NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024, Exams of Nursing

Download NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 and more Exams Nursing in PDF only on Docsity! think about s/s of Pulmonary disorders) lab test Hct and LDL NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 HEART FAILURE Assessment of left and right CAD: Left Sided Heart Failure ( • Most common • Prevents normal forward flowing blood • Blood backs up into the left atrium, and then to the pulmonary vein o Pressure increases, fluid leaks from the pulmonary capillary bed into the interstitium and then the alveoli o Results in pulmonary congestion and edema • Signs o LV heaves o Alternating pulses (strong, weak): o Increased HR o Decreased PaO2, slight increase PaCO2 (result poor oxygen exchange) o Crackles (pulmonary edema) o S3/S4 sounds o Pleural effusion o Changes in mental status, restlessness, confusion o Orthopnea, shallow respirations, dry hacking cough o Nocturia o **Frothy, pink- tinged sputum (advanced pulmonary edema) Right Sided Heart Failure • RV fails to contract effectively • Backup of blood into the right atrium, and then venous circulation • Venous congestion in systemic circulation results in o JVD o Hepatomegaly o Splenomegaly o Vascular congestion of GI tract NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 o Peripheral edema: blood returning is blocked/backed up • Can result from acute conditions such as RIGHT VENTRICULAR INFARCTION or P.E. • CorPulmonale: right ventricular dilation and hypertrophy caused by pulmonary disease • Primary cause: Left-sided HF o Left side HF results in pulmonary congestion, increased pressure in the blood vessels of lungs (pulmonary HTN) o Chronic pulmonary HTN puts increased right ventricular afterload and results in right-sided hypertrophy and HF • Signs/Symptoms o RV heaves, murmurs o JVD: 30-45 degree angle to be able to see o Edema (pedal, scrotum, sacrum) o Weight gain o Increased HR o Ascites: abdomen o Anasarca (massive generalized body edema): 2+ everywhere o Hepatomegaly (liver enlargement): o RUQ pain, anorexia, GI bloating NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 • Focus on reduction of anxiety (it stimulates the SNS response and increases workload), this is done by nursing interventions and the use of sedatives • Nursing responsibilities o Teaching the patient about changes that have occurred o Helping the patient to adapt to physiologic and psychological changes o Integrate the patient and caregiver in the overall plan o Provide a clear plan if s/s of HF occur o Emphasize they can live a productive life o Emphasize medication must be continued to keep HF under control even if they feel better o Teach action of the drugs and signs of drug toxicity o How to take a pulse rate (1 minute) if <50 withhold B-adrenergic blocker drugs. Provide information when these drugs should be held and when a provider should call o Teach s/s of hypo/per kalemia if diuretics are ordered o Give supplemental potassium to those taking thiazide or loop diuretics • Consult with physical/occupational therapist on energy conserving techniques • Exercise training (cardiac rehabilitation). Exercise is safe, help patient explore alternative activities that cause less physical stress o o Lab test: BNP B-typye Natriuretic Perptide- hallmark of heart failure o Table 35-6 • O2 therapy 2-6 L/min by nasal cannula • Rest-activity periods • Cardiac Rehabilitation • Home health nursing care (telehealth monitoring) • Drug therapy • Cardiac resynchronization therapy with biventricular pacing and internal cardioverter-defibrillator • LVAD • Cardiac transplantation • Palliative and end-of-life care NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 o o Drugs • Diuretics: Furosemide [Lasix], bumetanide [Bumex] o Be careful may lose to much potassium o Spironolactone: Aldactone: Potassium sparring • Sodium Nitroprusside [Nipride] o IV vasodilatory reduces preload/afterload o Improves contraction, increases CO, and reduce pulmonary congestion o Complications ▪ Hypotension ▪ Thiocyanate Toxicity (after 48 hrs of use) • Dopamine: o Look at IV site for extravasation o Tissue necrosis w/ sloughing o High dosages may produce ventricular dysrhythmias o o Discharge instructions: Table 35-10 NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 • Monitoring vital signs and weight, responses to therapy • Specialized programs dedicated to managing HF patients at home • S/S of HF (FACES- fatigue, limitations of activity, chest congestion/cough, edema, SOB) • S/S: orthostatic hypertension: Diuretics, vasodilators • Report to health care provider if o Weight gain of 3 lb in 2 days or 3-5 in a week o Difficulty breathing, exertion or lying flat, breathless at night, dry hacking cough (lying down), fatigue, weakness, swelling of ankles, feet, abdomen o Difficulty breathing or swelling of face if taking ACE inhibitors • Avoid heat/cold • Consult diet plan • Examine labels for sodium content, and OTC medications • Weigh yourself at each time each day • Eat smaller, frequent meals • Digoxin: anything below 60 pulse rate DO NOT GIVE! Or anything above 100 o o HYPERTENSION o Normal parameters • <120 and <80 • PREHTN: 120-139 or 80-89 • HTN ST1: 140-159 or 90-99 • HTN ST2: >160or > 100 • Confirmed on at least two visits o o Assessment: orthostatic BP assessment pg 723 • Assess in older adults, people taking antihypertensive drugs, and in patients who report symptoms consistent with reduced BP on standing (light-headedness, dizziness, syncope) • Arm level with heart • Measure BP and pulse with patient supine, sitting, standing, 1-2 minutes apart • Usually the SBP decreases <10 mmHg on standing, where DBP and pulse increase slightly NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 o o Rheumatic heart disease: assessment, o client education • Assessment o Carditis (inflammation of the heart, ALL LAYERS!) ▪ Fibrosis, lesions, STENOSIS!! ▪ Lesions are SYSTEMIC and involve the skin, joints, and CNS ▪ Painless subcutaneous nodules, arthralagias/arthritis, and chorea may develop o Monoarthritis or polyarthritis ▪ Most common finding ▪ Joint swelling, larger joints mostly o Sydenham’s Chorea ▪ Delayed sign ▪ Involuntary movements of face and limbs; muscle weakness, disturbances of speech and gait o Erythema Marginatum ▪ Bright pink, nonpruiritic, lesions on the trunk and proximal extremities, exacerbated by heat o Subcutaneous nodules (painless) NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 Myocarditis: o NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 • Minor Criteria o Clinical findings: Fever, polyarthralgia o Prolonged PR interval • Need 2 major criteria or 1 major and two minor PLUS evidence of A streptococcal infection(can cause of inflammation of the heart if left untreated) • Cardiac enlargement, murmurs, muffled heart sounds, chest pain, pericardial friction rub, signs of effusion o o CLIENT EDUCATION • Good nutrition, hygienic practices, adequate rest • Caution patient about the possible development of heart valve disease • Seek medical attention if symptoms such as excessive fatigue, dizziness, palpitations, and unexplained weight gain, exertional dyspnea. • Treatment with prophylactic antibiotics o w/o carditis they need until age of 20 and for min. 5 years. o o Mitral valve prolapse: client education: 37-11 • Take medications as prescribed (B-adrenergic blockers to control palpitations, chest pain) • Adopt health eating habits and avoid caffeine because it is a stimulant and may exacerbate symptoms • Stay hydrated • If you use diet pills or other OTC, check for common ingredients that are stimulants  can exacerbate symptoms • Begin (or maintain) an exercise program • Contact the health care provider or EMS if symptoms develop or worsen (palpitations, fatigue, SOB, anxiety) o Assessment • Inflammation of myocardium • Causes o Viruses, bacteria, fungi, radiation therapy, and pharmacologic and chemical factors NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 o May also be idiopathic o Coxsackie A and B viruses o Seen with acute pericarditis when it is caused by coxsackie B virus • Assessment o Fever o Fatigue o Malaise o Myalgias o Pharyngitis o Dyspnea o Lymphadenopathy o Pleuritic chest pain with a pericardial friction rub and effusion o LATE S/S: S3, crackles, JVD, syncope, peripheral edema, angina o o o NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 o Care of client • Nitrates: dilate peripheral blood vessels and coronary arteries and collateral vessels • Sublingual Nitroglycerin o Pt. should sit down before taking the nitroglycerin to decrease cardiac workload and prevent orthostatic hypotension o Under tongue, spray on tongue o Works in 3 minutes, duration 30-40 minutes o Take one, if symptoms continue for 5 minutes take another, up to 3x, if pain not relieved, call 911 o Should be accessible at all times, keep away from light and heat, should be replaced every 6 months o May cause dizziness, flushing, headache  take Tylenol o Can use before it happens o Orthostatic hypotension  monitor BP • ACE inhibitors o For patients with high risk for cardiac event o Vasodilation and reduced blood volume o If intolerant, use angiotensin II receptor blockers • Beta adrenergic blockers o Can be poorly tolerated w/ many side effects (bradycardia, hypotension, wheezing, GI complaints, weight gain, depression, sexual dysfunction) o Do not use if you have asthma o Caution in DM (it can mask s/s of hypoglycemia) • Calcium Channel Blockers o Primarily for Prinzmetal’s angina o Cause smooth muscle relaxation and relative vasodilation of coronary and systemic arteries thus increasing blood flow o Nursing Intervention • Position upright unless contraindicated and Adminster oxygen • Assess vital signs • Obtain a 12-lead ECG • Provide prompt pain relief first with a nitrate followed by an opioid • Ausculate heart and breath sounds o If you hear a new mumur during an angina attack they may have NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 ischemia of a papillary muscle of the mitral valve • o o Table 34-10 o Treatment of Stable Chronic Angina o A • Antiplatelet/anticoagulant therapy • Antianginal therapy • ACE inhibitor/angiotensin receptor blocker o B • B-adrenergic blocker • BP control NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 o C • Cigarette smoking cessation • Cholesterol (lipid) management • Calcium channel blockers • Cardiac rehab o D • Diet (weight mgmt.) • DM management • Depression Screening o E • Education • Exercise o F • Flu Vaccine o o Look at table 34-9 o o o o o Myocardial Infarction o Assessment • Sustained ischemia • Described by location of damage • Anterior wall: blockages in L. anterior decending artery • Lateral/posterior wall: blockages in the left circumflex artery • Inferior wall: right coronary artery • S/S o Pain: heaviness, pressure, tightness, burning, constriction, crushing ▪ Substernal, retrosternal, epigastric ▪ Epigastric can be confused with GI upset and they may take anatacids w/ no relief ▪ Can radiate to neck, jaw, arms, back ▪ Some do not have pain, older patient may have change in mental status, DM patient may have “silent” o SNS Stimulation NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 • Dysrhythmias o Most common complication o Caused by anything that disrupts the cell’s sensitivities to nerve impulses (ischemia, electrolyte imbalances, SNS stimulation) o Tachycardia, bradycardia, irregular HR o Ventricular Fibrillation: LETHAL!! o Life threatening occur with anterior wall infarction, HF, or shock • Heart Failure o Hearts pumping action is reduced o Dyspnea, restlessness, agitation, minor tachycardia o Pulmonary congestion, S3 S4, crackles, JVD • Cardiogenic Shock NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 o Occurs when oxygen and nutrients supplied to the tissues are inadequate because of severe left ventricular failure • Papillary Muscle Dysfunction o Occurs if the infarcted area includes or is near the papillary muscle that attaches to the mitral valve o **if you hear a mumur at the cardiac apex o echocardiogram confirms diagnosis o Causes mitral valve regurgitation • Ventricular Aneurysm o Infarcted myocardial wall is thin and bulges out during contraction o HF, dysrhythmias, angina o Rupture, and lead to an embolic stroke o • Pericarditis o Inflammation of the viscera/parietal pericardium resulting in cardiac tamponade, decreased ventricular filling and emptying, and HF o Chest pain, worse on inspiration, coughing, and movement of the upper body o Sitting in forward position relieves pain o Friction rub over the pericardium at the mid to lower left sternal border o Dx made with a 12-lead ECG • Dressler Syndrome o Pericarditis with effusion and fever that develops 4-6 weeks after MI or after cardiac surgery o Caused by an antigen-antibody reaction to the necrotic tissue o Pericardial pain, fever, friction rub, pericardial effusion, arthralgia o Elevated WBC count and sedimentation rate * Treat w/ short term corticosteroids o o Discharge instructions • Check pulse rate, know limits to which to exercise • If HR exceeds maximum HR and does not return to resting pulse, tell them to sit and rest • Should not exceed 20 beats/min over resting HR NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 • Should be regular, rhythmic, repetitive, using large muscles to build up endurance (isometric: walking, cycling, swimming, rowing) • At least 30 minutes long, may start at 5-10 and build up. • Do not use nitrates with erectile dysfunction drugs (severe hypotension and death) • Take NTG prophylactically o o Irregular Rhythms: CPR ??—if pt is unconscious. o o o o o o Pacemaker o Client Education • Maintain follow up care with cardiologist for regular function checks • Report any signs of infection to cardiologist immediately NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 o o o Varicose Veins: Assessment: • Heavy, achy feeling or pain after prolonged standing or sitting o Relieved by walking or limb elevation • Pressure, itchy, burning, tingling, throbbing, cramplike sensations • Swelling, restless or tired legs, fatigue, nocturnal leg cramps • SVT more frequent complication o Spontaneous, after trauma, surgical procedures, pregnancy • Primary: Congenital weakness of veins, more common in women • Secondary: previous VTE. Can occur in esophagus, vulva, spermatic NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 cords, anorectal, abnormal arteriovenous connections • Reticular:smaller, appear flat, flat, less tortuous, blue-green in color • Telangiectasias: Often referred to as spider veins, small visible vessels (less than 1 mm in diameter) that appear bluish, black, purple, red o o Venous Thrombus o Assessment • Formation of a thrombus in association with inflammation of the vein NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 • Superficial vein thrombosis o Thrombus formation in superficial vein, usually the greater or lesser saphenous vein o Palpable, firm, subcutaneous cordlike vein o Itchy, tender, painful to touch, reddened, warm o Mild temp elevation and leukocytosis (maybe) o Extremity edema may occur • Deep Vein Thrombosis o Thrombus in a deep vein, commonly the iliac and femoral veins o S/S: unilateral extremity edema, pain, warn skin, positive Homan’s Sign, Fullness in thigh/calf o Assessment: when Dorsiflexion is done by the examiner, the pt. will complain of calf pain if there is a blood clot o TX/Intervention: ▪ SCD – Sequential compression device ▪ TED hose- Thrombo Emboli deterrent ▪ IVF- Inferior Vena cava filter • Venous Thromboembolism: spectrum of the path from DVT to PE o May/may not have unilateral leg edema, pain, tenderness with palpation, dilated superficial veins, fullness in thigh or calf, paresthesias, warm skin, erythema, temperature > 100.4 o If inferior vena cava is involved, both legs may be edematous and cyanotic o Superior vena cava ▪ arms, neck, back, face • VIRCHOWS TRIAD o Venous stasis : Risk pt. afib, age, CHF, obesity, surgery, o Damage of the endothelium (inner lining of vein) : • Risk Pt. (Direct: surgery, trauma) o (Indirect: diabetes, sepsis) o Hypercoagulability of the blood : Risk Pt. dehydration, hormone replacement, oral contraceptives o RISK: pg 848 table 38-8 o NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 holding cold objects • Avoid extreme temperature/cold weather • Immerse hands in warm water to decrease vasospasm • Stop using tobacco products and avoid caffeine and other things with vasoconstrictive effects (cocaine, amphetamines, ergotamine, psudoephedrine) • Teach stress management strategies o o o o o o o o Venous Ulcers: Assessment pg 857 NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 • Located above the medial malleolus • Painful, edema and inflammation, worse when in dependent position • Untreated, becomes deeper and wider, increasing risk for infection • Osteomylelitis and malignant changes, amputation are severe complications • Comes from CVI • Evaluate the nutritional status need protein, calories, and nutrients (protein, vit A, vit C, Zinc) • INFECTION o Change in quantity, color, odor of drainage o Pus o Erythema o Change in sensation around wound o Warmth o Local pain, edema, dark colored granulation tissue o Induration around the wound, delayed healing, cellulitis o o Peripheral Artery Disease pg 835 o Assessment • Leading cause is atherosclerosis • Risk factors: tobacco, DM, hyperlipidemia, C-reactive protein elevated, uncontrolled HTN, family hx, hypertriglyceridemia, age, hyperhomocysteinemia, hyperuricemia, obesity, sedentary lifestyle, stress , cigarettes smoking • S/S depend on site and extent of blockage o Intermittent claudication: ischemic muscle pain that is caused by exercise, relieved in 10 minutes or less with rest ▪ Iliac arteries: pain in buttocks and thighs ▪ Femoral or popliteal: Calf ▪ Internal iliac arteries: erectile dysfunction o Paresthesia, peripheral neuropathy o Skin becomes thin, shiny, taut, hair loss or uneven distribution o Pedal, popliteal, femoral pulses diminished or absent o Pallor when foot elevated o Reactive hyperemia: dependent position NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 o Rest pain aggravated by limb elevation (tell pt to dangle their legs on side of bed) o Ulcerations on bony prominences, toes, foot, minimal drainage, black tissue (well-defined borders sores) o >3 seconds cap refill, cool temperature o Nails thickened, brittle o Bruits may be present at pulse sites o Diagnostic procedures • Doppler ultrasound o Segmental blood pressures using Doppler and sphygmomanometer at thigh, below knee, and ankle while patient is supine o <30 mmHg suggests PAD • Angiography and MRAngiography • Ankle-brachial index (ABI) screening tool o Dividng ankle systolic BP by higher of L/R brachial systolic BP. NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 o Inflammatory disorders (Crohns) • Iron-deficiency anemia o Pallor most common o Glossitis (inflammation of the tongue) o Cheilitis (inflammation of the lips) o Headache, paresthesias, NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 • Anemia of chronic disease o Elevated serum ferritin and increased iron stores (distinguish from iron- deficiency) o Normal folate and cobalamin blood levels • • Pernicious Anemia- Associated with cobalamin (Vit B12) deficiency • -lack of B12 absorption due to lack of intrinsic factor • S/S: Numbness of the extrimities • • Priority Nursing Care • Chronic diseases o Correct underlying disorder o Severe: blood transfusions (not recommended for long term) o Erythropoietin therapy related to renal disease/cancer • Blood loss o Replace blood volume to prevent shock o Identify the source of the hemorrhage and stop the blood loss o IV fluids: LR solution o Packed RBCs o Supplemental Iron • Fatigue o Correct status, limit visitors, encourage rest periods, monitor response, avoid physical activities right after meals, assist with activities • Imbalanced nutrition o Determine (with RD) # of calories and type of nutrients needed to meet requirements o Teach about food dairies o Monitor intake and calories o Encourage intake of PRO, iron, Vit C o High iron foods (meat, egg/omelet, whole wheat/bread) • Ineffective self-health management o Facilitate ID of eating behaviors that need to be changed o Use accepted nutritional standards o Discuss nutritional requirements o Provide referral or consultation to other health care team members o Review w/ patient measurements of hemoglobin values • • NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 • • Blood transfusions • Administered with large bore needle, cannula, or catheter (19 normally, if rapid transfusion, 18 or 16) o Smaller can be used for platelets, albumin, clotting factors • Verify patency before requesting blood component from the blood bank • SAFETY o Do not use dextrose solutions or LR for administering blood because they will cause RBC hemolysis o Do not give additives (including meds) via the same tubing as the blood unless the tubing is first cleared with saline • Make positive ID for the donor and the recipient (improper product-to-patient ID is most common cause of hemolytic transfusion reactions) NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 • Polycythemia: Tx • production and presence of increased numbers of RBCs leading to hyperviscosity and hypervolemia. • Treatment is directed toward reducing blood volume and viscosity and bone marrow activity o Phlebotomy o Goal: hematocrit < 45%-48% o 300-500 mL of blood may be removed every other day until hematocrit is reduced to normal levels o Repeated may become iron deficient, AVOID IRON SUPPLEMENTATION o Hydration therapy: reduce viscosity ▪ Evaluate fluid intake and output to avoid fluid overload or underhydration ▪ Nurse may perform the phlebotomy o Low dose asprin to prevent clotting o Alpha-IFN childbearing age, intractable pruritus o Anagrelide (Agrylin) reduce platelet count / inhibit platelet aggregation o Allopurinol (Zyloprim) reduce the number of acute gouty attacks o Assess nutritional status o Begin activities/medications to decrease thrombus formation, active/passive leg exercises, ambulation to decreased DVT o Polycythemia vera requires ongoing evaluation, phlebotomy may need to be done every 2 to 3 months reducing by 500 mL each time • • Thrombocytopenia: Nursing Care • Reduction of platelets below 100,000/uL • <20,000 spontaneous life threating hemorrhages can occur • transfusions usually only done when < 10,000 • Corticosteroids (suppress phagocytic response of macrophages, reduce capillary leakage) • Splenectomy- avoid person who are ill/ wash hands/ Due to Riskfor Infection, immunization such as pneumococcal is advisable • Plasma exchange • Discourage use of OTC mediations, aspirins, alcohol, antibiotics, analgesics, vitamins C/E, some herbal products, NSAIDS, heparin, digoxin • Encourage complete medical evaluation if manifestations of bleeding tendencies develop (prolonged NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 epistaxis, petechiae) • Observe for early signs in patient receiving chemotherapy • Emphasize that a seemingly minor nosebleed or new petechiae may indicate potential hemorrhage and their doctor should be notified • If you have to give a subcutaneous injection, use SMALL bore, pressure for 5- 10 minutes, or application of an ice pack • Avoid IM injections • Monitor all blood cell and coagulation studies (platelet count, coagulation studies, hemoglobin, hematocrit) o All consumed while bleeding occurs • Monitor menstrual blood loss (1 napkin = 50 mL of blood), menses may be inhibited during predictable periods such as using chemotherapy) • Teach to avoid causative agents when possible o Thiazide diuretics, digoxin, heparin, chemo, alcohol, NSAIDS, antibiotics, antiinfectives, anaglesics, antipsychotic/seizure, H2 receptor antagonists, spices, vitamins C, E, some herbs, quinine compounds (tonic water) o Avoid injury and trauma, know s/s of bleeding NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 o Planned periodic medical evaluations • • Thrombocytopenia: Client Education • Notify health care provider if you have experienced s/s of bleeding such as o Black tarry stools, bloody bowel movements, black/bloody vomit, sputum, or urine o Bruising or small red/purple spots on skin o Bleeding from mouth/anywhere on body o Headache or changes in vision o Difficulty talking, sudden weakness of arm or leg, confusion o Difficulty to arouse- indicates cerebral hemorrhage and its emergency • Ask HCP about restrictions in exercise, lifting weights. o Walking is safe w/ study shoes or slippers o If weak/fall risk, get help when getting out of bed • Do not blow nose forcefully, gently pat with tissue o If nosebleed, keep head up and apply firm pressure to nostrils o If continues, place an ice bag over bridge of your nose and the nape of your neck o After 10 minutes call HCP • Do not bend down with your head lower than your waist • Drink plenty of fluids to prevent constipation, do not strain, do not use suppository, enema, rectal thermometer w/o permission. Dr. May provide a stool softener • Shave only with electric razor, no blades • Do not pluck eyebrows or other body hair • Do not puncture your skin (tattoos, piercings) • Avoid any medication that can prolong bleeding (aspirin), herbs, if you are unsure, ask HCP or pharmacist in relation to dx • Use a soft-bristle tooth brush o Flossing is safe using thin tape floss o Do not use alcohol based mouth washes (dry up gums and increase bleeding) • Keep track of number of pads that are used per day (1=50 mL) o When you use more than usual, notify HCP. DO NOT USE TAMPONS. • Ask HCP before you have invasive procedures done, such as dental cleaning, manicure, or pedicure. • • Sickle Cell Disease: Client Education • Group if inherited, autosomal recessive disorders characterized by an abnormal form of hemoglobin in the RBC NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 o Recommended Female: >50 mg/dL o Low risk for CAD >60 mg/dL o High risk for CAD: < 40 mg/dL • Risk for cardiac disease is assessed by dividing the total cholesterol level by the HDL level and obtaining ratio o Low risk: <3 o Average: 3-5 o Increased risk: > 5 • BUN: 6-20 mg/dL • CREATININE: 0.6-1.2 mg/dL (more reliable than BUN) • Platelets : 150,000to 400,000 (low platelet, risk for bleeding) • • • Therapeutic range for INR-relationship to Coagulation (2 -3 normal for pt who is receiving Coumadin; 1 for healthy individual) – below 2 increased risk of infection • Normal Potassium Level NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 o 3.5- 5.0 • Normal Hemoglobin Level o Gas carrying capacity of RBC o Female: 11.7-16.0 g/dL o Male: 13.2-17.3 g/dL • Hematocrit o Male: 39 – 50% o Female: 35 -47% • • Procedures • • Cardiac Catheterization: Nursing Care • Insertion of a catheter to obtain information about oxygenation levels and pressure readings in the heart chambers • Contrast medium injected • Catheter into a vein for right side, artery for left side. • Nursing Responsibility o Check for sensitivity to contrast media o NPO 6-12 hrs prior / monitor Bp and ECG during procedure o Sedative and other drugs if ordered o Inform patient about local anesthesia, insertion of catheter, feeling of warmth when dye is injected, and possible fluttering sensation of heart as catheter is passed o The patient may need to cough / deep breath when dye is injected, ECG throughout procedure o After procedure ▪ Assess circulation to extremity used for catheter insertion ▪ Check peripheral pulses, color, sensation of extremity ▪ Observe puncture site for hematoma/bleeding place compression device over arterial site to achieve hemostasis ▪ Monitor VS and ECG ▪ Assess for hypotension or hypertension, dysrhythmias, s/s PE (respiratory difficulty) • • ECG: Client education • Emits and receives ultrasound waves on four positions on chest above the heart • Records sound waves and direction and flow of blood through heart and transforms it to audio and graphic data that measure valvular NURSING EXAM 2 MEDICAL SURGICAL STUDY GUIDE LATEST UPDATE 2023/2024 abnormalities, congenital cardiac defects, wall motion, EF, and cardiac function • May use IV contrast • Nursing o Patient in side-lying position facing equipment o Instruct patient about procedure and sensations (pressure and mechanical movement from head of transducer) o No contraindications to procedure exist o Monitor ECG if pt has pulse deficit (cardiac dysrrhytmias can be detected) • • Bone Marrow Biopsy: Nursing Care • Allows for full evaluation of hematopoiesis • Ability to obtain specimens for cytopathologic and chromosomal abnormalities • Preferred site: posterior iliac crest