber diets and those high in processed foods are associated with diverticular disease. Other correlates with the disorder are decreased activity levels and constipation. ➢ Pathophysiology o The muscles where there are diverticular areas thicken, and the lumen is narrowed, which increases intraluminal pressure. With the deficient fiber intake seen in diverticular disease, the bowel develops a higher pressure, and the mucosa herniates through the muscle wall, which forms the diverticulum. As the diverticulum increases in size, it obstructs the bowel area and causes irritability of the colon. ➢ Assessment with clinical manifestations o Constipation or diarrhea o Abdominal pain in the LLQ o IBS development o Abdominal cramping o Generalized fatigue o Low-grade fever ➢ Diagnostic tests o CT scan of the abdomen and pelvis o CBC (leukocytosis, elevated sedimentation rate) o X-ray ➢ Planning and implementation o Nurses can perform patient education in the community related to the necessary dietary changes, including an increased fiber intake and teaching the early symptoms of diverticular disease. Obstruction ➢ Etiology o Paralytic ileus reflects altered neuromuscular function that impairs gut motility and has multiple potential causes. o Medication use (some anesthetic agents, opiates) may contribute to this state of localized paralysis. Intraperitoneal and retroperitoneal infection, arterial or venous injury, and metabolic derangements (hypokalemia) may also be associated with ileus. ➢ Pathophysiology o Ingested fluids, food, swallowed air, digestive juices or secretions, and gas accumulate proximal to the blockage. The distal bowel collapses and the proximal loops dilate. Distension stimulates secretory activity, and the absorptive functions of mucous membranes fail. o Can be either mechanical (physical or structural) or functional. Most obstructions occur in the small intestine. ➢ Assessment with clinical manifestations 7 o Colicky, mid-abdominal pain often over a period of days. Vomiting occurs early in the course, especially with proximal simple obstruction. o A change in the character of the pain (continuous, increasing severity) suggests the development of more ominous ischemic complications. Pain lasting several days, with progressive distension, suggests a more distal obstruction. o Patients may report reduced to absent flatus for days preceding presentation and distension. o Auscultation typically reveals increased bowel sounds and high- pitched tinkling in early obstruction. ➢ Diagnostic tests o CBC o CT o Ultrasonography o MRI ➢ Nursing Interventions o Careful abdominal examination is necessary in suspected obstruction. Palpation should follow percussion, and severe pain is unusual, unless strangulation, ischemia or infarction, or perforation have occurred. o In that case, there may be signs suggestive of peritonitis and acute abdomen, including guarding and rebound tenderness. A careful search for inguinal hernias, a rectal exam for masses, and analysis of stool for occult blood conclude the abdominal assessment. o Strict bowel rest and careful attention to fluid replacement for loss as well as maintenance, with appropriate laboratory guided electrolyte supplementation (especially potassium), are indicated. Colorectal Cancer ➢ Cancer of the rectum or colon. ➢ Risk factors o Nonmodifiable risk factors for CRC include age greater than 50 years, male, gender African American, history of adenomatous polyps, ulcerative colitis, or Crohn’s disease, and first degree relative with FAP, HNPCC, or other inheritable syndrome, and ethnic background o Modifiable risk factors associated with CRC mortality include dietary intake, inactivity, excess weight, and smoking. ➢ Assessment with clinical manifestations o Left-sided tumors produce frank bleeding and change in bowel pattern, consistency. 10 o Female gender ▪ Short urethra ▪ Sexual intercourse ▪ Wet bathing suits ▪ Frequent submersion into baths or hot tubs o Alkaline urine promotes bacterial growth o Indwelling urinary catheters o Stool incontinence o Older adult clients ▪ Increased risk of bacteremia, sepsis and shock ▪ Fecal incontinence with poor perineal hygiene ➢ Assessment with clinical manifestations o Lower back or lower abdominal discomfort o N/V o Urinary frequency and urgency o Fever o Cloudy or foul-smelling urine o Older adults ▪ Confusion ▪ Loss of appetite ▪ Hypotension ➢ Diagnostic tests o Urinalysis and urine culture and sensitivity ➢ Client education o Drink at least 3L of fluid/d o Advise the client to urinate before and after intercourse o Drink cranberry juice to decrease the risk of infection o Female ▪ Wipe perineal area from front to back ▪ Avoid using bubble baths and feminine products and toilet paper containing perfumes. ▪ Avoid wearing pantyhose with slacks or tight clothing. Interstitial Cystitis ➢ Bladder mucosa becomes thinned or denuded. The exposed detrusor muscle is damaged and develops fibrosis. ➢ Chronic ➢ Genetics o Has not been considered a hereditable condition ➢ Assessment with clinical manifestations o Urgency, frequency, nocturia and dysuria o Pain associated with the bladder (Pain while bladder is full) ➢ Diagnostic tests 11 o Difficult to diagnose ➢ Client Education o Avoid alcohol, tomatoes, spices, chocolate, caffeinated drinks, acidic foods and artificial sweeteners. Pyelonephritis ➢ An infection and inflammation of the kidney pelvis, calyces and medulla. ➢ The infection usually begins in the lower urinary tract with organisms ascending into the kidney pelvis. ➢ Filtration, reabsorption and secretion are impaired which results in a decrease in kidney function. ➢ Risk Factors o Men over age of 65 who have prostatitis and hypertrophy of the prostate o Chronic urinary stone disorder o Pregnancy o Bladder tumors o Alkaline urine promotes bacterial growth ➢ Assessment with clinical manifestations o Chills o Colicky- type abdominal pain o N/V o Malaise, fatigue o Burning, urgency and frequency with urination o Hypertension o Flank and back pain ➢ Diagnostic tests o Urinalysis o X-ray of the kidneys, ureters and bladder (KUB) can demonstrate calculi or structural abnormalities. ➢ Medications o Antibiotics (14 days) or IV for 24-48hrs o Opioid analgesics ➢ Therapeutic procedures o Pyelolithotomy Removal of a large stone from the kidney that causes infections and blacks the flow of urine from the kidney. o Nephrectomy removal of the kidney when all procedures to clear the client of infection were unsuccessful o Ureteroplasty done to repair or revise the ureter and can involve reimplantation of the ureter in the bladder wall to preserve the function of the kidney and eliminate infection. ➢ Client Education o Drink at least 2 L 12 o Take rest periods from activity as needed Glomerulonephritis ➢ Immunologic kidney disorder that can start in the kidneys (not an infection). ➢ Can lead to end-stage kidney disease (ESKD) ➢ Chronic glomerulonephritis develops over a period of 20-30 years. ➢ Risk Factors o Recent infection particularly of the skin or upper respiratory tract o Recent travel or other possible exposure to bacteria viruses, fungi or parasites o Recent surgery or illness ➢ Assessment with clinical manifestations o Anorexia o Nausea o Dysuria, oliguria o Fatigue o Hypertension o Difficulty breathing o Crackles o Weight gain o Reddish-brown urine ➢ Diagnostic tests o Urinalysis shows RBCs and protein o 24 hr urine collection for protein assay ➢ Medications o Antibiotics o Antihypertensive ➢ Client Education o Monitor weight daily o Stress basic infection control practices, such as hand hygiene o Provide instruction on dietary and fluid restrictions. Nephrotic Syndrome ➢ Not a single disease but a group of symptoms. Symptoms include heavy proteinuria, hypoalbuminemia, edema, hypercholesterolemia, and normal renal function. ➢ Assessment with clinical manifestations o Periorbital edema o Foamy urine o Pitting edema (ankles & legs) o Anorexia o Irritability o Fatigue 15 ➢ Assessment with clinical manifestations o Appearance of the wound o Hematuria o Back Pain o Abdominal Pain/Tenderness o Nausea and Vomiting ➢ Renal injuries grades o Grade 1: Renal contusion and/or nonexpanding subcapsular hematoma o Grade 2: Superficial laceration <1 cm depth and does not involve the collecting system o Grade 3: Laceration >1 cm without extension into the renal pelvis or collecting system o Grade 4: Laceration > 1 cm involving the collecting system or renal vessel injury with hemorrhage. o Grade 5: Shattered kidney or complete laceration or thrombus of the main renal artery or vein ➢ Diagnostic tests o Urinalysis and Hct o Clinical evaluation, including repeated vital signs o If moderate or severe injury is suspected, contrast-enhanced CT ➢ Treatment o Strict bed rest with close monitoring of vital signs o Surgical repair or angiographic intervention for blunt and penetrating injuries Renal Vascular Disorders ➢ Renal artery stenosis ➢ Renal vein thrombosis ➢ Nephrosclerosis Renal Cancer ➢ Risk Factors o Exposure to lead o Age (55-60 years) o Family history of kidney, bladder, ureter, prostate gland, uterus, ovary or appendix cancer. o Genetic and hereditary risk factors o African American and American Indian clients ➢ Assessment with clinical manifestations o Hematuria (late finding) o Weight loss o Fever o Palpable mass 16 o Abdominal or flank pain o Inability to urinate or weak urine stream ➢ Diagnostic tests o Biopsy o Urinalysis o Nuclear imaging: IV urogram with nephrograms o CT, MRI, PET scans o Hematologic ➢ Nursing care o Monitor urine output and lab findings (BUN, creatinine, urinalysis) to assess renal function of the unaffected kidney. Bladder Cancer ➢ Risk Factors o Frequent contact with rubber, paint or eclectic cable o Inhalation of gas, fumes or chemical compounds o Tobacco use o Caucasian clients, male clients and clients older than 55 ➢ Assessment with clinical manifestations o Hematuria o Dysuria, frequency, urgency (infection or obstruction present) o Weight loss o Anorexia ➢ Diagnostic Procedures o Biopsy o Bladder wash o CT, MRI scan o Nuclear imaging o Urinalysis Urinary Incontinence ➢ Types o Urge: cannot hold urine when stimulus to void occurs o Functional: cannot physically get to the bathroom or is no aware of the stimulus to void o Stress: pressure such as coughing, straining, lifting, bearing down, or laughing causes incontinence; very common in middle- age women. ➢ Assessment with clinical manifestations o Stress test can assess for stress-induced leakage when the bladder is full. ➢ Nursing interventions o Use adult incontinence devices o Decrease the client’s fluid intake after 6pm 17 o Maintain a regular toilet schedule o Teach the client Kegel exercises to strengthen the sphincter ➢ Medications o Urge incontinence ▪ anticholinergics: tolterodine and oxybutynin o Stress incontinence ▪ Tricyclic antidepressant: imipramine Urinary Retention ➢ Pathophysiology o Caused by a physical obstruction of the urethra from acute or chronic causes ➢ Assessment with clinical manifestations o Dull low abdominal discomfort o Urge to urinate o Firm, distended bladder o Enlarged or tender prostate or suspected tumor ➢ Diagnostic tests o Urinalysis (underlying UTI) o Renal ultrasound, IVP, urethrography ➢ Nursing interventions o Stimulate relaxation of the urethral sphincter by providing the client privacy, placing the client’s hands in warm water (or turning on the water) and encouraging guided imagery. o Administer bethanechol chloride o Position the client upright o Ensure adequate fluid intake Urinary Diversion ➢ Removal of the bladder and surrounding structures to reroute urinary flow through a pouch and abdominal stoma ➢ Assessment with clinical manifestations o Most often, patients who are candidates for urinary diversions present with an appearance indicating obvious illness. o Easy fatigability o Weakness o Anorexia o Weight loss o Polydipsia o Nausea o Vomiting o Diarrhea ➢ Diagnostic tests o Ultrasound 20 o Reversible loss of consciousness induced by inhibiting neuronal impulses in several areas of CNS o Involves single or combination of agents o Depresses CNS, resulting in analgesia, amnesia, and unconsciousness with loss of muscle tone and reflexes ➢ Regional anesthesia o Blocks multiple peripheral nerves in specific body region: o Field o Nerve o Spinal o Epidural Prevent Complications in the OR ➢ Hypoventilation ➢ Hypothermia ➢ Hemodynamic Instability ➢ Risk for Infection ➢ Malignant Hyperthermia Nursing assessment in the PACU ➢ Vital signs- Presence of artificial airway, 02 sat, vitals, cardiac monitoring ➢ LOC- ability to follow command, pupillary response ➢ Urinary output ➢ Skin integrity ➢ Pain ➢ Condition of surgical wound (Mark drainage) ➢ Presence of IV lines ➢ Position of patient ➢ Transfer to floor when patient has met criteria Postoperative Management ➢ Maintain a patent airway ➢ Stabilize vital signs, monitor temperature (hypo/hyperthermia) ➢ Ensure patient safety ➢ Provide pain medication ➢ Recognize & manage complications ➢ Progression of diet (clear liquid to full liquid to soft/blend) Postoperative Nursing Care ➢ Wind: prevent respiratory complications (Incentive spirometry) ➢ Wound: prevent infection ➢ Water: monitor I & O ➢ Walk: prevent thrombophlebitis 21 Postoperative Phase Complications ➢ Respiratory ➢ Cardiovascular ➢ Gastrointestinal ➢ GU ➢ Hemorrhage ➢ Wound infection ➢ Wound dehiscence and evisceration Nasogastric Tube Drainage ➢ Nasogastric Tube inserted during surgery for the following reasons: o Decompress and drain the stomach o Promote GI rest o Allow the lower GI tract to heal o Provide an enteral feeding route o Assess drained material every 8 hr. o Do not move/manipulate or irrigate the tube after gastric surgery without an order from the physician/surgeon. Renal/Urinary System: Foley catheter ➢ Assess urine for color, clarity and amount ➢ Strict intake and output ➢ May need for urine retention. ➢ Report a urine output of < 30 ml/hr or less than 0.5mL/kg/hr for 2 hours Incisional Care Management ➢ Assess incision site ➢ Incisional care ➢ Dehiscence ➢ Evisceration-SURGICAL EMERGENCY Med Surg Exam 2 Hypertension, CAD/Atherosclerosis, Angina, Myocardial Infarction, & Reperfusion Blood Pressure “force exerted by the blood against the walls of the blood vessel” 22 Blood Pressure Regulation Sympathetic Nervous System  Activation of SNS for low bp = increased HR, cardiac contractility, vasoconstriction, release of renin  Receptors = alpha 1 & 2, Beta 1 & 2, dopamine  Baroreceptors – located in carotids and aortic arch, sense changes in BP and send info to the brainstem- related to activities  High BP= inhibition of SNS  Low BP= Stimulation of SNS Vascular endothelium  produces vasoactive substances to maintain arterial tone (vasoconstriction/vasodilation) Renal system  control sodium excretion and ECF volume  RAAS system (Renin Angiotensin Aldosterone System)  Increase BP by vasoconstricting and releasing aldosterone Endocrine  Adrenal medulla releases Epi and NE  Beta 2 stimulation and Alpha 1 stimulation