NURS 482 MIDTERM AND FINAL EXAM LATEST 2023-2024 FALL-SPRING SESSION TERM (GUARANTEED PAS, Exams of Nursing

Download NURS 482 MIDTERM AND FINAL EXAM LATEST 2023-2024 FALL-SPRING SESSION TERM (GUARANTEED PAS and more Exams Nursing in PDF only on Docsity! NURS 482 Advanced Medical Surgical Nursing Assess staf f members' hand hygiene practices answer- Power Point (PP) Slide 7 Igi-Pg 418. This is the best possible NURS 482 Advanced Medical Surgical Nursing NURS 482 MIDTERM AND FINAL EXAM LATEST 2023-2024 FALL-SPRING SESSION TERM (GUARANTEED PASS) A nursing manager is concerned about the number of infections on the hospital unit. What action by the manager would best help? The nursing instructor explaining infection tells students that which factor is the best and most important barrier to infection? Intact skin and mucous membrane Power Point Slide 5 Igi-p 415 Which type of transmission-based precautions must the nurse use to prevent the transmission of tuberculosis? Airborne Precautions pg 419 A nurse is assessing patients on a medical-surgical unit. Which adult patient does the nurse identify as being at greatest risk for insensible water loss? A patient who is febrile with diaphoresis A nurse is assessing a patient with hypokalemia and notes that the patient’s hand-grip strength has diminished since the previous assessment 1 hour ago. What action does the nurse take FIRST? Assess the patient's respiratory rate, rhythm, and depth Electrolyte table page 2 Which patient is at risk for hypokalemia? Fluid and Patient with pancreatitis who has continuous nasogastric suction Electrolyte Table pg 2 Fluid and 1. What is the minimum amount of urine per day needed to excrete toxic products? 400 to 600 mL Slide 6 pg 165 A patient with heart failure asks, ―Why do I need to weigh myself every day?‖ How would the nurse respond? ―Weight is the best indication that you are gaining or losing fluid." pg. 168 NURS 482 Advanced Medical Surgical Nursing The patient who has undergone which surgical procedure is most at risk for hypocalcemia? Parathyroidectomy A nurse is caring for a patient who is experiencing excessive diarrhea. The patient’s arterial blood gas values are pH 7.18, PaO2 98 mm Hg, PaCO2 45 mm Hg and HCO3 16 mEq/L. Which provider order does the nurse expect to receive? Sodium Bicarbonate 100 mEq diluted in 1 Liter of D5W Power Point Slide 11 in notes Igi page 195 The nurse is caring for a patient who is hyperventilating. The patient’s arterial blood gas values are pH 7.52, PaO2 94mmHg, PaCO2 31 mmHg and HCO3 26mEq. Which question would the nurse ask when developing this patient’s plan of care? You appear anxious. What is causing your distress? Open end question Asking for clarication A patient who has Clostridioides difficile with severe diarrhea will likely have related alteration in which acid base balance? Metabolic Acidosis Slide 11 p 192 Which nursing assessment nding indicates a worsening of respiratory acidosis? Respiratory Depression pg. 192 A patient has taken antacids for the past 3 weeks to relieve heart burn. What alteration in the acid base balance with the nurse likely nd? Metabolic Alkalosis pg. 196 The person is with respiratory acidosis is considered full compensated with which ABG? pH 7.35 PaCO2 is 75 and the HCO3 is 30 Slide 16 pg 190 NURS 482 Advanced Medical Surgical Nursing A student nurse asks what essential hypertension is. What response by the registered nurse is best? It is hypertension with no specific cause Slide 6 and Igi p. 721 Upon assessment the nurse identies the following: stasis dermatitis along ankles extending onto calves with +1 edema bilaterally. What condition is does the patient likely have? Venous Insufficiency Slide 34 pg 747 What statement by a middle age male patient shows an understanding of self-care with essential hypertension? ― I better limit my sweets and salts.‖ A patient with peripheral arterial disease comes into the oce for a follow up appointment. What tells you additional teaching is needed? Patient is seated with legs crossed and reading a book on healthy eating What is the normal measurement of the PR interval in an ECG? .12 to. 20 second Jones pg. 22 What is the fourth step in analyzing an ECG rhythm strip ? Measure the PR interval slide 23 Jones 26 What ECG rhythm is characterized by a saw-tooth waves instead of P-waves? Atrial Flutter Slide 43 Jones 42 When looking at ECG monitor paper. What does the horizontal axis represent? Time Slide 12 Jones pg 21 The nurse has just given a patient with a history of chronic angina his third dose of sublingual nitroglycerin. What statement warrants the nurse to notify the provider? My pain is a bit better, but it feels different than usual Chart 38-2 pg 773 NURS 482 Advanced Medical Surgical Nursing #1. The home health nurse has been caring for a patient with a chronic respiratory disorder. Today the patient seems confused when she is normally alert and oriented to time, place and person. What is the FIRST nursing action? . Check oxygen saturation with a pulse oximeter #2. The nurse has just taken report on a patient with COPD, who is experiencing severe dyspnea. The following have just resulted: ABG's =pH 7.32 PaCO2=62 PaO2=46 HCO3= 28. The patient has the following vital signs: T 99.8F, P 110, R 28 BP 150/80. What should the nurse do FIRST? Do a focused pulmonary assessment and titrate oxygen therapy #3. The nurse is instructing a patient regarding complications of COPD. Which statement by the patient indicates the need for additional teaching? "My COPD is a serious illness, but it will be cured if I quit smoking." #4. A patient has been diagnosed with tuberculosis. What action by the discharge nurse takes HIGHEST priority? . Educating the patient on the adherence to the treatment regimen. #5. A nurse is teaching a patient how to perform pursed lip breathing. Which instructions would the nurse include in this teaching? Close your mouth and breathe in through your nose #6. Which statement is true about the relationship between smoking cessation and the pathophysiology of COPD? . c. Smoking cessation slows the rate of disease progression of COPD #7. A patient with chronic asthma ask the nurse, "I am really enjoying going for walks, but I always have an asthma attack with exercise. Do you have any ideas?" Encourage the patient to use his short acting bronchodilator 30 minutes before he goes for walks #8 A family member of a patient with COPD asks the nurse, "What is the purpose of making him cough on a routine basis?" What' is the nurse's best response? "It improves air exchange by increasing airow in the large airways. NURS 482 Advanced Medical Surgical Nursing #9 . A patient is 12 hour post op from a left lower lobectomy. The patient asks; " Why do I have 2 chest tubes?" What is the BEST answer by the nurse? The upper chest tube is removing air from the pleural cavity and the lower chest tube is removing the bloody drainage." #10. The nurse is caring for a patient who is 12 hours post tracheostomy. While assessing the patient, which observation made by the nurse warrants immediate notication of the provider? Skin is puffy around the neck with a crackling sensation upon palpation #11. The nurse is caring for a patient with a chest tube. What is the correct nursing intervention for this patient? d. The patient is encouraged to cough and do deep-breathing exercises often and use incentive spirometry . #12. A patient has COPD with chronic diculty breathing. In planning this patient's care, what dietary requirements are needed for this patient? Patients with COPD have increased metabolic needs so encourage high calorie and high protein foods. #13. The nurse has just received an elderly patient from the recovery room who is drowsy but is capable of following instructions. Pulse oximetry has dropped from 95% to 90% on room air. What is the PRIORITY nursing intervention? . Have the patient use the incentive spirometer to help with pulmonary hygiene #14. The nurse is developing a teaching plan for a patient with COPD using the priority patient problem of insucient knowledge related to energy conservation. What does the nurse recommend the patient AVOID? . Eating three large meals per day #15. The nurse has completed a community presentation about Lung Cancer. Which statement from a participant demonstrates an understanding of the information presented? The primary prevention for reducing the risk of lung cancer is to stop smoking and avoid second- hand smoke #16. A patient with a tracheostomy is unable to speak. He is not in acute distress but is gesturing and trying to communicate with the nurse. Which nursing intervention is the best approach in this situation? Ask questions that can be answered with a "yes" or "no" response NURS 482 Advanced Medical Surgical Nursing A 22 year old patient with blunt force trauma to the chest was admitted from the emergency department with oxygen at 5 L/min per nasal cannula. The patient is resting comfortably in bed. Vital Signs are stable. Oxygen Saturation is 94%. Lung sounds are clear. Based on the nurse's knowledge of oxygen therapy. What nursing action should be a priority? Humidify oxygen to prevent drying of mucous membranes A patient is receiving oxygen therapy through a nonrebreather mask. What is the correct nursing intervention? Ensure that valves and rubber flaps are patent, functional and not stuck. After walking back from the bathroom, a patient with COPD has a pulse oximetry reading of 89%. What is the nurse's FIRST priority actio Assess the patient for respiratory distress and recheck the pulse oximeter reading in 15 minutes A nurse is caring for a patient who is day 2 post-op from a left total knee replacement. The patient's admission history documents the patient is a 2 pack a day cigarette smoker x 20 years. Which statement by the patient requires further investigation? c. "I am coughing up some nasty rust colored, thick, milky stuff." A nurse is caring for a patient with pulmonary emphysema. The patient states, " I really don't go out with my friends and family anymore." How should the nurse respond? . "What is causing you to limit your social activities? The nurse is caring for a patient with chronic bronchitis and notes the following clinical ndings: Dependent Edema, Distended Neck Veins, Increasing Dyspnea and Increased Fatigue. What condition is the patient exhibiting? . Cor Pulmonale What principle guides the nurse when providing oxygen therapy for a patient with COPD? The patient with COPD should receive oxygen therapy at rates to reduce hypoxia and bring the SpO2 level to between 88% and 92%. The nurse is caring for an adult patient with a chronic respiratory disorder. What is BEST information about vaccine? . It is important to get a pneumonia vaccine; and get a yearly seasonal inuenza vaccine NURS 482 Advanced Medical Surgical Nursing A nurse is caring for a patient who has been using oxygen therapy for the past 5 days in the hospital. What assessment nding indicates that outcomes for patient safety with oxygen therapy are being met? Intact skin behind the ears The nurse is caring for an older adult who uses a wheelchair and spends over half of the day in bed. Which interventions is important in promoting pulmonary hygiene related to age and decreased mobility? Assist the patient with turning, coughing and deep breathing every 2 hours. A patient is being readmitted for worsening pulmonary emphysema. The patient is noncompliant with medication regimen and continues to smoke. What action does the nurse perform FIRST? . Assess the patient's respiratory status When caring for a patient with chronic bronchitis, which of these nursing interventions will NOT help the patient mobilize secretions? b. Limit fluid intake to less than 2 liters a day A home health nurse is visiting a new patient who uses oxygen in the home. For which factors does the nurse assess when determining if the patient if using oxygen safely? (SELECT ALL THAT APPLY) a. A "NO SMOKING" sign is posted on the door , c. Electrical appliances have a three-prong cord. Flammable liquids are stored outside in the garage. Which parameter does the nurse monitor to ensure that a patient's response to oxygen therapy gas exchange is adequate? SELECT ALL THAT APPLY Pulse oximetry level of consciousness respiratory rate arterial blood gases The nurse is taking a history on a patient who reports sleeping in a recliner chair at night because lying in the bed causes shortness of breath and air hunger. How is this documented? a. Orthopnea NURS 482 Advanced Medical Surgical Nursing A patient has been complaint with drug therapy for tuberculosis and has returned as instructed for follow up. Which indicates that the patient is no longer contagious? . Three negative sputum cultures Exam 3 The nurse is assessing a patient with Parkinson Disease. Which assessment ndings does the nurse expect to observe? (Select all that apply). The correct answers are: tremors upper extremities, rigidity, postural instability, slowness of movement. A nurse assesses a client who has a history of migraine. Which clinical manifestation would the nurse identify as an early sign of a migraine with aura? 875 The nurse is assessing a patient after thyroid surgery and discovers harsh, high pitched respiratory sounds. The patient is drooling and is a having diculty swallowing. What is the nurse's FIRST action? Call the rapid response team Laryngeal Stridor is an acute respiratory obstruction, respond by immediatedly call a rapid response team to aid in intubation. pg . 1269. The nurse is caring for an older alert and oriented adult patient who is at risk for falling related to altered balance and decreased coordination. Which initial intervention will the nurse employ for this patient? (Select all that apply) The correct answers are: Instruct the patient to move slowly when changing positions., Instruct the patient to call for assistance before getting out of bed., Place the call bell and personal items within the patient’s reach Visual disturbances throbbing, accompanied by a sensitive scalp and photophobia. pg The typical migraine is described as unilateral, NURS 482 Advanced Medical Surgical Nursing Antiepileptic such as carbamazepine. therapy is carbamazepine which is an antiepileptic. Pg. 924 The rst choice for drug Depression and withdrawal Depression is the most common reason for seeking medical attention in patients with hypothyroidism pg. 1272. The correct answers are: Present one step commands., Speak slowly., Allow extra time for response. Present one idea or thought, speak slowly not loudly. Do not rush patient when trying to speak. A nurse is caring for five patients on a neurological step-down unit. After receiving the hand off report, which patient should the nurse see rst? Patient with a Glasgow coma scale score that was 10 and is now 8. The Glasgow coma scale is used to establish a patient’s neurological assessment the lower the number shows a decrease in neurological function. After teaching a client newly diagnosed with epilepsy, the nurse assesses the client’s understanding. Which statement indicates a need for additional teaching? ―As long as I take my seizure medications, I will not have another seizure.‖ pg. 880 health teaching for patient with epilepsy. A patient is diagnosed with trigeminal neuralgia. Which therapy is the rst-line choice for this patient? Which priority problem should the nurse address with a patient with hypothyroidism? A patient with myasthenia gravis reports having difficulty climbing stairs, lifting heavy objects, and raising arms over the head. What is pathophysiology of this patient’s symptoms due to? Progressive muscle weakness. Chart 44-3 Key Features of myasthenia gravis Motor manifestations affecting mobility A nurse plans care for an 82-year-old patient who is experiencing age-related sensory perception changes. Which priority intervention would the nurse include in the patient’s plan of care? Ensure that the path to the bathroom is free from clutter. Touch sensation decreases and may not feel items underfoot. Pg. 845. Which statements about hypothyroidism are accurate? NURS 482 Advanced Medical Surgical Nursing The correct answers are: It occurs more often in women., It can be caused by a iodine deficiency., Myxedema coma is a rare but serious complication. Order: Levothyroxine 0.05 mg PO daily Available: Levothyroxine 50 mcg/tab How many tabs will you given? 1.0 tablets The nurse is caring for a patient with Parkinson's disease; writes a problem of "impaired nutrition." Which nursing intervention would be included in the plan of care? Provide 6 small meals per day with a soft consistency. Small frequent meals may aid a patient with difficulty swallowing. pg. 871. The nurse is preparing to discharge a patient with transient ischemic attack (TIA). What topics should the nurse include in discharge education? (Select all that apply) The correct answers are: reduction of high blood pressure, antiplatelet medication regimen, smoking cessation, Controlling diabetes Pg. 928 Preventing another TIA or possible stroke may include reduction of high blood pressure, use of antiplatelet medications and modifying rest factors. A patient has been diagnosed with Bell’s Palsy. What statement by the patient reinforces the need of additional discharge education? ―My face will look like this forever.‖ patients go into remission within 3 months. A nurse is teaching older adults at a senior center about changes to the ears that occur with aging. What instruction should the nurse include? (Select all that apply.) Hair in the ear canal may become coarser and longer causing more ear wax build up., Hearing function may be reduced because ear wax becomes drier and impacts more easily., The pinna becomes elongated because of loss of subcutaneous tissue. A nurse assesses a patient with type 2 diabetes and notes decreased tactile sensation in both feet. What action would the nurse take FIRST? Assess the patient's feet for sign s of injury. Assessment of the diabetic foot is important in care of the diabetic patient. Chart 64-5 pg. 1306. pg. 924 Facial Paralysis. Most NURS 482 Advanced Medical Surgical Nursing The client diagnosed with myasthenia gravis is being discharged home. Which intervention has priority when teaching the client’s primary care giver? learn resuscitation procedures Which patient has the highest risk factors for restless leg syndrome? peripheral neuropathy. A client with diabetes mellitus has a blood glucose level of 644 mg/dl. The nurse interprets that this client is at risk for developing which type of acid base imbalance? Metabolic Acidosis DM can lead to metabolic acidosis. When the body does not have sufficient circulating insulin, the blood glucose rises. At the same time, the cells of the body use all available glucose. Then the body breaks down fat and glycogen for fuel. The byproduct of fat metabolism is acidotic. Pg. 1311 A 68 year old patient has arrived in the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is a PRIORITY? Schedule a STAT computed tomography (CT) of the head. CT perfusion scan is used to assess ischemia of brain tissue. pg. 935. A patient is 12 hours post-operative from a thyroidectomy for uncontrolled hyperthyroidism. At 1200 the patient has a temperature of 98.9 F and at 1230 has a temperature of 99.8F. What is the nurse’s PRIORITY? Call the provider Critical Rescue Box pg. 1270 Even a 1-degree difference in temperature may indicate an impending thyroid crisis. During a patient’s last visit, the nurse instructed the patient about migraine headaches and techniques to manage this condition. Which statement by the patient indicates teaching has been successful? ―I have been keeping track of when my headaches occur and what might be triggers.‖ pg. 875 trigger avoidance and management are important interventions for preventing migraine. Encourage the primary caregiver to learn resuscitation procedures. Because of risk for respiratory compromise encourage family to pg. 922 A 65-year-old smoker with type 2 diabetes. higher in patients with DM type 2, chronic kidney disease and Pg. 922 The incidence is NURS 482 Advanced Medical Surgical Nursing The patient has arrived on the unit after having lithotripsy for urolithiasis. Which initial interventions will the nurse employ for this patient? (Select all that apply) Strain the urine for stone fragments. Assess for bruising to the Nank on the affected side A patient receiving 3 units of packed red blood cells has one peripheral IV access. It is time to start one of three IV antibiotics. What is the best action by the nurse? Start a second IV access and run the IV antibiotic. The patient is recovering from a bone marrow transplant. A family member complains, ―You nurses are spoiling him; I am sure he can help more with his bath.‖ What is the nurse‘s best response?‖ ―Independence is important, but too much activity at this time can be detrimental to his recovery.‖ A patient in sickle cell crisis arrives to the emergency department complaining of a pain level of 10 and shortness of breath with the following vital signs. Temperature = 99.1F Pulse = 100 Respirations = 26 BP= 130/80 Oxygen Saturation = 88% and a pain level of 10. Which nursing intervention should the nurse implement FIRST? Start oxygen therapy The nurse caring for a patient with anemia writes a problem of ―activity intolerance.‖ Which nursing intervention would be included in the plan of care? Pace activities according to tolerance. The nurse is reviewing the following lab work with a patient with a history of type 2 diabetes and hypertension. Hemoglobin AIC = 9%. Potassium = 4.0 mEq/L Creatine= 0 .7mg/dL GFR= > 90 mL/min. The patient states, ―I do not want to be on hemodialysis like my father.‖ What is the nurse‘s BEST response? Lowering your Hemoglobin A!C will help preserve your kidney function. A nurse is caring for four patients on an oncology unit. After receiving the hand off report, which patient should the nurse see `first? NURS 482 Advanced Medical Surgical Nursing A nurse is caring for four patients on an oncology unit. After receiving the hand off report, which patient should the nurse see `first? Patient whose temperature is elevated one degree to 99.8F in 4 hours. A nurse is caring for four patients who are postoperative from a transurethral resection of the prostate. After receiving the hand off report, which patient should the nurse see `rst? The patient with continuous bladder irrigation with dark red opaque urine. The nurse is admitting a client with renal calculi. Which should be the nurse‘s priority? Assess the location and severity of the client's pain. The nurse is preparing to discharge a patient with stress incontinence. Which statement made by the patient indicates the need for additional teaching? ―This is a normal sign of aging.‖ The nurse is preparing to discharge a patient with stress incontinence. Which statement made by the patient indicates the need for additional teaching ―This is a normal sign of aging.‖ A patient with pyelonephritis states, ―I am embarrassed to talk about my symptoms.‖ What is the nurse‘s BEST response from the nurse? Take your time and use your own words.‖ A patient with interstitial cystitis has been consuming cranberry juice to decrease the recurrence of UTI‘s. What patient education should the nurse provide regarding the use of cranberry products? Cranberry juice should be avoided in patients with interstitial cystitis. A patient is unsure if peritoneal dialysis is the best choice of treatment for them. Which statements by the nurse are accurate regarding peritoneal dialysis? (Select all that apply) ―You will not need vascular access to perform peritoneal dialysis. ―You can do your peritoneal dialysis at home.‖ NURS 482 Advanced Medical Surgical Nursing The nurse is reviewing the charts of patients with urinary catheters. Which conditions should the nurse recommend the catheter be removed? (SELECT ALL THAT APPLY) Urinary retention with hydronephrosis Critically ill patient at risk for hypovolemic shock. Which statement should the nurse include in discharge teaching for a client with polycystic kidney disease (PKD) ? ―Daily check your blood pressure and notify your provider of changes. The nurse is assessing a patient with benign prostatic hyperplasia. Which assessment [ndings warrant further investigation? (Select all that apply). Cloudy Urine Hematuria The nurse is completing preoperative teaching for a patient who is undergoing a transurethral resection of the prostate. Which statement by the client indicates the need for additional teaching? ―I am glad I will never have to worry about this prostate problem again.‖ Which patient would be a candidate for a bladder training program? A patient who complains of a strong urge to void and leaks large volumes of urine. During the initial 15 minutes of a blood transfusion. The patient develops low back pain and a headache. What is the FIRST action by the nurse? Stop the transfusion A patient with chronic leukemia states, ―I was told my white blood cell count is higher today. Why am I still at risk for infection?‖ ―Too many of the white blood cells you have are not mature enough to fight an infection A nurse is assessing a patient with Polycystic Kidney Disease. Which assessment [ndings does the nurse expect to observe? (Select all that apply). a. Nocturia ! , Flank Pain Edema. NURS 482 Advanced Medical Surgical Nursing A patient is admitted to con[rm the diagnosis of leukemia. Which test is needed to con[rm this diagnosis? Bone marrow biopsy The nurse is developing a plan of care for a patient with stage 4 chronic kidney disease. Which nursing problem is the PRIORITY for this patient? Excess fluid volume. A patient is complaining of urinary incontinence with laughing, coughing, and sneezing. How should the nurse document these symptoms? Stress Incontinence A patient has received a bone marrow transplant and is waiting for engraftment. What actions by the nurse are most appropriate? (Select all that apply.) Encourage frequent hand hygiene. Provide 6 easy to eat meals, instead of 3 large meals. Encourage the use of an electric razor. The nurse is assessing a patient with Nephrotic Syndrome. Which assessment [ndings does the nurse expect to observe? (Select all that apply) Proteinuria Decreased albumin in the plasma . Edema Who is at greatest risk for the development of prostate cancer? 45 year old African American male A nurse is caring for a patient with End Stage Chronic Kidney Disease (Stage 5) . Which intervention is important when caring for this patient? Auscultate the AV [stula for the presence of a bruit An African American patient has a hemoglobin of 6 g/dL. An experienced nurse remarks to the new nurse, ―The patient is very pale. We need to check his oxygenation saturation.‖ How can the nurse note cyanosis in an African American patient? Assess the patient's oral mucosa NURS 482 Advanced Medical Surgical Nursing The long-term care facility has many residents with urinary tract infections. Which factor is the cause of greatest concern? A large percentage of residents have an indwelling urinary catheter for over a month. TEST 5 The registered nurse (RN) is assigning staff for four clients on day shift. Which client should be assigned to the licensed practical nurse (LPN)? A client with gastritis expecting discharge in the morning A patient with Crohn‘s disease has 2 draining fistula between the bowel and the skin. Which nursing intervention is the PRIORITY for this patient? Assess the skin around the fistula. Which statement should the nurse include when teaching about home colostomy care? Apply skin sealant and allow to dry before applying the pouch. A nurse cares for a patient with a new ileostomy. The patient states, ―I don‘t think my friends will accept me with this ostomy.‖ How should the nurse respond? Tell me more about your concerns.‖ Which intervention should be included in the collaborative management of a client with Crohn's disease? Using long-term steroid therapy as prescribed. Which factors are related to the development of gastroesophageal reTux disease (GERD)? Select All that Apply. Delayed gastric emptying, Eating large meals, Hiatal hernia, Obesity A patient has ulcerative colitis. What assessment findings would warrant further investigation? Select all that apply. Abdominal Distention, Temperature of 101F., Tachycardia NURS 482 Advanced Medical Surgical Nursing A patient with an esophageal tumor has dysphagia and has been working with the speech pathologist on eating. What nursing assessment finding is FIRST PRIORITY for this patient? Clear lung sounds on auscultation. A nurse answers a client's call light and finds the client in the bathroom, vomiting large amounts of bright red blood. Which action would the nurse take first? Put on a pair of gloves. A client asks a nurse what to expect after being diagnosed with gallstones. What would be the nurse's best response? "There may be RUQ abdominal cramping after eating a fatty meal." After receiving the hand-off report, which post-surgical patient should patient nurse see Irst? The patient who had an esophagectomy and now has a temperature of 101 F. and pulse of 100 beats per minute. The nurse is preparing to discharge a patient treated for fecal impaction. What topics should the nurse include in discharge education? (Select all that apply) ―Drink prune juice to stimulate peristalsis.‖, ―Eat a high-`ber diet including raw fruits and vegetables.‖, ―Participate in daily exercise including walking.‖, ―Take Metamucil or other bulk- forming products.‖ The nurse is completing a history assessment on patient with irritable bowel syndrome (IBS). Which questions will assist with the plan of care? (SELECT ALL THAT APPLY) Which food types cause an exacerbation of symptoms?‖, ―Where is your pain and what does it feel like?‖, ―Do you experience nausea associated with defecation?‖ A nurse is admitting a client with irritable bowel syndrome (IBS). Which questions would the nurse include in this client's assessment? Select All that Apply "Do you experience abdominal distention and Tatulence?", "Where is your pain and what does it feel like?", "Which food types cause an exacerbation of symptoms?" A patient with cirrhosis is at risk for which complications? SELECT ALL THAT APPLY NURS 482 Advanced Medical Surgical Nursing A nurse assesses a client with irritable bowel syndrome (IBS). Which questions would the nurse include in this client‘s assessment? Select All that Apply "Which food types cause an exacerbation of symptoms?‖, "Where is your pain and what does it feel like?‖, "Do you experience nausea with meals or during bowel movements?‖ After teaching a patient with irritable bowel syndrome (IBS), a nurse assesses the patient‘s understanding. Which menu selection indicates that the patient correctly understands the dietary teaching? Broiled chicken with boiled potatoes, steamed broccoli, bottle of water. A patient with an intestinal obstruction has a nasogastric (NG) tube. Which interventions are important when caring for this patient? (Select all that apply.) Assess for proper placement of the tube every 4 hours, Disconnect suction when auscultating bowel peristalsis, Monitor the patient‘s skin around the tube site for irritation. A client has just had a hemorrhoidectomy. Which nursing intervention is appropriate for this client? Encourage a high fiber diet to promote bowel movements without straining. A patient has a gastrointestinal hemorrhage and is prescribed two units of packed red blood cells. What actions should the nurse perform prior to hanging the blood? (Select all that apply.) Ask a second nurse to double-check the blood., Prime the IV tubing with normal saline, Take and record a set of vital signs. The nurse is teaching the client who has viral gastroenteritis. Which dietary instruction would the nurse include in the client's education? "Drink plenty of fluids to prevent dehydration." A patient with a mechanical bowel obstruction reported intermittent abdominal pain this am and now reports constant abdominal pain. Which action should the nurse take FIRST? Assess the patient's abdomen and location of the pain. A nurse teaches a patient about post-operative care following a colon resection. Which statements should the nurse include in this patient‘s teaching? ―Take a laxative with a stool softener to prevent constipation.‖ Following a paracentesis, during which 2500 ml of fluid was removed, which assessment finding is most important to communicate to the healthcare provider? NURS 482 Advanced Medical Surgical Nursing The client‘s heart rate is 122 beats/min The nurse is preparing to discharge a patient with diverticular disease. Which statement made by the patient indicates the need for additional teaching? ―I will take a stimulant laxative nightly at bedtime to avoid becoming constipated.‖ The nurse has taught a client about lifestyle modifications for gastroesophageal reflux disease (GERD). Which statements made by the client indicate good understanding of the teaching? Select All that Apply. "I just joined a gym, so I hope that helps me lose weight.", "I sure hate to give up my coffee, but Iguess I have to.", "I will eat slowly and chew my food more thoroughly.", "Sitting upright and not lying down after meals will help." The nurse is preparing to discharge a patient with alcohol-induced cirrhosis. Which statement made by the patient indicates the need for additional teaching? I can take over-the-counter medications for pain.‖ The nurse recognizes which disorders as being associated with age-related physiologic changes in the gastrointestinal system? (Select all that apply.) Decreased absorption of iron., Decrease ability to digest fat, Diminished sensation to defecate. What would be the priority focus of nursing care for a client with peritonitis? Fluid and electrolyte balance A nurse cares for a patient newly diagnosed with colon cancer who has become withdrawn from family members. Which action would the nurse take? Encourage the patient to verbalize feelings about the diagnosis. The nurse is caring for a client who is a chronic Hepatitis B carrier from substance abuse. The client states, "All of my family hates me." How would the nurse respond? "I will help you identify a support system." NURS 482 Advanced Medical Surgical Nursing Review Parkinson’s Disease including common medications used in treatment. · Parkinson’s Disease: progressive neurodegenerative disorder defined by decrease in dopamine, diagnosed by ruling out other things o 4 cardinal symptoms: tremor, muscle rigidity, bradykinesia or akinesia (slow or no movement), and postural instability o S/S: gradual onset usually after age 50, mask like face- blank expression, pill rolling, tremor, stooped posture, shuffling/propulsive gait, bradykinesia, muscle rigidity, dysphagia o Care/Interventions: promote mobility, drug therapy, exercise therapy or PT. o Meds: § dopamine agonist: mimics dopamine agents by stimulating dopamine receptors in brain. Beneficial for first 3-5 years § Catechol O- methyltransferases (COMTs): enzymes that inactivate dopamine. Prolongs action of levodopa. Used in combination with levodopa. § MAOIs: helps reduce s&s. avoid with tyramine foods and drink. (wine, cheese, smoked or cured foods) § Levodopa-carbidopa: give before meals. Less expensive and better at controlling muscle function than dopamine agonist. Long term use can cause dyskinesia. Review CVA and be aware of what kind of stroke causes paralysis where? CVA vs. TIA -TIA: Temporary neurologic dysfunction resulting from a brief interruption on cerebral blood flow that lasts typically b/w 30-60 mins but can cause damage with repeated occurrences. S/S include blurred vision, diplopia, blindness in one eye, tunnel vision, weakness ( facial droop, arm or leg drift, hand grasp), ataxia, numbness (face, hand, arm, or leg), vertigo, aphasia, and dysarthria (slurred speech) that usually resolve typically within 24 hours. Prevention includes managing HTN (#1 cause), anticoagulants (heparin, warfarin), antiplatelet drugs (aspirin, clopidogrel), managing DM (Target 100-180), and a healthy lifestyle (exercise, nutrition, stress management). -CVA: “Brain attack or stroke” is caused by an interruption of perfusion to any part of the brain usually caused by HTN, arterio-venous malformation, or aneurysm. Ischemic (lack of blood supply) or hemorrhagic (bleeding/ aneurysm, HTN, arterio-venous issues). S/S include headache, mental changes (confusion, disorientation, memory impairment), resp problems, decreased cough and swallow reflex, agnosia (decreased sens. interpretation), incontinence, seizure, hemiparesis/plegia, hyperthermia, visual changes, vomiting, HTN, apraxia (decreased learned movements) NURS 482 Advanced Medical Surgical Nursing drugs, sodium iodine IV, correct dehydration, provide comfort/cooling measures, and monitor VS. Hypo/hyper thyroid -Hypothyroidism: Low levels of thyroid hormones that decrease metabolism, stimulate anterior pituitary gland to increase TSH to try to stimulate the thyroid which can lead to goiter but without increase in thyroid function. (Dry skin, hair loss, brittle hair/nails, bradycardia, weight gain, lethargy, cold intolerance, constipation, periorbital edema, thick tongue, confusion) Can cause Myxedema Coma. Dx includes blood work that shows low T3 and T4 and high TSH levels. Management includes lifelong thyroid hormone replacement therapy. -Hyperthyroidism: High levels of thyroid hormones (thyroxine) that increase metabolism and if not treated can lead to a thyroid storm. (goiter, thyrotoxicosis, exophthalmos, pretibial myxedema, heat intolerance, chest pain, bruit in neck, tachycardia, hyperactive DTR). Dx includes blood work that shows high levels of T3 and T4 with low levels of TSH as well as an ultrasound. Management includes lifelong anti-thyroid medication or a thyroidectomy. DM Types 1 and 2 -DMT1: An autoimmune disease in which the body’s immune system attacks and destroys the insulin-producing cells of the pancreas ( Beta cells), which leads to absolute insulin deficiency. Management includes insulin therapy (Basal pump insulin), BG monitoring 8-10x daily, carb counting, and education on hypo/hyper glycemia. -DMT2: A Progressive metabolic disorder in which a person’s body still produces insulin but is unable to use it effectively; combination of insulin resistance and decreased secretion. Management includes weight loss, dietary changes, and possibly pharm treatment. -Diagnostics for both DM includes a urinalysis for ketones, microalbuminuria, proteinuria, urine glucose, and an HgbA1c. DKA -is a serious complication of diabetes characterized by uncontrolled hyperglycemia, metabolic acidosis, and increased production of ketones seen in urine. Symptoms include kussmaul respirations, 3 P’s, fruity breath, nausea, and abdominal pain. Management includes insulin therapy and F&E balance. Sick Day Rules for DM pg 1314 -Notify your PCP that you are ill, monitor BG levels at least every 4 hours,Test for ketones in urine when BG level is >240 mg/dL, continue insulin therapy/antidiabetic medications, prevent dehydration by drinking 8-12 oz. every hour you're awake, continue meals at usual time, treat symptoms (diarrhea, nausea, vomiting, fever) as directed by PCP, get plenty of rest, and call PCP NURS 482 Advanced Medical Surgical Nursing for any danger signals (persistent N/V, moderate/large amount of ketones, BG elevation after 2 doses of insulin therapy, increasing fever). Blood glucose control in the hospitalized patients page 1301 -1302 -Current American Association of Clinical Endocrinologists and ADA guidelines recommend treatment protocols that maintain BG levels b/w 140-180 mg/dL for critically ill patients.For non-critical patients, glucose targets should be below 140 mg/dL. Continuous IV insulin is most effective in the critically ill. Scheduled subQ injections with basal, meal, and correction elements are preferred in the non-critical patients. Prevention of hypo/hyper is also a part of protocol. Key features of myasthenia gravis -An acquired autoimmune disease characterized by muscle weakness that increases with fatigue; insidious onset (gradual). Key features include visual disturbance, ptosis (drooping of eyelid), diplopia, incomplete eye closure, bulbar involvement (cranial nerves 9-12), and chewing/speech is impacted. ABG’s § PaCO2: base 35-45mmHg acid § HCO3: acid 22-26mEq/L base § pH: acid 7.35-7.45 base o Respiratory Acidosis: hypoventilation, rapid/shallow breath, pale, cyanotic, headache, hyperkalemia, dysthymia, drowsy, weakness o Respiratory Alkalosis: seizure, deep/rapid breathing, tachycardia, hyperventilation, hypokalemia, decreased BP, numbness, tingling, lethargy, confusion, lightheaded, N/V o Metabolic Acidosis: headache, decreased Bp, hyperkalemia, muscle twitching, warm/flushed skin, Kussmaul respiration, diarrhea o Metabolic Alkalosis: restless, tachycardia, hypoventilation, confusion, vomit, tremor, cramps, tingling, hypokalemia Neuro Changes before stroke 1. Sudden confusion or trouble speaking or understanding others 2. Sudden numbness or weakness of the face, arm or leg 3. Sudden trouble seeing in one or both eyes 4. Sudden dizziness, trouble walking, or loss of balance and/or coordination 5. Sudden severe headache with no known cause Neuro Changes after stroke NURS 482 Advanced Medical Surgical Nursing - Right sided stroke: left side paralysis, spacial perceptual deficits, minimize problems, short attention span, visual field deficit, impaired judgment, impulsive, impaired time concept, hearing deficit - Left sided stroke: paralyzed right side, impaired speech and language (aphasia), slow performance, visual field deficits, aware of deficits, depression, anxiety, impaired comprehension, hearing is not altered a. Aphasia: inability to speak or comprehend language b. Dyslexia: difficulty reading c. Agraphia: difficulty writing d. Hemiplegia: paralysis on one side of the body e. Hemiparesis: Weakness on one side of body Glasgow Coma Scale (GCS): Assessment that determines level of consciousness. Highest score is 15, lowest score is 3: total unresponsive pt. 8 is coma o eye opening (spontaneous - 4 to never - 1) o motor response (obeys commands - 6 to none - 1) o verbal response (oriented - 5 to none - 1) highest score is 15 Prostate cancer risk factors and testicular cancer risk factors Prostate cancer: increased risk with age and familial tendency, BPH, weakened urine flow, inability to urinate, burning on urination, back pain Testicular cancer: men with undescended testis (cryptochidism), HIV, family history of testicular caner Benign prostatic hypertrophy - Very common problem- 80% over 80 - When aging hyperplasia of prostate gland along with inflammation and enlargement - Extends up into bladder and inward causing bladder outlet obstruction - Urinary elimination issues - Increased residual urine and chronic urinary retention - Urine leaks or dribbles causing overflow urinary incontinence - Prostate enlarged- causing inability to urinate. - Nocturia - Hematuria Assessment: - International prostate score NURS 482 Advanced Medical Surgical Nursing Minimum output a day, for a patient without kidney disease, no less than 500mL or at least 30mL/hour HIV transmission 1. sexual : oral, anal or genital 2. Parenteral: Shared needles or healthcare workers- exposure of nonintact skin/mucous membranes to blood and body fluids 3. Perinatal Management of chest tube drainage system 1. Patient: a. Ensure dressing around the tube is tight and intact b. Access for effectiveness of breathing using pulse ox and auscultating. c. Check skin and insertion site for breakdown and infection d. Pulmonary toilet e. Reposition patient who reports a burning pain in the chest 2. Drainage system a. Do NOT strip chest tube b. Keep drainage system lower than patients chest c. Asses for gentle bubbling in water-seal chamber d. Assess for tidaling (rise and fall of water in chamber) e. Check and document mount, color and characteristics of fluid in the collection chamber 3. Notifying provider or Rapid response team a. Tracheal deviation b. Sudden onset or increased intensity of dyspnea c. OSat less than 90% d. Chest tube falls out of pts chest e. Chest tube disconnects from the drainage system. f. Drainage tube stops in first 24 hours. NURS 482 Advanced Medical Surgical Nursing MED SURG FINAL HELPFUL HINTS Parkinson’s Disease: progressive neurodegenerative disease - Debilitating disease that affects motor mobility - Characterized by four cardinal symptoms: tremor, muscle rigidity, bradykinesia or akinesia, and postural instability - Rarely occurs in black population; onset usually gradual, after age 50 - Dopamine levels are decreased o Normal function of dopamine is to inhibit the function of excitatory neurons, allowing control over voluntary movements o Excessive excitation of neurons prevents person from controlling or initiating voluntary movement - Symptoms: four cardinal 1. Tremors ▪ Hands and arms ▪ May increase or decrease with purposeful movement ▪ Pill rolling ▪ Aggravated by stress 2. Muscle rigidity – may need antispasmodic ▪ Increased resistance to passive movement ▪ Cog wheel, jerky, slow movement 3. Bradykinesia or akinesia ▪ Loss of normal arm swing while walking; r/f falls d/t inability to balance ▪ Decreased blinking of eyelids – dry eyes • need eye drops, lubricant, possible patch ▪ Loss of ability to swallow ▪ Blank expression – looks like Botox ▪ Difficulty initiating movement ▪ Chewing and or swallowing issues – facial nerves damaged; concern for choking 4. Postural instability ▪ Stooped ▪ Shuffling, propulsive gait - Diagnosis: no specific test, usually S&S and ruling out other conditions - Pharmacologic Treatment: know first 2 most o Dopamine Agonists ▪ Apomorphine, pramipexole, ropinirole ▪ Side effects = hypotension, drowsiness, hallucinations (if seen, toxic; need to decrease/stop dose) o Levodopa-Carbidopa – most common medication ▪ Improves motor function ▪ Before meals for best absorption o Catechol O-Methyltransferases (COMTs) NURS 482 Advanced Medical Surgical Nursing ▪ Stalevo (combination of levodopa, carbidopa, entacapone) blocks the enzymes that inactivate dopamine o MAOIs ▪ Increase dopamine concentration ▪ Avoid foods with tyramine (cheese, smoked/cured foods and sausage, red wine, beer, artificial sweeteners) Stroke (Brain Attack): caused by interruption of perfusion to any part of the brain - Medical emergency; should be treated immediately to reduce/prevent permanent disability - Types: ischemic (thrombotic, embolic) and hemorrhagic (aneurysm, AV malformation, HTN) o Ischemic: blood clots stop the flow of blood to an area of the brain o Hemorrhagic: weakened/diseased blood vessels rupture; blood leaks into brain tissue, hypertension - Neurological blood flow to r/t area, size, - Frequent cause of death and disability - Risk Factors: deficits r/t decreased area of brain; deficits and length of time o Modifiable risk factors: smoking, cocaine use, obesity, sedentary lifestyle, contraceptive use, heavy alcohol use o Non-modifiable factors: genetics, ethnicity, gender, age o Women: pregnancy, birth control, HRT, obesity, high triglycerides, migraines all increase risk for strokes o Black people > than all other ethnicities - Symptoms/Assessment o Cognitive Changes ▪ Headache (―worst of life‖) ▪ Confusion, disorientation, memory impairment ▪ Aphasia (inability to speak or comprehend language) seen w/ left hemisphere • Receptive = they can‘t understand you • Expressive = they can‘t get their words out, but they can still understand you • Global = both ▪ Denial of illness ▪ Spatial and proprioceptive (awareness of body position in space) dysfunction ▪ Impairment of memory/judgement/problem solving NURS 482 Advanced Medical Surgical Nursing - Perform double check of dose; use programmable pump to deliver initial dose of 0.9 mg/kg over 60 minutes, with 10% of dose given as bolus over 1 minute - Admit patient to CCU or specialized stroke unit - Perform neuro assessments, including vital signs Q10-15m during infusion and Q30m after that for at least 6 hours - If systolic BP >180 or diastolic is >105 during or after tPA, give antihypertensives PRN - To prevent bleeding, do not place invasive tubes, such as NG tubes or indwelling urinary catheters, until PT is stable - Discontinue infusion if patient reports severe headache or has severe HTN, bleeding, N/V; notify HCP immediately - Obtain follow-up CT scan after treatment before starting antiplatelet/anticoagulant drugs Nursing Interventions During and After IV Administration of Alteplase o Monitor S&S of stroke – r/f repeat stroke d/t clot breaking off o Position PT in semi-fowlers after o Fibrinolytic Therapy (aka thrombolytic therapy): Alteplase (rtPA) ▪ Only for ischemic strokes; early intervention to improve blood flow to viable tissue around infarct or through brain; success depends on interval between the time that symptoms begin and treatment is available ▪ IV (systemic) dissolves cerebral artery occlusion to re-establish blood flow and prevent cerebral infarction ▪ Dosage of drug is based on patient‘s weight ▪ Eligibility Criteria: • <4.5 hours of symptom onset and time seen in stroke center • Not given if use of anticoagulation regardless of INR • Not given if baseline National Institutes of Health Stroke Scale score >25 - Nursing Care o Use alternate forms of communication – read lips, writing, pictures, hand signals, eye blinking o Nutrition ▪ While feeding, high fowlers ▪ After eating, semi-fowlers ▪ Thickened liquids o Pain (may be permanent nerve pain, the stronger side may be in pain d/t bearing the load) o Safety o Fatigue o Bowel and bladder training (get them to bathroom Q2H if able to ambulate) - Core Measures for Ischemic Stroke Care (8) – prevent complications o VTE prophylaxis (Heparin, SCDs) o Discharge with antithrombotic therapy o Discharge w/ anticoagulation therapy if caused by atrial fibrillation/flutter o Thrombolytic therapy as indicated (if w/in 4.5 hours of symptom onset) o Antithrombotic therapy re-evaluated by end of hospital day 2 o Discharge on statin medication NURS 482 Advanced Medical Surgical Nursing o Stroke education provided and documented o Assessment for need for rehabilitation (can‘t perform ADLs, live alone, forgetful, no support) Transient Ischemic Stroke (TIA) & Reversible Neurologic Deficit - Serves as a warning sign for ischemic strokes - Temporary neurologic dysfunction resulting from brief interruption in cerebral blood flow - Brain tissue may be damaged with repeated insults, however more than likely patients revert back to baseline after - Usually symptoms resolve w/in 30-60 minutes, last a few minutes to <24 hours (?) - Symptoms: headache, confusion, vertigo, dysarthria, transient hemiparesis, temporary vision changes, syncope - Diagnosis: o Neuro assessment (cranial nerves, GCS, pain, alertness, strength, etc.) o Labs glucose, H&H, electrolytes o ECG look for A. Fib or A. flutter (increased r/f clots/strokes) o CT will tell us if patient is having a bleed ▪ If they are having a bleed, may be eligible for tPA o Later on: MRI, ultrasound carotids (supply blood to brain, check to see if blocked), echocardiogram done to determine risk for stroke - Preventive Measures: o Managing HTN (#1 cause of strokes) o Add on anticoagulant or antiplatelet prevent thrombotic or embolic strokes ▪ Blood coagulation studies o Controlling diabetes (target BG 100-180) o Promote healthy lifestyle Know about anticoagulant therapy ( i.e. warfarin, heparin ) and antiplatelet therapy. (i.e. clopidogrel) Meniere’s Disease - Three features: 1. Tinnitus (continuous low-pitched roaring or humming) NURS 482 Advanced Medical Surgical Nursing 2. One-sided sensorineural hearing loss 3. Vertigo (periods of whirling) - Symptoms o Severe, debilitating alternate w/ symptom-free periods o Prior to an attack: headache, increasing tinnitus, feeling of fullness in the affected ear - Interventions o Move slowly, concerned w/ safety d/t vertigo o Take prescribed antiemetics o low sodium o Smoking cessation Bell’s Palsy (aka Facial Palsy) - Acute paralysis of cranial nerve VII (facial nerve) - Maximum paralysis attained in 48 hours to 5 days - Cause: HSV-1 - Symptoms o Pain behind ear or on face may occur a few hours/days before paralysis o Masklike face that sags o May lose ability for eye to tear (drying up) ▪ Provide artificial tears, lubricants, patch, etc. o Test facial nerve VII by asking them to smile, lift eyebrows, make scary face, etc. - Medications o Corticosteroids o Antiviral – acyclovir or valacyclovir o Analgesics o Gabapentin - Full recovery expected w/in weeks to months care of the patient after total joint arthroplasty. NURS 482 Advanced Medical Surgical Nursing o Increased risk for infection o Risk for cerebral aneurysms (d/t often paralleling polycystic vein disease) ▪ severe headache requires attention o In the beginning, there is hyperfiltration which causes wasting of sodium and water; later as kidney function declines, patient begins to retain sodium and water (causes HTN, edema, & uremic symptoms such as anorexia, N/V, fatigue) - Assessment: o Family history o Always palpate abdomen gently – it‘s painful - Diagnostics: o Renal ultrasound initial, CT/MRI definitive to see cysts (5+ cysts = PKD) o Urinalysis: ▪ Proteinuria ▪ Hematuria (gross or microscopic) ▪ Elevated creatinine and BUN ▪ Low GFR ▪ May see either sodium loss or sodium retention based off of kidney‘s handling of things - Interventions: o Manage hypertension necessary to reduce CV complications and slow progression ▪ Education and self-management o Pain management ▪ NSAIDS not recommended b/c they can reduce kidney blood flow o Diet ▪ No sodium restriction initially ▪ Na restriction as disease progresses and fluids are being retained o Prevention of infection, constipation, ESKD - Patient/Family Education: o Measure/record BP daily and notify HCP for consistent changes o Take temperature if fever suspected; notify physician/nurse if present o Weight self daily! Same time, same amount of clothing. Notify if changes o limit salt intake to help control BP once hyperfiltration is no longer a symptom of disease o notify HCP if urine smells foul or has new occurrence of blood in it o notify HCP if persistent headache or visual disturbances symptoms of stroke o monitor bowel movements to prevent constipation TB including drug therapy Preventing Pneumonia NURS 482 Advanced Medical Surgical Nursing - Surgical Management: total or subtotal thyroidectomy o Pre-Op ▪ Thionamide drug to achieve euthyroid (means everything is balanced) ▪ Iodine to decrease size and vascularity of thyroid • If this is not done they will bleed to death, thyroid very vascular ▪ High protein/high carb ▪ Teach pulmonary toilet (C&DB, IS) ▪ Hoarseness expected for a few days ▪ Support the neck when coughing or moving ▪ Teach S&S hypothyroidism ▪ Neck dressing and drain o Post-Op ▪ Hemorrhage: most likely w/in 1st 24 hours • May complain of fullness at suture site ▪ Laryngeal stridor acute respiratory obstruction • In the post-operative period, must have a trach at the bedside • This is due to hypocalcemia ▪ Hypocalcemia and tetany parathyroid gland manipulation/damage ▪ Suture line pressure edema expected, make sure dressing not too tight ▪ Laryngeal nerve damage hoarseness and weak voice that persists • Only way we know is if they are hoarse for longer than we expect (if longer than a week or two, cause for concern) ▪ Thyroid storm life threatening, excessive hyperthyroidism • Not seen as often post-op d/t better management pre-operatively • All VS increase! o Even temperature increase of 1 degree – monitor closely! • Maintain airway, antithyroid drugs PO, sodium iodide solution, IV fluids (hypotonic), monitor VS • Lower HR and BP w/ beta blockers • Chart 63-5: emergency care o Maintain patent airway and adequate ventilation o Give oral antithyroid drugs as prescribed (Methmiazole, propylthiouracil) o Administer sodium iodide solution 2 g IV NURS 482 Advanced Medical Surgical Nursing o Give propranolol, 1-3 mg IV as prescribed o Give glucocorticoids as prescribed: hydrocortisone, prednisone, dexamethasone o Monitor continually for cardiac dysrhythmias o Monitor vital signs Q30 minutes o Provide comfort measures, including a cooling blanket o Give nonsalicylate antipyretics as prescribed o Correct dehydration w/ normal saline infusions o Apply cooling blanket or ice packs to reduce fever Hypothyroidism - Low levels of thyroid hormones decrease metabolism stimulates anterior pituitary to increase TSH to try to stimulate thyroid gland enlargement of gland forming goiter, thyroid function does not increase - Cellular energy decreased causing buildup of metabolites increases mucus and water cellular edema myxedema coma - Multiple causes – can be pituitary issue, thyroid issue - Slower onset - Symptoms: o Intolerance to cold o Receding hairline, hair loss o Facial & eyelid edema o Dull-blank expression, apathy o Extreme fatigue, lethargy o Thick tongue, slow speech o Anorexia o Brittle nails & hair, dry skin (coarse & scaly) o Menstrual disturbances o Constipation o Muscle aches/weakness o Late Clinical Manifestations: ▪ Subnormal temperature ▪ Bradycardia ▪ Weight gain ▪ Decreased LOC ▪ Thickened skin ▪ Cardiac complications - Drug Therapy: o Levothyroxine (Synthroid) – most common hormone replacement ▪ Take on empty stomach; do not take with other medications ▪ Decrease use of foods high in iodine (iodized salt, shrimp) Function of thyroid: metabolism NURS 482 Advanced Medical Surgical Nursing - Hyperglycemia linked to higher infection rates, longer hospital stays, increased need to intensive care, and greater mortality - Stringent targets may be appropriate in stable patients with previous tight glycemic control o Not a good idea for patients whose body is used to living at higher glycemic index - Preferred method of treatment: Scheduled subcutaneous insulin with basal, nutritional, and correction components (SSI) - If patient NPO: basal insulin should not be held w/o HCP order; hold rapid, short acting, and mixtures (prandial) Hypoglycemia (BG<70) - Causes include too much insulin/oral medications, reduced food/sugar intake, excessive exercise, NPO status - Symptoms: neurological; brain cannot function w/out sugar o Tachycardia o Irritability, altered mental status o Restless, shakiness, trembling o Excessive hunger o Diaphoresis o Depression o Unconsciousness, seizures, brain damage, death - Beta blockers affect S/S of hypoglycemia frequent blood sugar checks important! - 20-25 minutes of no glucose in brain is equivalent to 4-6 minutes with no oxygen - Elderly: more prone to complications including hypoglycemia d/t frailty, undernourishment, multiple- organ failure, and polypharmacy (esp. beta blockers) - Table 64-11 & 64-12, page 1309 - Treating: o Conscious adult: ▪ Rule of 15: • 15-20 grams of fast-acting carbohydrate/glucose (e.g. juice, candy) • 15 minutes re-check blood sugar • Repeat until BG >70 ▪ Follow w/ protein snack or meal – keeps blood sugar staying up higher ▪ See chart 64-7 page 1310 o Unconscious adult: ▪ Glucagon given IM; this usually induces vomiting to place person on side ▪ IV Dextrose: will raise BS quickly and often causes person to be hyperglycemic for period of time or blood sugar will drop rapidly again • Can cause extravasation ▪ Critical rescue: • Give glucagon 1 mg SQ or IM • Repeat dose in 10 minutes if PT remains unconscious • Notify HCP immediately Glycemic Goals in Adults (per American Diabetic Association) NURS 482 Advanced Medical Surgical Nursing 1. Lower HgbA1C to below or around 7% (NCLEX <6.5) 2. Decrease/prevent long-term complications (so control glucose!) 3. Decrease cardiac risk factors (lipids – HDL, LDL, triglycerides; blood pressure) 4. Incorporate psychological assessment; 1/3 people w/ diabetes will experience depression Checking BG at Home - Assess PT‘s ability/willingness to perform - No sharing of meter - How to use meter - Wash hands – alcohol not needed in home - Monitor BG as required and PRN - Sick Day Rules o More frequent glucose checks o Still take regular insulin o Re-test if BS is abnormal DKA Blood glucose control in the hospitalized patients page 1301 -1302 Myasthenia Gravis: acquired autoimmune disease characterized by muscle weakness that increases with fatigue - Insidious onset (very slow) - Symptoms: o Fatigue and weakness o Ptosis; incomplete eye closure (provide eye drops, eye patch, lubricant) o Diplopia o Muscle facial expression o Chewing, dysphagia o Monitor respiratory function! o Bulbar involvement: refers to a range of symptoms linked to impairment of function of the cranial nerves 9-12; muscle of face, chewing and speech ▪ Biggest concern is aspiration and respiratory compromise for MG patients!!! - Diagnosis: o Tensilon Test: done with cholinesterase inhibitor edrophonium chloride ▪ If person has MG, symptoms will improve w/in 30-60 seconds; lasts 4-5 minutes ▪ Also helps determine whether increasing weakness in previously diagnosed myasthenic patient is due to… • Cholinergic crisis too much cholinesterase inhibitor drug; muscle tone does not improve after giving the drug. Weakness may increase o Means they have too much cholinergic drugs in them; decrease dose NURS 482 Advanced Medical Surgical Nursing - Treating: o Interventions = maintaining respiratory function, anticholinergic drugs withheld while on ventilator r/t increase respiratory secretions, atropine • Myasthenic crisis too little cholinesterase inhibitor drug; improvement in muscle tone after administering o Means they have too little cholinergic medication in them, give them more o Interventions: maintain respiratory function, cholinesterase- inhibiting drugs withheld ▪ Watch for cardiac dysrhythmias, cardiac arrest • Antidote = atropine, bag valve and suction (have present before pushing the medication) o Immunosuppression ▪ Corticosteroids (Prednisone) – produce remission and control/improve symptoms o Plasmapheresis: removes circulating antibodies to decrease symptoms ▪ Short-term management of an exacerbation ▪ Increases r/f infection o Thymectomy: removal of thymus gland ▪ May take up to 2 years to show symptom improvement ▪ Critical Rescue!!: monitor respiratory effort & promote healthy gas exchange. Observe for S&S of pneumothorax or hemothorax: • Chest pain, sudden SOB, diminished chest wall expansion, diminished/absent breath sounds, restlessness, change in vital signs • Provide oxygen and raise HOB to 45 degrees; report RRT immediately o Cholinesterase Inhibitor Drugs (Anticholinesterase/Antimyasthenics) ▪ Pyridostigmine = drug of choice, given SQ ▪ 1st line management ▪ Enhance neuromuscular impulse transmission by preventing decrease of acetylcholine by enzyme cholinesterase increases nerve impulses to muscles increases muscle strength • Basically, gets muscles working so symptoms are reduced; independence is increased ▪ Drug Alert: eat meals 45 minutes – 1 hour after taking ChE inhibitors to avoid aspiration (helps them eat more easily) ▪ Potential Adverse Effect: Cholinergic Crisis! • Hypersalivation, sweating, increased bronchial secretions; bronchospasms, bradycardia • Interventions: o maintain respiratory function o anticholinergic drugs withheld while on ventilator d/t increased respiratory secretions o atropine ▪ Potential Adverse Effect: Myasthenic Crisis! NURS 482 Advanced Medical Surgical Nursing • Vasodilation (warm, flushed skin) • Kussmaul‘s breathing • Decreased muscle tone • Decreased reflexes Metabolic Alkalosis – pH >7.45; HCO3 > 26 - Caused by excessive loss of acids or increase of HCO3 into bloodstream - Common causes • Rebound from metabolic acidosis (too much HCO3 administered) • Vomiting, diarrhea, excess GI suctioning • Non-potassium sparing diuretics - Symptoms • Restlessness followed by lethargy • Dysrhythmias (tachy) • Confusion (↓LOC, dizzy, irritable) • Tremors, cramps, tingling • Hypokalemia RULES OF ABG COMPENSATION - Uncompensated: pH & 1 other value outside expected range. Worst type - Partial Compensation: all 3 values outside expected range - Fully Compensated: pH within expected range, other 2 values outside expected range Glasgow Coma Scale: a standard rapid neurologic assessment tool; lowest possible score = 3 - used in many acute care settings to establish baseline data in each of these areas: eye opening, motor response, and verbal response - Cause pain by sternal rub if eyes not opening lower the score, lower the patient‘s neurologic function NURS 482 Advanced Medical Surgical Nursing Testicular Cancer - Men between 15 and 40 (younger) - Five-year survival rate 96% if localized - Importance of testicular exam - Leading cancer killer for males age 15-40 - Euro-American men are at higher risk - Cause unknown: higher incidence in men with undescended testicles - Surgery, radiation therapy and chemotherapy used Benign Prostatic Hyperplasia (BPH) - Enlargement of the prostate that most often occurs with aging, d/t increased dihydrotestosterone levels - Risk factors include obesity, DM, testosterone, decreased physical activity - If prostate becomes swollen enough, patient may be unable to void (acute urinary retention) or may develop hydronephrosis - Assessment: o History: ▪ International Prostate Symptom Score (I-PSS) ▪ Elimination patterns – assess for urinary frequency and urgency o Physical Assessment: ▪ HCP examines PT for physical changes of prostate gland – void beforehand ▪ Frequent urination ▪ Nocturia ▪ Urgency to urinate ▪ Difficulty starting urination – straining ▪ Weak urine stream ▪ Dribbling at the end of urination ▪ Inability to completely empty the bladder ▪ UTIs d/t retention ▪ Hematuria may mean cancer ▪ Possible sexual dysfunction o Psychosocial Examination: ▪ Irritability, depression ▪ Libido may be affected ▪ Social isolation ▪ Anxiety - Diagnosing: o Laboratory assessment ▪ Urinalysis and culture NURS 482 Advanced Medical Surgical Nursing ▪ CBC to check for systemic infection or anemia ▪ BUN and serum creatinine to evaluate renal function ▪ Prostate-Specific Antigen (PSA) – performed before digital exam • Typically elevated o Transabdominal Ultrasound/MRI – will show enlarged prostate Chemotherapy - Treatment of cancer w/ chemical agents; used to cure and increase survival time. Damages DNA and interferes w/ cell division and cellular regulation - Disrupts cell cycle different phases – stops replication and cell metabolism; some work through entire cycle, others specific - Systemic, so they also exert their cytotoxic effects on healthy effects o Especially effect rapidly dividing cells skin, hair, intestinal tissues, spermatocytes, and blood-forming cells - Neoadjuvant chemotherapy – used to shrink tumor before surgery or radiation - Adjuvant chemotherapy – when it’s used to kill remaining cancer cells following surgery or radiation - Some possible side effects: o Hemorrhagic cystitis, cardiac muscle damage, loss of bone density o Bone marrow suppression, chemotherapy-induced N/V, mucositis, alopecia, changes in cognitive function, peripheral neuropathy - Classes: o Alkylating agents o Antimetabolites o Antitumor antibiotics o Mitotic inhibitors o Hormones and hormone antagonists ▪ Common w/ breast/prostate cancer o Others - Administration: never given peripherally o Extravasation o Toxic o Vascular access devices o PICCS, Hickmans, Groshongs o Implanted – Mediport - Patient-Centered Nursing Care: o Infection risk o Chemotherapy-induced N/V (CINV) ▪ Antiemetic therapy: • Serotonin antagonists: ondansetron (IV or PO) • Corticosteroids: dexamethasone • Benzodiazepines: lorazepam (relaxing patient may help decrease N/V) • Haloperidol (Haldol) NURS 482 Advanced Medical Surgical Nursing - Palliation – reduce size, reduce pain - Kill tumor - External vs. internal o External (teletherapy) – delivered from source outside of the patient; patient is not radioactive so no hazard to others ▪ care of patient’s skin o Internal (brachytherapy) – radiation source comes into direct, continuous contact w/ tumor for specific time period, limiting the dose in surrounding normal tissues ▪ Ex. Put radioactive seeds in prostate ▪ Patient emits radiation for a period of time and is a potential hazard - Safety: time, distance, shielding o Especially radioactive precautions - Side Effects of Radiation Therapy o Vary according to site o Local effects: radiation dermatitis (redness/rash/local skin changes), alopecia (likely permanent depending on dose) o Systemic effects: altered taste (aversion to red meats), fatigue (r/t increased energy demands), and bone marrow suppression o Inflammatory responses that cause tissue fibrosis and scarring in localized areas ▪ Ex. If someone has radiation therapy in reproductive area, may have bowel issues later on Acute and Late Site-Specific Effects of Radiation Therapy Acute Effects Late Effects Brain - Alopecia and radiodermatitis of the scalp - Ear and external auditory canal irritation - Cerebral edema - N/V - Somnolence syndrome Head & Neck - Oral mucositis - Taste changes - Oral candidiasis - Oral herpes - Acute xerostomia - Dental caries - Esophagitis & pharyngitis Breast & Chest Wall - Skin reactions - Esophagitis Chest & Lung - Esophagitis & pharyngitis - Taste changes - Pneumonia Subcutaneous & Soft Tissue - Radiation-induced fibrosis Central Nervous System - Brain necrosis - Leukoencephalopathy - Cognitive & emotional dysfunction - Pituitary and hypothalamic dysfunction - Spinal cord myelopathies Head & Neck - Xerostomia and dental caries - Trismus - Osteoradionecrosis - Hypothyroidism Lung - Pulmonary fibrosis Heart - Pericarditis - Cardiomyopathy - Coronary artery disease Breast/Chest Wall - Atrophy, fibrosis of breast tissue NURS 482 Advanced Medical Surgical Nursing Abdomen & Pelvis - Anorexia - N/V - Diarrhea and proctitis - Cystitis - Vaginal dryness/vaginitis Eye - Conjunctival edema and tearing - Lymphedema Abdomen and Pelvis - Small and large bowel injury - Nursing Care o Action alert: radioactive patients: ensure they are not touched by anyone; handle wastes according to guidelines; pregnant women and children not allowed to visit the patient. after the isotope is completely eliminated from the body, neither the patient nor the body wastes are radioactive o Care of Patient w/ Sealed Implants of Radioactive Sources ▪ Assign patient to private room w/ private bath ▪ Place “Caution: Radioactive Material” sign on door of room ▪ If portable lead shields are used, place them between the patient and the door ▪ Keep door closed as much as possible ▪ Wear a dosimeter film badge at all times while caring for patients with radioactive implants; badge offers no protection by measures a person’s exposure to radiation. Each person caring for the patient should have a separate dosimeter to calculate their specific radiation exposure ▪ Do not perform direct patient care if attempting to conceive, pregnant ▪ No child visitors (or pregnant) ▪ Limit each visitor to 30 minutes per day & they must stay at least 6 feet away from patient ▪ Do not touch radioactive source w/ bare hands; if it is dislodged, use forceps to retrieve it and deposit in lead container ▪ Save all dressings and bed linens in the patient’s room until after the radioactive source is removed. Then dispose of them in a usual manner. Other equipment can be removed from the room at any time without special precautions and does not pose a hazard to other people o Teach accurate objective facts to help patient cope lots of anxiety o Do not remove skin markings until therapy is completed o When possible, shield tissues that are most sensitive to external radiation (bone marrow cells, skin, MM, hair follicles, germ cells [ova & sperm]) o Xerostomia may have negative impact on speaking, chewing, and swallowing saliva- substitute sprays, lozenges, mouth rinses, regular dental visits, sucking on ice may help o Risk for pathologic fractures handle body carefully; fracture precautions o Skin Care: Patient & Family Education ▪ Skin in radiation path becomes dry and may breakdown NURS 482 Advanced Medical Surgical Nursing ▪ Wash irradiated area gently each day with water or mild soap & water ▪ Use hand rather than washcloth when cleansing the therapy site ▪ Rinse soap thoroughly from your skin ▪ If ink or dye markings are present, take care not to remove them ▪ Dry with patting motions instead of rubbing and use soft towel/cloth ▪ Use only powders, ointments, lotions, or creams that are prescribed by team ▪ Wear soft clothing over skin at radiation site ▪ Avoid wearing belts, buckles, straps, or any type of clothing that binds or rubs the skin at radiation site ▪ Avoid sun exposure to irradiated area wear clothing, go outside in early morning or evening, stay under umbrellas if outside (advise against direct skin exposure for at least 1 year after completing treatment) ▪ Avoid heat exposure Angina vs MI Minimum urinary output - Fluid Loss – occurs through several routes o Obligatory urine output = 400-600 mL/day (this is the minimum urine amount needed to excrete toxic waste products) ▪ Expect patients to excrete 30 mL/hour at a minimum o Insensible water loss – through skin, lungs, stool ▪ Elderly have more loss through this way NURS 482 Advanced Medical Surgical Nursing High risk for breast cancer options: BRCA1 and BRCA2 gene removal prophylactic mastectomy prophylactic oophorectomy (removal of the ovaries) Common Complementary and Integrative Therapies used by patients with breast cancer PHYSICAL • pain (acupuncture, chiropractic therapy, hypnosis, massage, music, reiki, shiatsu) • nausea/vomiting (acupuncture, aromatherapy, ginger, hypnosis, progressive muscle relaxation, shiatsu) • Fatigue (Acupuncture, massage, meditation, reiki, tai chi, yoga) • Hot flashes (acupuncture, flaxseed) • muscle tension (aromatherapy, massage, shiatsu) EMOTIONAL • anxiety/stress/fear (aromatherapy, guided imagery, hypnosis, journaling, massage, meditation, music therapy, progressive muscle relaxation, prayer, support groups, tai chi, yoga) • depression (aromatherapy, yoga, journaling, progressive muscle relaxation) For a non-surgical candidate - adjuvant therapy, systemic chemotherapy, radiation therapy, palliative therapy Surgery for Breast Cancer Breast Conserving Surgery lumpectomy - removal of tumor and small amount of tissue partial mastectomy tumor and some normal tissue Total Mastectomy Removes breast tissue Modified Radical Mastectomy Entire breast some lymph nodes and maybe part of chest wall Priority interventions for pre-operative care of breast cancer relieving anxiety, providing information to increase patients knowledge, include spouse or significant other. Avoid using affected arm for BP, infections, or drawing blood. Keep head of bed elevated 30 degrees, Elevate affected arm, manage pain. DVT prevention, watch drainage NURS 482 Advanced Medical Surgical Nursing Post-Mastectomy Exercises Hand Wall Climbing, Pulley Exercise, Rope Turning (tie a rope to the knob of the closed door, hold the other end of the rope and step back from the door until your arm is almost straight in front of you. Swing rope in a circle , start with small circles and gradually increase to larger circles) Postoperative Care of the Patient After Breast Reconstruction • Assess the incision and flap for signs of infection (excessive redness, drainage, odor) during dressing changes • Assess the incision and flap for signs of poor tissue perfusion (duskiness, decreased capillary refill) during dressing changes • Avoid pressure on flap and suture lines by positioning patient on nonoperative side • monitor and measure drainage in collection devices like jackson pratt • Teach patient to return to usual activity level gradually and to avoid heavy lifting • avoid sleeping in a prone position • avoid contact sports or any trauma to chest • Teach patient to avoid minimize pressure on breast during sexual activity • Refrain from driving until cleared • ask at 6 week post op visit to continue exercises • optimal appearance may not occur until 3 to 6 months after surgery • if implants, teach how to massage • emphasize breast self-awareness. Review breast self-examination technique Recovery From Breast Cancer Surgery • change dressing if soiled and if persistent drainage is occurring • empty reservoir twice a day and record measurements • drains are removed when drainage is less than 30mL/day for 3 consecutive days • take sponge baths or tub baths making sure incision stays dry. • start exercising, exercises that involve the wrist, hand, elbow such as flexing your fingers, circular wrist motions, touching hand to shoulder are very good • may have impaired comfort or mild pain after surgery but gets better 4-5 days after • Numbness in the area of the surgery and along the inner side of the arm from the armpit to the elbow occurs in all women • pamphlets on exercise, hand and arm care, general facts about breast cancer are available NURS 482 Advanced Medical Surgical Nursing Patients Recovering From Breast Cancer Surgery • Assess cardiovascular, respiratory, urinary status (vital signs, lung sounds, urine output patterns) • assess for pain • assess for drainage (drainage around site, color and amount of drainage, symptoms of infection) • Assess for status of affected extremity (range of motion, ability to perform exercise regimen, lymphedema) • Assess nutritional status (food and fluid intake, presence of nausea and vomiting, bowel sounds) • Assess functional ability (ADL, Mobility and ambulation) • Assess home environment (safety, structural barriers ) • Assess patient's compliance and knowledge of illness and treatment plan (follow-up appointment with surgeon, symptoms to report to health care provider, hand and arm care guidelines) • Assess patient and caregiver coping skills (whether patient and or caregiver looked at incision site, patient or caregiver reaction to incision site) To decrease the chance of a surgical infection carefully observe the surgical wound after breast surgery for signs of swelling and infection throughout recovery. Assess the incision and flap of the post-mastectomy patient for signs of bleeding, infection, and poor tissue perfusion. Drainage tubes are usually removed 1 to 3 weeks after hospital discharge. Drainage amount should be less than 2 to 30 mL in a 24 hour period. Tell patient these impair comfort and that analgesia should be administered before taking out tube., Normal Cell Characteristics • none or slow cell division • specific morphologic features • small nuclear to cytoplasmic ratio • many functions • tight adherence • does not migrate • well-regulated growth • diploid (euploid) chromosomes NURS 482 Advanced Medical Surgical Nursing *Advancing age is the single most important risk factor for cancer* Seven warning signs of Cancer CAUTION Changes in bowel or bladder habits A sore that does not heal Unusual bleeding or discharge Thickening or lump in breast or elsewhere Indigestion or difficulty in swallowing Obvious change in a wart or mole Nagging cough or hoarseness Prevention of cancer Lifestyle changes, identifying high-risk groups, screenings, physicals, self-exams Primary prevention avoidance of known or potential carcinogens, modifying associated factors, removal of at-risk tissue like moles, colon polyps, and breasts Secondary Prevention: Mammography annually 40 to 44, annual 45 to 54. Biennial (every other year) over 55. Colonoscopy is at 50 years of age and every 10 years after that General Disease-Related Consequences of Cancer impaired immunity and blood producing fuction - can occur when cancer invades the bone marrow causing anemia and thrombocytopenia. Altered GI function - increase the metabolic rate and the need for nutrients. Cancer treatment can cause loss of appetite and alteration in taste. Altered Peripheral Nerve Function - most common cause is chemo and spine tumors can change peripheral nerves. Motor and sensory deficits - calcium invades bone or brain or compress nerves. Pain- cancer pain is best managed by an interprofessional team. Altered respiratory and cardiac function - calcium can disrupt respiratory function, capacity and gas exchange. Can lead to death How to go about the cancer route: prophylactic (potentially cancerous tissue), diagnosis, cure, control, palliation, second-look surgery, reconstruction or rehabilitation. NURS 482 Advanced Medical Surgical Nursing Side effects of surgical therapy: any organ loss reduces function, scarring, disfigurement Care of the patient with sealed implants of radioactive sources • Assign the patient to a private room and bath • place a caution: radioactive material sign on the door • if portable shields are used, place between patient and door • wear a dosimeter film badge at all times. measures persons exposure to radiation • wear a lead apron while providing care. front of apron facing source of radiation • don't perform on people who are pregnant • pregnant nurses should not care for these patients • limit each visitor for thirty minutes each day . stay 6 feet away from source • never touch radioactive source with barehands. if dislodged, use long-handled forceps • Save all bed linens and dressings in patients room until after the radioactive source is removed. once removed, dispose of the dressings and bed linens. Radiation therapy: most ionizing and particles cell nucleus rearranged. lethal injury to DNA mechanism, they die or become unable to divide. 3 types of energy used, gamma is the most common. Teletherapy - source outside of patient and emits radiation for a period of time and is a hazard to others. Exposure - amount of radiation delivered. Radiation - amount of radiation absorbed 3 factors that determine radiation dose: intensity, duration, closeness. Cells do not all die at once in 24 hours, some are related to specific cells. Skin Protection During Radiation Therapy ****************** • Wash the irritated area with either water or a mild soap and water • use hand rather than washcloth when cleansing the site • rinse soap thoroughly from your skin • if ink or dye is present on patient do not remove them • clean using patting motions • use only powders, creams, lotions, ointments that are prescribed by radiologist. • wear soft clothing over the skin at radiation site • avoid wearing belts, buckles, straps that binds or rubs skin • avoid exposure of irritated area with sun: protect by wearing clothing over it, try to only go outdoors in the early morning or evening to avoid intense sun rays, stay under shade. avoid heat exposure. • care for xerostomia (dry mouth) Skin in the radiation path action alert NURS 482 Advanced Medical Surgical Nursing become photosensitive, increasing the risk for sunburn and sun damage. Advise against direct skin exposure to the sun during treatment and for at least 1 year after completing radiation therapy. Side Effects of Radiation therapy: vary according to site, local skin changes and hair loss is likely, altered taste sensations, fatigue related to increased energy demands, inflammatory responses that cause tissue fibrosis and scarring. Acute Effects of Brain: alopecia and radiodermatitis of scalp, ear and external auditory canal irritation, cerebral edema, nausea and vomiting, somnolence syndrome Acute effects of the head and neck: oral mucositis, taste changes, oral candidiasis, oral herpes, acute xerostomia, dental caries, esophagitis and pharyngitis Acute effects of the breast and chest wall: skin reactions and esophagitis Acute effects of the chest and lung: esophagitis and pharyngitis, taste changes, pneumonia Acute effects of the abdomen and pelvis: anorexia, nausea and vomiting, diarrhea and proctitis, cystitis, vaginal dryness Acute effects of the eye: conjunctival edema and tearing Late effects of subcutaneous and soft tissue : radiation induced fibrosis Late effects of central nervous system: brain necrosis, leukoencephalopathy, cognitive and emotional dysfunction, pituitary and hypothalamic dysfunction, spinal cord myelopathies Late effects of the head and neck xerostomia , trimus, osteoadinoecrosis, hypothyroidism Late effects of the lung: pulmonary fibrosis Late effects of the heart: pericarditis, cardiomyopathy, coronary artery disease Late signs of breast/chest wall: atrophy, fibrosis of breast tissue, lymphedema Late signs of abdomen and pelvis: small and large bowel injury Chemotherapy has adverse effects and disrupts the cell cycle at different phases. stops replication and cell metabolism. Combination therapy is used and can be given in cycles. Chemo is to be given only be a RN who has completed an approved chemotherapy program and has demonstrated competence in administering chemo agents . NURS 482 Advanced Medical Surgical Nursing • avoid the use of tobacco or drinking alcoholic beverages • avoid spicy foods • cool liquids to prevent burns and irritation • only use dentures during meals Chemotherapy-Induced Peripheral Neuropathy • Protect feet and other body areas where sensation is reduced . do not walk around barefoot • be sure that shoes are long enough and wide enough to prevent creating sores and blisters • buy shoes in afternoon or evening to accommodate for feet swelling • provide a long break-in period for new shoes. do not wear shoes longer than 2 hours at a time • avoid pointed-toe shoes and shoes with heels higher than 2 inches • inspect feet daily for open areas or redness • avoid temperature extremes • test water temperature with a thermometer before washing dishes • use potholders while cooking • use gloves when washing dishes and gardening • do not eat foods that are steaming hot • eat foods that are high in fiber • drink 2-3 liters of fluid a day • use actions for fall preventions • get up slowly from a lying or sitting position. if you feel dizzy sit back down. • to prevent tripping or falling look at your feet and the floor • avoid using area rugs especially those that slide easily • keep floors free of clutter that can lead to a fall • use handrails when going up or down steps Mucositis - sores in mucous membranes is a dose limiting side effect of cancer therapy and is a common reason for stopping or delaying treatment Alopecia - hair loss, temporary regrowth one month after completion of treatment. Changes in cognitive function is the most common when they have reduced ability to concentrate. Peripheral neuropathy is associated with exposure to certain chemo. Targeted therapies Small molecule therapies drug action alert administered as oral agents, people do not want to take it because it is "just a pill" emphasize with patients and their family members and caregivers the importance of taking the drugs as prescribed and using safe handling techniques. Only patient can handle the oral chemotherapy and that a family member needs to wear gloves when handling the chemotherapy drug. NURS 482 Advanced Medical Surgical Nursing During chemotherapy administration verify the blood return every 2 to 5 mL for IV push drugs and every 5 to 10 minutes for short continuous infusions Skeletal System composes of bones and joints and muscular system is composed of smooth, cardiac, skeletal muscle. Long bones - femur, cylindric with rounded ends that often bear weight. short bones - phalanges which ae small and bear little to no weight. flat bones - such as the scapula, which protects vital organs and contain blood forming cells. Structure unit of the cortical compact bone is the haversian system which is a complex network of blood vessels that supply nutrients and oxygen to bone and lacunae which houses osteocytes. Softer cancellous tissue contains large spaces or trabeculae which are filled with red (production of red blood cells) and yellow marrow (contain fat cells). fat cells become emboli Joints - a space in which 2 or more bones come together. Synovial joints lined with synovium which helps with lubrication and shock absorption. Muscular - smooth muscles are responsible for contractions of organs and blood vessels controlled by the autonomic nervous system ANS Cardiac muscles controlled by autonomic nervous system Skeletal muscles are controlled by the central and peripheral nervous system. Main function is movement of the body and its parts. If immobility is effected it effects other body systems like prolonged immobility can lead to skin breakdown, constipation, thrombus formation. NURS 482 Advanced Medical Surgical Nursing Changes in Musculoskeletal System Related to Aging decreased bone density - teach safety tips to prevent falls and reinforce the need to exercise especially weight-bearing exercises because porous bones are more likely to fracture, and exercise slows bone loss. Increased bone prominence - prevent pressure on bony prominences because there is less soft tissue to prevent skin breakdown. Kyphotic posture: widened gait, shift in the center of gravity - teach proper body mechanics and instruct the patient to sit in supportive chairs with arms because correction of posture problems prevents further deformity and the patient should have support for bony structures. Cartilage degeneration (arthritis) - provide warm moist heat such as a shower or warm, moist compresses because moist heat increases blood flow to area decreased range of motion - assess patient’s ability to perform ADL's and mobility because the patient may need help with self-care skills muscle atrophy, decreased strength - teach isometric exercises because exercise increases muscle strength. Slowed movement - do not rush the person, be patient because the patient may become frustrated if hurried. Osteoporosis - disease with severe osteopenia it occurs in many older adults especially white, thin, women. Health promotion for osteoporosis vitamin D, calcium, dietary nutrients weight bearing activities (walking) accidents, illnesses, lifestyle and substance abuse can contribute to occurrence of musculoskeletal injury. High impact sports can lead to musculoskeletal injury. stop smoking no excessive alcohol use What to ask with osteoporosis: any traumatic injuries, nutritional history, fam history, occupation, recreational activities, obesity, lactose intolerance, socioeconomic status (can they afford the right type of foods) comfort, weakness With someone that has musculoskeletal issues perform a complete neurovascular assessment (circ check) which includes palpation in the extremities below the level of injury and assessment of sensation, movement, color, temperature, and pain in injured part. NURS 482 Advanced Medical Surgical Nursing Conservative: ROM, strengthening, aerobic exercises balanced with periods of rest, heat and ice, assistive devices as needed, weight loss if obese Surgical interventions: arthroscopy and joint arthroplasty Teach the patient to use ice packs that are not too heavy. Do not place them directly on the skin and instead wrap them in a towel or soft cloth and apply for a maximum of 20 minutes at a time. Heat may decrease muscle tension around the tender joint decreasing pain and cold works by numbing nerve endings and decreasing secondary joint inflammation. Nursing Interventions to Prevent Major Complications of Lower-Extremity total Joint Arthroplasty • Dislocation of the hip - position correctly, keep legs slightly abducted, prevent hip flexion beyond 90 degrees, prevent hip hyperextension, assess for acute pain, rotation, and extremity shortening, perform frequent neurovascular assessments at least every 4 hours for a total of 24 hours. Report dislocation immediately to surgeon. • Infection - Use aseptic technique for wound care and emptying drains, wash hands thoroughly when caring for a patient, culture drainage fluid, monitor temperature, report excessive inflammation or drainage to physician • Venous Thromboembolism - Have patient wear elastic stockings and/or sequential compression device, leg exercises, encourage fluid intake, observe for signs of deep vein thrombosis (redness, swelling, pain), observe patient for changes in mental status, administer anticoagulants, do not massage legs, do not flex knees for a prolonged period of time. • Hypotension, bleeding, infection - Take vital signs at least every 4 hours for the first 24 hours per agency protocol, observe patient for bleeding, report excessively low blood pressure or bleeding to physician. for patients with arthritis, have them lose weight if obese, range of motion that does not increase pain, stop smoking, decrease/eliminate caffeine. Check and document color, temperature, distal pulses, capillary refill, movement, and sensation Care of patients with total hip arthroplasty after hospital discharge NURS 482 Advanced Medical Surgical Nursing • Hip precautions: do not sit or stand for prolonged periods • do not cross legs beyond midline of the body • for posterior surgery, do not bend hips more than 90 degrees • for anterior surgery, do not hyperextend post operative leg behind you • do not twist body when standing • use the prescribed ambulatory aid like a walker • do not put more weight on affected leg than allowed and instructed • resume sexual intercourse is fine • Pain Management: • report increased hip or anterior thigh pain to surgeon • take oral analgesics as prescribed • do not overexert yourself. take frequent rests • use ice as needed to operative hip • Incisional Care: • follow instructions provided regarding dressing changes • inspect hip incision everyday for redness, heat, drainage, if present all healthcare provider • do not bathe the incision or apply anything directly to the incision unless instructed to do so. • Other care • continue walking and performing leg exercises as you learned them in the hospital • do not cross legs to help prevent blood clots • report pain, redness, swelling in legs to surgeon immediately • call 911 for acute chest pain or shortness of breath • if taking an anticoagulant, take bleeding precautions • keep follow up appointments The patient using a continuous passive motion CPM machine • ensure machine is well padded • check the cycle and range of motion settings once every 8 hours • ensure the joint being moved is properly positioned on machine • if patient is confused, place the controls to the machine out of his or her reach • assess patient's response to the machine • turn off the machine while the patient is having a meal in bed • when the machine is not in use do not store it on the floor Rheumatoid Arthritis (RA) overview NURS 482 Advanced Medical Surgical Nursing chronic , progressive, systemic autoimmune disease that causes inflammation of connective tissue (joint), early onset at 20-40 years and occurs in multiple symmetrical joints. Synovium is affected leading to snyovitis Diagnostic Criteria symmetrical joints affected morning stiffness for at least 1 hour lasting 6 weeks, swelling or effusion of joints (3 or more) that lasts for 6 weeks, involves wrist, MCP, PIP joint arthritis, rheumatoid nodules, positive serum rheumatoid factor, and radiologic arthritic changes in hands and wrists. The patient with rheumatoid arthritis Early systemic signs: low grade fever, fatigue/weakness, anorexia, paresthesia (burning/tingling) Late systemic signs: peripheral neuropathy, anemia, subcutaneous nodules, pericarditis, enlarged liver and spleen Early joint signs: inflammation Late joint signs: deformities (swan neck or ulnar deviation), morning stiffness, moderate to severe pain Signs and symptoms: bilateral symmetrical joint involvement, swollen, inflammed joints, joint instability, limited range of motion in affected joints, ulnar deviation of fingers (swan- neck deformity), flexion contractures, respiratory complications, fibrosis and pulmonary hypertension, cardiac complications pericarditis and myocarditis. SEVEN S"S sunrise stiffness greater than 30 minutes soft, tender, warm joint symmetrical synovium inflammed systemic stages: synovitis, pannus, anklyosis Diagnostic x- rays (shows joint detoriation), bone scan, MRI/CT, rheumatoid factor, antinuclear body, erythrocyte sedimentation rate, c-reactive protein, SPEP, synovial fluid Energy conservation for the patient with arthritis NURS 482 Advanced Medical Surgical Nursing serum uric acid level is above 7 -> formation of monosodium urate crystals in peripheral tissues -> crystals deposit in synovial membranes, cartilage, connective tissues of the joint, stimulation of the inflammatory process -> neutrophils respond -> tissues are damaged -> inflammatory process exacerbates Gout type of arthritis due to the accumulation of uric acid in the blood that causes needle-like crystals to form in the joints. Primary gout - production of uric acid exceeds the excretion capability of the kidneys. Sodium urate is deposited in synovium and other tissues resulting in inflammation. most common type and results from metabolism issues. Affects middle-age and older men and postmenopausal women. The peak time of onset in men is between 40-50 years of age Secondary gout - affects people of all ages. Renal insufficiency, diuretic therapy, "crash" diets and certain chemotherapeutic agents. older patients with cardiovascular disease health problems, obese people, postmenopausal women Modifiable risk factors obesity, hypertension, elevated blood glucose levels, diet high in meat and seafood, alcohol, meds: diuretics and aspirin Non-modifiable risk factors: age and gender Stages of gout: asymptomatic hyperuricemia, acute gouty arthritis, tophaceous (chronic gout) Initial onset: acute time of day: night involves first metatarsophalangeal joint (great toe) Manifestations: hyperuricemia > 6.5, single joint inflammation with reoccurrence, tophi, renal disease, renal stones Acute gouty arthritis. single joint, usually great toe, instep, ankle, knee, wrist, elbow. Acute pain intensifies in 4-6 hours along with stiffness. Red, hot, swollen, tender joint that is too painful to be touched or moved. Fever, chills, malaise and elevated WBC and sedimentation rate Tophaceous (chronic) gout tophi (white yellowish nodules) evident on joints, bursae, tendon sheaths, pressure points, helix of ear. Joint stiffness, limited range of motion and deformity, ulceration of tophi with chalky discharge, at risk for renal stones. Diagnostics serum uric acid, WBC count elevated, sedimentation rate is elevated during an acute attack, 24 hour urine specimen, BUN/creatine, fluid aspiration from joint, fasting blood sugar/hgbA1C Pharmacological interventions of Gout NURS 482 Advanced Medical Surgical Nursing AVOID ASPIRIN AND DIURETICS AS THEY CAN PRECIPITATE AN EXACERBATION OF THE DISEAE!!! NSAIDS ARE THE TREATMENT OF CHOICE , AVOID IN PEPTIC ULCER DISEASE! Colchicine: interrupts the cycle of urate crystal deposition and inflammation and limited to gout. Avoid grapefruit juice Benemid: inhibits tubular reabsorption of urates and promotes excretion of uric acid and decreases serum uric acid levels. Give after meals or with milk. increase fluids to 3L a day to prevent kidney calculi. Give sodium bicarbonate or potassium citrate with this. Sulfinpyrazone (anturane) potentiates renal excretion of uric acid and used to prevent recurrent attacks as well as treat acute episodes. Allopurinol: reduces production of uric acid and decreases serum and urinary concentrations of uric acid and increase fluid intake and assess BUN and creatine levels. Give with meals and educate taking regular eye exams. Avoid vitamin C supplements that can increase renal calculi. Polyarticular gout responds to oral steroid therapy Pegloticase enzyme that works directly on uric acid. Monitor closely forallergic reactions including anaphylaxis Nutrition Therapy with Gout *low purine diet is recommended* Avoid: organ meat, shellfish, oily fish with bones (sardines) foods known to exacerbate gout, alcohol, fad diets, drugs that exacerbate gout that include aspirin and diuretics, excessive physical activity, and dehydration. Consume: plenty of fluids to reduce urinary stones ], increase pH by eating citrus juices and fruits, milk and dairy products. Stress management techniques. Primary nursing interventions for gout fluid intake over 3 liters a day, monitor medication side effects, bed rest until 24 hours after attack has subsided, elevate affected joint, apply hot and cold compress for comfort, weight loss for obesity, avoid fasting! Lyme Disease Stages NURS 482 Advanced Medical Surgical Nursing Localized stage 1: (7-14 days after infection), flu like symptoms, erythema migrans (round, oval, flat, slightly raised rash) or BULLS eye lesion, pain and stiffness in muscles and joints . Antibiotics (doxycycline or amoxicillin) (erythromycin for PCN allergy) for 14-21 days. Stage II - early disseminated stage (2-12 weeks after infection) cariditis with dysrhythmias dyspnea dizziness palpatations CNS disorders (facial paralysis, peripheral neuritis, meningitis) IV antibiotics (ceftriaxone or cefotaxime) for 30 days Stage III - Chronic Persistent Stage Months to years after the tick bite arthritis chronic fatigue memory/thinking problems may not respond to antibiotics Chronic Metabolic Bone Disorder loss of bone mass, more porous, increased bone fragility, increased fracture risk that includes hip, spine, wrist. normal bone remodeling: osteoclasts reabsorb old bone and osteoblasts form new bone. Role of the bone: protect and support organs, give our body its shape, movement. Inctricate system that maintains our survival through production of RBC, WBC, platlets . Stores blood cells, calcium, phosphate, lipids. Primary Osteoporosis take glucocorticoids for 3 months, anticonvulsants NURS 482 Advanced Medical Surgical Nursing Forteo - daily subcutaneous injection, used for those who do not tolerate other meds Aredia - infuse over 4 hours diluted with 1000 D5W , can not be given with calcium containing solutions (LR) x Fractures a fracture is a break or disruption in the continuity of a bone that often affects mobility and causes pain. Fragility or Pathologic fracture occurs after minimal trauma to a bone that has been weakened by disease. Fatigue or stress fracture results from excessive strain or stress on the bone. (seen in athletes) Compression fracture caused by a loading force applied to the long axis of cancellous bone (vertebrae of elderly) painful. Initial Trauma Assessment life threatening complications, vital signs, urine for blood (pelvic fractures) alignment of extremity, neurovascular status. Manifestations deformity, swelling, pain/tenderness, numbness/tingling, guarding of area, crepitus, hypovolemic shock, muscle spasms, ecchymosis Fracture Complications compartment syndrome, hemorrhage/hypovolemic shock, DVP, fat embolism, pulmonary embolism, osteomyelitis, delayed union (fracture that has not healed within 6 months of injury), nonunion (never completely heal) malunion (does not heal correctly) Compartment Syndrome EMERGENCY • increased compartment pressure (no change) NURS 482 Advanced Medical Surgical Nursing • increased capillary permeability (edema) • release of histamine (increased edema) • increased blood flow to the area (pulses present, pink tissue) • pressure on nerve endings (pain) • increased tissue pressure (referred pain to compartment) • decreased tissue perfusion (increased edema) • decreased oxygen to tissues (pallor) • increased production of lactic acid (unequal pulses, fixed posture) • anerobic metabolism (cyanosis) • vasodilation (increased edema) • increased blood flow (tense muscle swelling) • increased tissue pressure (tingling and numbness) • increased edema (paresthesia) • muscle ischemia (severe pain unrelieved by drugs) • tissue necrosis (paralysis) *LOOK FOR THE 6 P's - pain, pressure pallor, paresthesia, paralysis, pulselessness** Relieve pressure by removing restrictive casts or dressings. Fasciotomy and do not elevate the extremity above the heart level. The pain experienced is greater for the injury. Edema increases pressure on nerve endings causing the pain and reduces perfusion. Reduced perfusion causes pallor and paresthesia sensory perception deficits leads to paralysis and pulselessness. Emergency that can lead to sepsis, acute renal failure due to myoglobin release from muscle cells or loss of limb usually within the first 48 hours after surgery due to the release of histamine from the trauma, decreased blood flow, vasodilation, causing increased edema. Hemorrhage/hypovolemic shock: bleeding is a risk with bone injury because the bone is very vascular and can cause injury to arteries from the broken bone. Classic signs and symptoms of DVT calf or groin pain, sudden onset of unilateral swelling in one leg. Prevention early ambulation, adequate hydration, compression stockings, SCD hose, anticoagulant therapy Embolism who at risk? Patients with prolonged immobility, fractures of pelvis or long bones, total joint arthroplasty. Blood clot (pulmonary embolism) obstruction of the pulmonary artery by a blood clot Symptoms: sudden onset of anxiety, chest pain, dyspnea, crackles, tachycardia, chest pain Treatment: Anticoagulants, respiratory support including oxygen, bedrest NURS 482 Advanced Medical Surgical Nursing Fat Embolism obstruction of pulmonary vascular bed by fat globules. contains petechiae Symptoms: slow onset, altered mental status (early sign), chest pain, dyspnea, crackles, decreased oxygen, and VS. Petechial rash Treatment: supportive care: oxygen, hydration with IV fluids, diuretics, steroids, bedrest Fat embolism: fat globules are released from the yellow bone marrow into the bloodstream. these fat globules clog small blood vessels that supply vital organs. MOST COMMON LUNGS. EARLY SIGN: arterial oxygen level, dyspnea, tachypnea. LATE SIGNS: headache, lethargy, agitation, confusion, decreased LOC, seizures, vision changes. The petechiae over the neck, upper arms and chest is a classic sign and is a late symptom. Abnormal labs for a fat embolism include decreased oxygen pressure (below 60mmHg), increased erythrocyte sedimentation rate, decreased serum calcium level, decreased RBC and platelets, increased serum lipid serum. Chest x-ray will show bilateral infiltrates and fat embolus syndrome can lead to respiratory failure and death. Osteomyelitis Most common with open fractures and after surgical repair. Acute signs and symptoms; : fever above101, swelling around the area, tenderness, bone pain (constant and pulsating, worsens with movement) Chronic signs and symptoms: Foot ulcers are most common. Older adults may not have a temperature elevation even in the presence of severe infection. An acute onset of confusion (delirium) often suggests an infection in the older-adult patient Patients with one or more fractured ribs have severe pain when they take deep breaths. Monitor respiratory status which may be severely compromised from pain or pneumothorax . assess pain before anything. Swelling at the fracture site is rapid and can result in marked neurovascular compromose as a result of decreased arterial perfusion. Perform a neurovascular assessment and compare extremities . If not in severe pain, check capillary refill. circulation, movement, and sensation. Fracture Care Goals: prevent neurovascular compromise, prevent infection, effective immobilization, maintain tissue perfusion. Diagnosis: x-rays, bone scans, coagulation studies, CBC