Study Guide for N120 HESICardiovascular

Coronary Artery Bypass Graft (CABG): the construction of new conduits (vessels to transport blood) between the aorta, or other major arteries.

o Requires use of Sternotomy (opening of the chest cavity) & the use of cardiopulmonary bypass (CPB).

o Internal mammary artery (IMA); most common artery for graft

o Palliative treatment for those with CAD, not a cure Stent: an expandable meshlike structure designed to maintain vessel patency by

compressing the arterial wall & resisting vasoconstriction Peripheral Vascular Disease (PVD)

o Most common disease of the artery caused by build-up of fatty material w/in the vessels (atherosclerosis).

o A gradual process where the artery gradually becomes blocked, narrowed, or weakened.

o Causes: ischemia, gangrene, stroke, blood cloto Risk factors: positive family Hx, > 50 yrs old, overweight/obese, inactive lifestyle,

Diabetes, ↑BP/cholesterol/or LDL (bad cholesterol), plus high triglycerides & low HDL

Congestive Heart Failure (CHF) o an abnormal clinical condition involving impaired cardiac pumping.o Results in characteristic pathophysiologic changes of vasoconstriction & fluid

retention.o Classified as:

Systolic failure (inability to pump blood) Diastolic failure (inability of ventricles to relax & fill during diastole).

o Left sided Heart Failure is related to respiratory conditions => ex) Pulmonary edema

Dyspnea, wet lung sounds, confusion, cough, tachycardia o R ight sided Heart Failure is related to peripheral conditions => ex) Peripheral

edema Peripheral edema, distended neck veins, nocturia, weakness, weight gain

o Collaborative management: decrease intravascular volume, decrease venous return, decrease afterload, improve gas exchange/oxygenation, reduce anxiety,

B-blockers, ARB’s, Ace Inhibitors, Diuretics, Nitrates Dysrhythmia: Cardiac dysrhythmia occurs when the average adult HR falls below or rises

above the normal range of 60 to 100 beats per minute (see page 849 for various types)o can be seen using and electrocardiogram (ECG)o determine serum drug levels (especially K & Mg), determine drug levels

Deep Vein Thrombosis: a disorder involving a thrombus in a deep vein (most commonly the iliac & femoral veins)

o the treatment options are anticoagulation, thrombolysis, embolectomy, surgical revascularization, or amputation

Anticoagulants are administered immediately to prevent further enlargement of a thrombus and inhibit embolization. (Administer heparin!!!!!)

Prior to administering Heparin, check PTT or APPT values!!! 1.5-2.5 times the normal control When using heparin, don’t massage area or aspirate

Respiratory Trauma

Acute Respiratory Distress Syndrome (ARDS): Serious reaction to numerous injuries to the lung.

o Characterized by inflammation of the lung, parenchyma leading to impaired gas exchange with concomitant systemic release of inflammatory mediators causing inflammation, hypoxemia and frequently resulting in multiple organ failure. This condition is often fatal, usually requiring mechanical ventilation and admission to an ICU. A less severe form is called acute lung injury.

o S/s: SOB, tachypnea, & confusion Emphysema: Increase size of air spaces w/ loss of elastic recoil of lung due to

hyperinflation of distal airways causing airway obstruction. Emphysema & bronchitis are known as COPD

o Destruction of alveolar walls & diffuse airway narrowing causes resistance to airflow because the loss of supporting structure & bronchospasm further impeded airflow.

o Clinical manifestations: cyanosis, barrel chest, crackles, dyspnea, clubbing Superior Vena Cava (SVC) syndrome: results from obstruction of the superior vena cava

by a tumor or thrombosis. Most common causes are lung cancer, non Hodgkins lymphoma, & metastatic breast cancer.

o Clinical Manifestations: Facial edema, periorbital edema, distention of the veins of the head/neck/chest, headaches, & seizures.

o Treatment: radiation therapy to site of obstruction (chemotherapy may also be used)

Laryngospasm: a brief spasm of the vocal cords that temporarily makes it difficult to speak or breathe.

o Clinical Manifestations: Inspiratory stridor, sternal retraction, acute respiratory distress

o Treatment: O2, pos. pressure ventilation, IV muscle relaxant, Lidocaine, Corticosteroids

Breathing Exercises: may assist the patient during rest and activity by decreasing dyspnea, improving oxygenation, and slowing the respiratory use.

o Typically performed by Respiratory or Physical Therapists

o Main types are: Pursed Lip Breathing: purpose is to prolong exhalation and thus prevent

bronchiolar collapse and air trapping. (slows RR) Patient taught to inhale slowly through nose and exhale slowly

through purse lips (as if whistling) Recommended for severe COPD (diaphragmatic breathing may

cause hyperinflation, thus is not recommended in this case) Diaphragmatic Breathing: focuses on using the diaphragm rather than

accessory muscles of the chest to 1) achieve maximum inhalation 2) slow the RR

Fingernail Clubbingo a thickening of the flesh under the toenails and fingernails. The nail curves

downward, similar to the shape of the round part of an upside-down spoon.o Seen in those suffering from chronic hypoxemia, cystic fibrosis, lung cancer, and

bronchiectasis (also may be seen in COPD) Pneumonia: an acute inflammation of the lung parenchyma caused by a microbial

organism. o Acquired via aspiration, inhalation, or hematogenous spreado Clinical Manifestations: fever, chills, SOB, cough (productive purulent sputum),

chest pain, confusion (elderly), hypoxiao Treatment: antibiotics (penicillin), antipyretics, analgesics, bronchodilator,

flu/pneumonia vaccine, increase fluids, breathing/coughing exercises, O2 therapy Crush Injury: occurs when a body part is subjected to a high degree of force or pressure,

usually after being squeezed between two heavy objects.o May result in: bleeding, bruising, compartment syndrome, fracture, laceration

Chronic Obstructive Pulmonary Disorder (COPD): a preventable & treatable disease state characterized by airflow limitation that is not truly reversible.

o Encompasses chronic bronchitis and Emphysema o Cigarette smoking is a major risk factor toward COPDo Characterized by chronic inflammation found in the airways, lung parenchyma,

and pulmonary vasculature. o S/s: barrel chest, decreased abd. breathing, relying on intercostals/accessory

muscles for breathing, non productive cough, purse lips breathing, hypoxemia, cyanosis

o ABG’s: usually assessed in the severe stages and monitored in those hospitalized with acute exacerbations.

values Sample RangespH 7.35-7.45 ↓ ↑ ↑ ↓ PCO2 35-45

mmHq↑ ↑ ↓ ↓

HCO3 21-27 mEq/L

X ↑ X ↓

Respiratory Acidosis

Metabolic Alkalosis

Respiratory Alkalosis

Metabolic Acidosis

Endocrine

Chvosteks sign (tetany???)o Chvosteks sign is a contraction of facial muscles in response to a light tap over

the facial nerve n the front of the ear.o Also indicates hypocalcemia with latent tetany. o Tetany is the increased nerve excitability and sustained muscle contraction.

Troussseau’s sign: refers to carpal spasm induces by inflating a blood pressure cuff on the arm.

Cushings Syndrome: A spectrum of clinical abnormalities caused by an excess of corticosteroids (glucocorticoids in particular).

o Clinical Manifestations: weight gain, hyperglycemia, protein wasting, loss of collagen, HTN, mood disturbances, moon face

o Primary Goal: to normalize hormone secretion Goal of Drug Therapy: inhibition of adrenal function.

o Tx: surgical (laparoscopic adrenalectomy) or meds (Mitotane, Metyrapone, aminoglutethimide, ketoconazole)

Diabeteso Diabetes mellitus is a chronic multisystem disease related to abnormal insulin

production, impaired insulin utilization, or both.o Type I Diabetes Mellitus: formerly known as “juvenile onset” or “insulin

dependant” diabetes, type I diabetes most often occurs in those under 30 yrs of age. This condition is the end result of a long standing process in which the body’s own T cells attack and destroy pancreatic B cells, which are the source of the body’s insulin.

Classic symptoms of type I diabetes include Polydipsia, Polyphagia, and Polyurea (the 3 P’s)

o Type II Dia betes Mellitus is formerly known as “adult onset diabetes” usually occurring in those over 35 yrs (kids at high risk today), & involves the pancreas being able to make endogenous insulin which is either insufficient for the needs of the body, &/or is poorly utilized by the tissues.

Clinical manifestations are often nonspecific but often include: fatigue, recurrent infections, prolonged wound healing, visual changes

Hyperparathyroidism: a condition involving an ↑secretion of parathyroid hormone (PTH)

o Associated with increased serum Calcium levels Excessively high levels of circulating PTH usually lead to hypercalcemia

and hypophosphatemiao Clinical Manifestations: weakness, loss of appetite, constipation, incr. need for

sleep, emotional disorders, kidney stone, and shortened attention span.

May result in calcium loss from bone (decrease bone density) May cause renal caliculi

o Tx: moderate Ca intake and increase fluid intake, Biphosphonates, Calcimimetic agents (incr sensitivity of Ca receptor on parathyroid gland)

Propanolol (thyroid???)o Beta blockers such as propanolol can help to control the heart rate, and

intravenous steroids may be used to help support circulationo Reduces HR, myocardial irritability, and force of contractions.

Parathyroid: The parathyroid glands secrete parathyroid hormone (PTH) also known as parathormone. Its role is to regulate the blood level of calcium by acting on bone, kidneys, and GI tract (indirectly).

o PTH stimulates renal conversion of Vitamin D which enhances the intestinal absorption of Calcium.

o When Ca serum is low, PTH secretion rises; when Ca serum is high, PTH secretion falls.

o Low Ca levels allow Na to move into excitable cells, decreasing the threshold of action potentials with subsequent depolarization of the cells.

Results in Tetany (increased nerve excitability & sustained muscle contractions)

Adrenalectomy: the surgical removal of one or both adrenal glandso may be performed through laparoscopic or open surgeryo an open surgical adrenalectomy is used to treat adrenal cancer.

Diabetes A1C: a test useful in determining glycemic levels over time.o Used by diabetic patients and health care providers to monitor success of

treatment and to implement changes in treatment modalitieso Indicates the overall glucose control for the previous 90-120 days.o For people with diabetes, the ideal A1C goal is 7.0% or less according to the

ADA. The American College of Endocrinology recommends an A1C of less than 6.5%.

Normal HbA1C levels decrease the incidence of neuropathy, nephropathy, and retinopathy.

Diabetic Neuropathy: nerve damage that occurs because of the metabolic derangements associated with Diabetes Mellitus.

o the most common type is sensory neuropathy, which may lead to the loss of protective sensation in the lower extremities, and coupled with other factors, this significantly increases the risk for complications that result in a lower limb amputation.

o Autonomic Neuropathy can affect nearly all body systems and lead to hypoglycemic unawareness, bowel incontinence/diarrhea, and urinary retention.

A diabetic w/ postural hypotension should change from a lying or sitting position slowly.

Myxedema coma: mental sluggishness, drowsiness, and lethargy of hypothyroidism may progress gradually or suddenly to this notable impairment of consciousness or coma.

o S/s: subnormal temperature, hypotension, hypoventilation Propylthiouracil (PTU): a first line antithyroid drug which inhibits the synthesis of

thyroid hormones. Also blocks peripheral conversion of T4 to T3. (not curative)o There is a high rate of recurrence of hyperthyroidism if this drug is discontinued. o Lowers hormone levels more quickly but must be taken three times a day.

Tracheostomy: a stoma that results from the tracheotomy (surgical incision into the trachea for the purpose of establishing an airway). Indications for a tracheotomy are to:

o Bypass an upper airway obstructiono Facilitate removal of secretionso Permit long term mechanical ventilationo Permit oral intake & speech in a patient who requires long term mechanical

ventilation. Parathyroidectomy: partial or complete surgical removal of the parathyroid glands.

o Leads to a rapid reduction of chronically high Ca levels What is the only kind of insulin that can be given via an IV? => Regular Insulin

GI/Hepatic/Renal

Appendicitis: an inflammation of the appendix (a narrow blind tube extending from the inferior part of the cecum).

o Most common causes are obstruction of the lumen by accumulated feces (fecalith), foreign bodies, tumor of the cecum or appendix, or intramural thickening caused by excessive growth of lymphoid tissue.

o S/s: periumbilical pain, anorexia, n/v (pain located around McBurneys point)o Preop:

Until physician sees patient, the patient remains NPO Place ice bag to right lower quadrant to decrease flow of blood to the

area and impede the inflammatory process. (heat may cause appendix to rupture)

Surgery performed as soon as a Diagnosis is made.o Postop:

Patient observed for evidence of peritonitis Ambulation begins day of surgery or the first postop day Diet advanced as tolerated by patient D/c on first or second post op day

Diverticulitis: results from retention of stool and bacteria in the diverticulum, forming a hardened mass called fecalith. This causes inflammation and usually small perforations.

Alleviate stress Provide symptomatic relief Improve quality of life

o Inflammation spreads to the surrounding area in the intestines causing the tissue to become edematous (abnormal accumulation of fluid in the body tissues or in the body cavities causing swelling or distention of the affected parts)

o Diet: high fiber diet (mainly from fruits and vegetables), ↓intake of fat/red meat,

Guaiac Test: finds hidden (occult) blood in the stool (bowel movement) o ***Vitamin K should be administered if blood is evident in the stools, as vitamin

K may help in clotting the source of the bleed. N/G Tube: a silicone tube that is inserted through the nose down into the stomach, and

is used for short term feeding problems. (use x-ray to determine placement prior to initiating feeding)

o Coughing, cyanosis or choking may indicate that the NG tube has passed through the larynx. If this occurs, retract tubing so it is out of the larynx & reinsert into the stomach.

Perforated Ulcer: perforation of a peptic ulcer occurs when the ulcer penetrates the serosal surface, with spillage of either gastric or duodenal contents into the peritoneal cavity.

o Larger perforation = longer duration that the patient had the ulcero Bacterial peritonitis may occur within 6-12 hourso Treatment: H2 Receptor Blockers, PPI’s, antibiotics, antacids

Ulcerative Colitis: part of the group (along with Crohns Disease) called Inflammatory Bowel Disease (IBD). Characterized by chronic inflammation of the intestine with periods of remission interspersed with periods of exacerbation.

o Ulcerative Colitis usually begins in the Rectum and advances to the cecum spreading in a continuous pattern (unlike Crohns disease).

o S/s: bloody diarrhea and abdominal paino Goals of Treatment:

Res the bowels Control inflammation Combat infection Correct malnutrition

Reflux (cancer risk): in GERD, there is a risk of Barrets Syndrome, which is a precancerous lesion that increases the risk for esophageal cancer

Systemic Lupus Erythematosus (SLE): a multisystem inflammatory disease of autoimmune origin. A complex disorder of multifactorial origin resulting from interactions among genetic, hormonal, environmental, and immunologic factors.

o **Skin care is extremely important; wear protective clothing and sunscreens when outdoors, however try to minimize outdoor exposure to the sun if at all possible.

Dilutional hyponatremia: metabolic condition in which there is not enough sodium (salt) in the body fluids outside the cells. Causes hypoosmolality with a shift of water into the cells.

o S/s: n/v, confusion, lethargy, muscle weakness, spasms, seizures, ↓LOC, restlessness

o Nursing Interventions: fluid restriction, IV hypertonic saline solution, fluid replacement with sodium containing solutions.

Hypermagnesemia: an electrolyte (magnesium) imbalance caused by an increase in magnesium intake accompanied by renal insufficiency or failure.

o Depresses neuromuscular and CNS functionso S/s: lethargy, drowsiness, n/v, deep tendon reflexes, somnolence, resp./cardiac

arrest Kayexalate (ARF??): hyperkalemia is one of the most serious complications in Acute

Renal Failure (ARF) as it can cause life threatening cardiac dysrhythmias. Sodium polysterene (Kayaxalate) and dialysis remove potassium from the body.

o Causes diarrhea Peritoneal dialysis (CAPD); used to treat Chronic Kidney Disease (CKD)

o Continuous Ambulatory Peritoneal Dialysis (CAPD): carried out manually by exchanging 1.5-3 L of peritoneal dialysate at least 4 times daily, with dwell times of 4 to 10 hours.

Potassium Hypokalemia Indicators: o Clinical Manifestations:

Cardiac changes; impaired repolarization, flattened T wave, emergence of a U wave, increased (possible peak) P wave, Lethal Ventricular Dysrhythmias, bradycardi

Decreased GI motility Paresthesias (decreased reflexes) Polyuria Hyperglycemia Muscle weakness (soft flabby muscles)

Urolithiasis: calculi in the urinary tract, bladder, ureters, and kidneyso predisposed by immobility, hypercalcemia, UTI, urine stasis, high urine specific

gravityo S/s: acute sharp pain, dull tender ache in flank, n/v, hematuria, abd distension

GERD (Bed Blocks???): the nurse should ensure that the head of the bed is elevated to approximately 30° (usually on 4-6 inch blocks) & that the patient does not lie down after eating.

T-tube: a narrow flexible tube in the form of a T that is used for drainage; especially of the common bile duct

Paralytic ileus: a lack of intestinal peristalsis and presence of no bowel sounds o (intervention):

Patient placed on NPO status Insertion of NG tube (decompress bowel) Insertion of IV (NS or Lactated Ringers + Potassium) No improvement in 24-48 hours? => surgery to remove obstruction

Prostate cancer Spinal cord disease Strictures Trauma (back, pelvis, perineum)

o Goals: 1) relief of the obstruction 2) Correction & maintenance of fluid/electrolytes

Acute Renal Failure: a clinical syndrome characterized by a rapid loss of renal function with progressive azotemia (accumulation f nitrogenous waste products like urea nitrogen and creatinine in the blood).

o (renal cause): Prerenal causes: due to factors external to the kidneys that reduce renal

blood flow and lead to decreased glomerular perfusion & filtration. Hypovolemia, dehydration, hemorrahage, GI losses, diuresis,

hypoalbuminemia, burns Decreased CO, dysrhythmias, cardiogenic shock, HF, MI Decreased peripheral vascular resistance, anaphylaxis, neurologic

injury, septic shock Decreased renovascular blood flow, bilateral renal vein

thrombosis, embolism, hepatorenal syndrome, renal artery thrombosis

Intrarenal causes: conditions that cause direct damage to the renal tissue (parenchyma), resulting in impaired nephron function.

Prolonged prerenal ischemia Nephrotoxic injury , drugs, radiocontrast agents, hemolytic blood

transfusion reaction, severe crush injury, chemical exposures Interstitial nephritis, allergies (meds/antibiotics), infections Acute glomerulonephritis Thrombotic disorders Toxemia of pregnancy Malignant HTN SLE

Postrenal causes: involve mechanical obstruction of urinary outflow, thus impairing kidney function.

Benign prostatic hyperplasia Bladder cancer Calculi formation Neuromuscular disorders

Hyponatremia (what is the best IV): 5% Dextrose in water, hypotonic saline Fluid Volume:

o Fluid Volume Excess: results from excessive intake of fluids, abnormal retention of fluids, or interstitial to plasma fluid shift.

removal of fluid w/o producing abnormal changes in the electrolyte composition or osmolality of ECF

Diuretics & fluid restriction are primary forms of therapyo Fluid Volume Deficit: can occur with abnormal loss of body fluids inadequate

intake, or a plasma to interstitial fluid shift

Muscle & joint pains Tenderness in the area of your liver

Correct underlying cause and replace both water and any needed electrolytes.

Parecentesis (bleeding?): needle puncture of the abdominal cavityo may be performed to remove ascetic fluid (tends to accumulate thus this is

temporary)o Liver disease, one of the main causes of abd fluid build-up, can also cause

susceptibility to clotting problems. After the needle is removed from the abdomen, bleeding may continue to occur from the vessels providing blood flow to the inner abdominal wall.

PET -Oncologyo A diagnostic examination used to detect cancer, determine the stage of cancer,

& evaluate effectiveness of cancer tx, such as chemotherapy or radiation therapy.

o Permits a physician to accurately image many organs of the body w/ a single scan in order to detect malignancy.

Laxative abuse: overuse of laxatives may lead to chronic constipationo People who continue to use laxatives & enemas eventually become unable to

have a bowel movement w/o them. (many abuse laxatives to lose weight)o At risk for dehydration as well as electrolyte imbalance

UTI (Clean catch specimen): in order to test for a UTI, the patient will need to provide a clean catch specimen.

o Instruct the patient to fill the urine cup midstream (urinate a little, stop, then fill specimen cup w/ as much with the remaining urine).

Crohns disease: inflammation involves the all layers of the bowel wallo S/s: diarrhea, colicky abdominal pain, weight loss (due to malabsorption), fever,

rectal bleed (not as common as in Ulcerative Colitis) Esophageal varices

o Teach: Avoid ingesting alcohol, aspirin, and irritating foods, o Goal: avoidance of bleeding and hemorrhage

Hepatitis C: infection caused by a virus that attacks the liver and leads to inflammationo Transmission usually due to percutaneous needle exposure or other blood

exposure and undetected parenteral transmissiono Generally asymptomatic (early) later on, s/s may be:

Fatigue Fever Nausea or poor appetite

o Although positive for Hepatitis C, one may not need Tx (severe cases need Tx) Teaching-Ileostomy care-stoma

o Explain that an ostomy is a surgical opening in the body for discharge of body wastes

o Describe underlying conditions that result in the need for an ostomy

o Perform activities like: Remove old skin barrier, cleans skin, and apply new skin barriers Apply, empty, clean, and remove old pouch Empty pouch before it is 1/3 full to prevent leakage Irrigate colostomy to regulate bowel elimination

o Explain how to contact the enterostomal therapy nurse w/ questionso Explain dietary & fluid management

Id a well balanced diet and dietary supplements to prevent nutritional deficiencies

Id foods to avoid to reduce diarrhea, gas, or obstruction (w/ illiostomy) Drink at least 3000 ml/day of fluid to prevent dehydration Explain how to contact RD w/ questions Explain how to recognize problems & how to contact the appropriate

HCP.o Describe community resources to assist w/ emotional/psych. adjustment to the

ostomyo Explain the importance of follow up careo Describe the ostomy’s potential effects of sexual activity, social life, work, and

recreation and strategies to manage these influences.

Immune/Hematology/Fluid and Electrolytes

Hemolyzed specimen: Platelets (thrombocytes): function in initiating the clotting process by producing a plug

at the site of the injury. o Normal platelet count: 150,000-450,000/mm3 o Increased platelet count signifies the possibility of a cloto Decreased platelet count signifies bleeding

Decreased neutrophil is a condition known as neutropenia, and is identified as a neutrophil count less than 1000 to 1500 /ul.

o Normal levels: 4000-11000/ulo Predisposed to infections of normal flora

Minor infections lead rapidly to sepsis (immediate treatment necessary)o Collaborative care:

Determine case of neutropenia Id offending organisms if an infection has developed Institute prophylactic, empiric, or therapeutic antibiotic therapy Administer hematopoietic growth factors Institute protective environmental practices, like strict hand washing,

visitor restrictions, and a private room if hospitalized. Risk factors for skin cancer

o Having a fair skin typeo History of chronic sun exposureo Family history of skin cancer

o Environmental factors (living near equator, outdoor occupations, frequent outdoor activities)

o Indoor and outdoor tanningo Smoking

HIV CD4 count: below 200 cells/ul + opportunistic infection + wasting + ADC = AIDS Dx

o Pathology: RNA virus binds to specific CD4 and chemokine receptors to enter cell. Reverse transcriptase assists to make viral DNA Viral DNA enters cell nucleus and splices itself into genome permanently. Consequence of integration into genetic structure

All daughter cells are infected Viral DNA will direct cell to make HIV

Cells w/ CD4 receptor sites infected T helper cells, lymphocytes, monocytes/macrophages, astrocytes,

oligodendrocytes Immune dysfunction results mostly from destruction of CD4 T cells which

are key from immune recognition and defense against pathogens. Viral activity destroys 1 billion T cells daily Immune problems begin when CD4 T cells ddrop below 500 cells/ul

Normal range is 800-1200 cells/ul Well differentiated cells

Integumentary/Oncology

Flu-like syndrome: Tumor lysis syndrome (TLS)-hyperkalemia: a metabolic complication characterized by

rapid release of intracellular components in response to chemotherapy.o 4 hallmark signs of TLS are:

Hyperuricemia Hyperphosphatemia ***Hyperkalemia*** Hypocalcemia

o Goal: preventing renal failure and severe electrolyte imbalances Prophylactic mastectomy (post op)

o Patient stays in the hospital for 1 to 3 days (depending on the type of surgery) simple mastectomy = patient may go home on the same day. Most go home after 1 to 2 days. may stay longer if you have breast reconstruction.

o Many women go home with drains still in their chest. The doctor then removes them later during an office visit.

o Patient may have pain around the site of your incision after surgery.

o Fluid may collect in armpit called seroma (relatively common). It usually goes away on its own, but it may need to be drained.

Allopurinol (prior to chemotherapy)o This medication, also known as (Zyloprim), is used for the treatment and

prevention of gout attacks and certain types of kidney stones. It is also used to treat elevated uric acid levels in the blood and urine, which may occur in patients receiving chemotherapy for treatment of leukemia, lymphoma, and other types of cancer. If left untreated, high uric acid levels in those receiving cancer chemo may cause kidney stones and kidney failure.

IV site care Stomatitis (antineoplastics) Agranulocytosis: failure of the bone marrow to make enough white blood cells

(neutrophils) AIDS dementia: Decline in mental processes is a common complication of HIV infection

(and many other conditions. The AIDS dementia complex affects behavior, memory, thinking, and movement

o symptoms include decline in thinking, or "cognitive," functions such as memory, reasoning, judgment, concentration, and problem solving.

o Furthermore, changes in personality and behavior, speech problems, and motor (movement) problems such as clumsiness and poor balance occur.

Radiation therapy (tender skin): the skin contains rapidly proliferating cells, thus is affected by radiation therapy.

o The skin changes induced by radiation may be acute or chronic based on the area, dosage, and technique.

o Skin care to manage most desquamation includes keeping tissues clean w/ normal saline compresses or modified Burow’s solution soaks and protected from further damage with moisture vapor- permeable dressings or Vaseline.

Musculoskeletal/Neuro

Cast care tightness: Cast Syndrome may occur if the body cast is applied too tightly and the cast compresses the superior mesenteric artery against the duodenum.

o Results in patient complaining of abdominal pain, n/v, & abdominal pressure.o Tx: gastric decompression w/ NG tube, remove or split cast.

Compartment syndrome: a condition in which the elevated intracompartmental pressure w/in a confined myofascial compartment compromises the neurovascular function of the tissues w/in that space.

o Causes capillary perfusion to be reduced below a level necessary for tissue viability and is classified as acute, chronic/exertional, or crush syndrome.

o Characteristics of an impending Compartment Syndrome: Paresthesia (numbness & tingling) Pain (distal to injury & unrelieved by opioid analgesics in addition to pain

on passive stretch of muscle traveling through compartment) Pressure (increases in compartment)

Pallor (coolness, & loss of normal color of the extremity) Paralysis (loss of function) Pulselessness (diminished/absent peripheral pulses)

o Assess urine output (watch for myoglobinurea; red/brown urine & s/s of ARF) Hip replacement (dislocation) (Athroplasty)

o Athroplasty performed in order to relieve pain, improve or maintain ROM, and correct the deformity.

o Foam pillow placed between joints in order to prevent dislocationo Physical therapy initiated first postop day & weight bearing exercises w/ a walker

begino Monitor for infection, and prevention of DVT are key concepts for home care.

Rheumatoid arthritis (use of heat): the use of heat for Rheumatoid Arthritis is an excellent non-pharmacological remedy.

Hip replacemento post op activity

pain management CPT Management of catheter Management of Hemovac Bed rest w/ legs abducted

o chest pain-report findings activity Osteoporosis (goal):

o Reduce bone losso Prevent fractureo Control paino Prevent diability

Fractured ribs: a condition known as Flail Chest may result from multiple rib fractures, causing an unstable chest wall.

o Dx is made on the basis of fracture of two or more ribs, in tow or more separate locations, causing an unstable segment.

Laminectomy (reposition): this procedure involves the surgical excision of part of the posterior arch of the vertebra to gain access to part of or the entire protruding disk to remove it.

Brachytherapy (precautions)o A form of radiotherapy where a radiation source is placed inside or next to the

area requiring treatment. Commonly used as an effective treatment for cervical, prostate, breast, and skin cancer, and can also be used to treat tumors in many other body sites. Can be used alone or in combination with other therapies such as surgery, External Beam radiotherapy, and chemotherapy.

o If temporary barchytherapy is used, there is no risk to friends or family from being in close proximity with the patient.

Emboli prevention Ambulation Wound care Patient teaching (home care)

o In permanent brachytherapy, low dose radioactive seeds are left in the body following treatment, and devrease over time. However, as a precaution, those receiving permanent brachytherapy may be advised to not hold any small children or be close to pregnant women for a short time following treatment.

Cranial radiation: intracranial metastasis occurs in up to 39% of patients with Small Cell Lung Cancer (SCLC). This procedure is effective in preventing metastasis (20%), although it is not known if it increases survival. Toxicities of this therapy may include scalp erythema, fatigue, and alopecia.

o Most chemotherapy drugs do not penetrate the blood brain barrier, thus this procedure is used.

Operative

Ambulation (postop): usually patients ambulated day of operation or 1st day postop. OR surgical scrub: The scrub nurse follows the designated scrub procedure & remains in

the sterile field. Postop risk

o Airway Obstructiono Hypoxemiao Hypoventilation o Hypotension/HTN, dysryhthmias, Deep Vein Thrombosuso Emergence delirium, delayed emergenceo Pain/discomforto Hypothermiao Acute urinary retentiono n/vo wound dehiscence

Preop teach assess (checklist, allergy, NPO) Op permit (legal for RN): nurse can witness the patient sign the consent form ensuring

that the patient was fully informed, understood everything, and signed the consent voluntarily.

PACU assessmento General info: name, age, ACP, Surgeon, surgical procedureo Patient Hx: indication for surgery, medical hx, meds, allergieso Intraoperative management

Anesthetic medications Other meds received preoperatively or intraoperatively blood loss fluid replacement totals (blood transfusions???) urine output

o Intraoperative Course Unexpected anesthetic events or rxns Unexpected surgical events

Vitals and monitoring trends Results of intraoperative lab tests

Malignant hyperthermia: a rare metabolic disease characterized by hyperthermia w/ rigidity of skeletal muscles that can result in death.

o Occurs in affected people exposed to certain anesthetic agents. Suctioning needed: this procedure is done especially for patients who have a

tracheostomy and are breathing through a trach. o Be sure to use aseptic/sterile technique throughout the procedureo Apply suction only when w/drawing catheter (gently rotate)

Never suction from more than 10-15 seconds (pass 3 or fewer times)o Suction when:

Adventitious breath sounds are hear Secretions are present Gurgling sounds are noted

Laboratory Values PT: 10-13 seconds INR: <2 aPPT: 25-39 seconds Hgb: 13.2-17.3 g/dl (men)/11.7-15.5 g/dl (female) Hct: 43%-49% (male)/38%-44% (female) WBC’s: 4500-10000 mm3

Potassium: 3.5-5.0 mEq/L Sodium: 135-145 mEq/L Magnesium: 1.6-2.6 mg/dL

Conversion Factors

1 L = 100 ml 1kg = 1000 g 1g = 1000 mg1 ml = 1 cc 1mg = 1000 mcg 1 g = 15 gr1 dram = 4 ml 1 oz = 30 ml 1 tsp = 5 ml1 tbs = 15 ml 1 unit = 1000 milliunits 1 kg = 2.2 lbs

Pounds (lbs)-Kilograms (kg): divide by 2.2Kilograms (kg)-Pounds (lbs): multiply by 2.2

Ounces (oz)-Pounds (lbs): divide by 16

Essential Calculations

Desire x supply = Amount Have

Check PT/INR prior to administering CoumadinCheck aPPT prior to administering Heparin

IV Piggy Back: mL x TF = gtt/min for microdrip TF= 60 gtt (macrodrip is given as there are many)

min

Finding the amount of a drug in a solution: Amount of Drug = amount of drug in mL

Amout of Fluid (mL)

How long an IV will run: number of mL = hrs number of mL/hr

mg/min-Rule and Calculation:

Reduce numbers in standard solution to mg/mL Change mg-mcg Divide by 60 to get mcg/min Solve for mL/hr

HESI Review 1

1. Respiratory – COPD

a. S/S: Increased RR, Easily fatigued, frequent respiratory infections, use of accessory

muscles to breath, orthopneic, Cor Pulmonale(late in disease) Thin in appearance,

wheezing, pursed lip breathing, chronic cough, barrel chest, dyspnea, prolonged

expiratory time, Bronchitis-increased sputum, digital clubbing fingernail-chronic

b. ABG’s: Normal PH 7.35-7.45 PaC02 35-45 mm Hg, Pa02 80-95 mm Hg, O2 Sat 96-100%

Serum HCO3 22-26 mEq/L in respiratory conditions, clients can experience acidosis

(when PH is lower than 7.35) or alkalosis (when PH is greater than 7.45)

2. Outcome evaluation

a. Nursing process: Identifies expected outcomes and establishes goals and timeframes

for achieving them.

3. Rheumatoid Arthritis

a. Autoimmune disorder/ Connective tissue disorder: Chronic systemic autoimmune

disease that affects all areas of the body; inflammatory responses occur in all connective

tissue. Higher incidence in women. Symmetrical joint involvement, systemic effects are

vasculitis, pulmonary fibrosis, pericarditis, sjogrens. Goal is to relieve pain and preserve

joint mobility and muscle strength, *use warm compresses to promote relaxation and to

decrease stiffness, use cold to decrease inflammation.

b. Resources (leadership): Teaching about modification of daily functions, grasping, lifting,

use of special devices (utensils)

4. Elimination

a. Vagal response (geriatrics): If performing a digital removal of impacted feces, nursing

priority is to monitor client’s heart rate during and after; a vagal response can

precipitate bradycardia.

b. Straining of bowel movements: Teach client to avoid straining. High fiber diets/ stool

softeners/exercise.

5. Mobility/ Ambulation

a. Type of shoes: Velcro shoes or non skid socks

6. Safety restraints

a. Mittens who wears them and why? Protection to avoid self harm: when clients are high

risk for removing IV lines (non compliant or decrease in LOC) or to avoid scratching

7. IV

a. Gtts/min – reference med math book from skills

8. IV

a. mL/hour reference med math book from skills

9. PO

a. How many oz in a mL? 1 oz = 30 ml

10. Pressure ulcer

a. Digital imaging photographs taken of wound to watch progression or healing of wound.

b. Consent? Client’s face should not be in photo.

11. Fluid volume overload – conditions

a. CHF: Congestive heart failure due to left sided heart failure cause fluid accumulation in

lungs, Right sided heart failure causes peripheral edema.

b. Renal failure: The kidneys are not able to filter through and excrete waste and

byproducts of metabolism, causing peripheral and pulmonary

c. Monitor VS, weight, electrolytes, Intake and Output. Monitor lung sounds periodically

for signs of pulmonary edema, monitor for cardiac dysrhythmias, maintain fluid

restrictions as ordered, and administer drugs, including diuretics as ordered. Monitor for

complications.

12. Fluid loss (Hypovolemia; volume loss)

a. Monitor VS for hypotension or tachycardia (indicates increasing hypovolemia) monitor

for electrolytes for hypokalemia and other lab abnormalities, assess mucous membrane

and moisten as needed, monitor strict intake and output, administer IV fluids as ordered

and oral fluids to maintain hydration, institute fall precautions from orthostatic

hypotension, weakness, dizziness. Monitor for complications.

13. UTI

a. Clean catch

i. Patients must first wash their hands thoroughly, and then wash the penis or

vulva and surrounding area four times, with front-to-back strokes, using a new

soapy sponge each time.

ii. The patient must then begin urinating into the toilet and stop after a few drops.

iii. The patient then positions the container to catch the middle portion of the

stream. Ideally, this urine will contain only the bacteria and other evidence of

the urinary tract infection.

iv. The patient then urinates the remainder into the toilet.

v. The patient securely screws the container cap in place without touching the

inside of the rim.

14. Crutch

a. 3 point gait

i. Move BOTH crutches and the WEAKER LEG forward

ii. Move the STRONGER leg forward

** How to go up stairs

1. Tuck both crutches under your strong side arm and use the handrail to support your weight

on your injured side.

2. Lean forward slightly and swing your good leg up to the next step. Then lift your body weight

by straightening the hip and knee of your good leg as you do in normal stair climbing.

** How to go down stairs

With the crutches on your good leg side and your opposite hand on the railing:

1. Stand on your good leg leaving your injured leg behind on step above.

2. Bend forwards slightly and move your crutches down a step.

3. Support your body weight with the crutches on your good side and the handrail on your

injured side and swing your good leg down. Keep your head and shoulders back to prevent your

center of balance from pitching forward.

15. Hip replacement

a. Abduction pillow

i. A foam abduction pillow is placed to prevent dislocation of the new joint

b. Ambulation

i. PT is initiated the first post op day, with ambulation and weight bearing with a

walker.

c. 90° flexion of the hip must be avoided for 4-6wks post op

d. Elevated toilet seats and chair alterations at home are necessary

e. Do not cross your legs.

16. Walker

a. Strength of upper extremity and unaffected leg are assessed and improved with

exercises, if necessary, so that that upper body is strong enough to use walker.

b. Client lifts and advances the walker and steps forward.

17. Cyanosis

a. Bluish discoloration of skin and mucous membranes. Caused by cardio respiratory

problems, vasoconstriction, asphyxiation, anemia, leukemia, and malignancies.

b. Safety: Make sure client is getting adequate O2

18. Korotkoff sounds

a. Korotkoff sounds are distinctive sounds that can be distinguished when a blood pressure

cuff is applied and adjusted.

Five Kortokoffs signs:

o The first Korotkoff sound is the snapping sound first heard at the systolic pressure. A

clear tapping sound; onset of the sound for two consecutive beats is considered

systolic.

o The second sounds are the murmurs heard for most of the area between the

systolic and diastolic pressures.

o The third = A loud, crisp tapping sound.

o The fourth sound, at pressures within 10 mmHg above the diastolic blood pressure,

were described as "thumping" and "muting".

o The fifth Korotkoff sound is silence as the cuff pressure drops below the diastolic

blood pressure. The disappearance of sound is considered diastolic blood pressure-

two points below the last sound heard.

19. Hypokalemia

a. Cardiac changes: Impaired repolarization resulting in a flattening of the t wave and

eventually in emergences of a u wave.

b. Cardiac monitoring to detect cardiac changes related to potassium imbalance.

c. Decrease GI motility, fatigue, muscle weakness, leg cramping, nausea vomiting, paralytic

ileus, weak, irregular pulse, polyuria, hyperglycemia.

20. Inhaled corticosteroids (first line of therapy for patients with Asthma).

a. Must be administered 1 to 2 weeks before maximum therapeutic effects can be seen.

b. At the highest dosage level, have been associated with easy bruising, accelerated bone

loss, candidiasis, hoarseness, dry cough.

c. Using spacers and gargling with water or mouthwash after each use and reduce side

effects.

21. Peripheral vision confrontation

a. How do you talk to the patient? Where do you stand? Approach them from the side

that the patient can see.

22. Nursing process

a. Compare data to normal values to figure what to do next in the nursing process.

23. Hypertension (High BP)

a. DASH diet: The diet involves eating several servings of fish each week, eating plenty of

fruits and vegetables, increasing fiber intake and drinking a lot of water. Decrease

cholesterol, sodium and saturated fats. Limit alcohol consumption

24. Choking – geriatrics

a. Not sure on this one but I know that the elderly have decrease liver function. Soft foods

are recommended to prevent choking or aspiration. To prevent chocking for geriatric

patients before a meal, chop food into small pieces. Ensure the set of denture is in its

fixed position and not loose. (sry guys couldn’t find a lot on this related to hepatic)

25. Endocrine (*micro- retinal neuropathy, nephropathy, peripheral neuropathy; macro- CAD*)

a. DM: complications of long term DM can cause nephropathy, retinal neuropathy, and

peripheral neuropathy if not taken care of can lead to CAD which can then lead to

stroke.

26. Diabetes

a. Type I: Inability of the pancreas to produce any insulin in response to elevated blood

sugar levels. Usually juvenile onset. Assess polyuria, polydipsea, polyphagia, blood sugar

levels, dietary plan, irritability, fatigue, poor wound healing, weight changes, presence

of glucose or ketones in urine, Hgb A1C. Complications are stroke, hyperlipidemia,

coronary artery disease, HTN Kidney disease, blindness, poor wound healing,

hyperglycemia (DKA); hypoglycemia.

b. Type II: Inability of the pancreas to produce enough insulin in response to elevated

blood sugar levels. Usually adult onset, linked to obesity, sedentary lifestyles. Leads to

other chronic diseases including hyperlipidemia, CAD, kidney disease, poor wound

healing, blindness, and peripheral neuropathy. Assess history of infection, polyuria,

polydipsea, polyphagia, blood sugar levels, dietary plan, irritability, fatigue, poor wound

healing, weight gain, obesity, presence of glucose, or ketones in urine, Hgb A1C, history

of cardiovascular disease or co-morbities including hypertension, high cholesterol, CAD.

Complications stroke, hyperlipidemia, coronary artery disease, HTN Kidney disease,

blindness, poor wound healing, hyperglycemia (DKA, HHNS); hypoglycemia

27. Pneumonia prevention

a. Identify high risk clients, encourage pneumococcal vaccine every 5 years, encourage

mobility and ambulation. Good respiratory hygiene, turn, cough and deep breath.

b. Stop smoking, stay away from sick people, hand washing important, and pneumovac.

28. DVT

a. Bed rest, elevate limb, warm moist packs, support stockings if edema is present (only

after client is ambulatory), treatment with Heparin.

b. Heparin (apTT) activated partial thromboplastin time, used to determine adequacy of

anticoagulation with heparin, do not draw sample from extremity with a hep lock or

infusion. Normal 30-45 seconds.

29. Cardiac sounds

a. S1: Closure of the mitral and tricuspid valves - normal

b. S2: Closure of the pulmonic and aortic valves-normal

c. S3: Represents rapid ventricular filling, in adults it may be an indication of volume

overload, ventricular dysfunction secondary to hypertension. Abnormal

d. S4: Extra sounds during atrial contraction are abnormal

30. HbA1c

a. A test to monitor the average glucose attached to hemoglobin for the past 3-4 months.

b. Normal range is 2-6% for non diabetics, 2-6.4% for diabetics with good control (for

diabetics 7% is the goal) over 8% is poor control.

31. GERD/ reflux

a. Teaching: Avoid drinking beverages during meals, including alcohol and carbonated

beverages. Avoid temperature extremes in food, avoid drinking fluids 3 hours before

bedtime, and elevate the head of the bed on 6-8 inch blocks. If overweight, lose weight

to decrease abdominal pressure gradient. Avoid tobacco, NSAIDS, and salicilytes.

Decrease intake of highly seasoned foods and tomato products, eat small frequent

meals (up to 5 per day at 3 hour intervals) to prevent gastric dilation. Avoid any food

that precipitates discomfort; do not lie down for 2-3hours after eating.

32. AIDS

a. Dementia: The most frequently documented neurologic manifestation in human

immunodeficiency virus (HIV) seropositive patients is known as acquired

immunodeficiency syndrome (AIDS) dementia complex. Three stages of dementia

progression have been identified with impairment noted in cognitive, behavioral and

motor function (cannot write). Specific diagnostic findings include diffuse cortical

atrophy on computed tomography (CT) scan and magnetic resonance imaging (MRI) and

alterations in cerebrospinal fluid (CSF) findings. Current research hypothesizes that AIDS

dementia is the result of direct HIV infiltration of the central nervous system (CNS) and

autopsy studies have addressed this theory. Nursing's role in the care of the patient with

AIDS dementia focuses on neurologic assessment, counseling of patient and family,

supportive care and prevention of complications. Recognition of disease progression

and the maintenance of the patient's self-worth are essential. Nursing diagnoses with

respect to this patient population have been provided.

33. Braden scale

a. Risk assessment: Scores six subscales, sensory perception, moisture, activity-mobility,

nutrition, friction, and shear, total score range is 6-23; a lower score indicates a higher

risk for pressure ulcer development, most reliable and most often used assessment

scale for pressure ulcer risk; score of 18 is cut-off for adults.

34. Cast care – tightness

a. Check for neurological sensations: Cap refill, pulses, color tone of skin and temperature,

edema, sensations to touch.

35. Compartment syndrome

a. When muscles, nerves and vessels are restricted to a confined space within an extremity

can be caused by a cast, splints, tight bandages, and tight surgical closure. If there is a

cast it can be bivalved or split in half and then wrapped with ace bandage to keep cast in

place.

b. Pain: Clients complain of intractable pain unrelieved by analgesics, immediate attention

is necessary to avoid permanent damage (get the doctor).

36. Compound fracture

a. Is an open wound with bone protruding

b. Increase WBC can indicate infection, especially in clients with compound fractures.

* A high WBC is a normal stress response for open fractures. It is the body’s normal reaction as

a protective mechanism.

37. Degenerative joint disease

a. Progressive non systemic, no inflammatory, disease that causes progressive

degeneration of synovial joints of weight bearing long bones, primarily associated with

aging, but can be caused by injury or repetitive damage to joints. Radiological findings

degenerative cause of joint space narrowing is characterized by osteophytes; bone

sclerosis; subchondral cysts, or geodes; asymmetric joint space narrowing.

b. Pain occurs on motion and with weight bearing. Pain increases in severity with activity.

38. CVA - Spatial perception

a. Due to right brain strokes minimize danger. Put sharp objects and dangerous chemicals

out of reach to minimize the chance of accidental injury. Pad edges. Cover corners and

edges of furniture and doorways to avoid bumps and bruises. You can buy childproofing

products at the hardware store, or you can improvise your own using foam rubber or

towels. Emphasize the right side. If a stroke survivor has lost her entire left visual field,

place most items she uses frequently on her right side. One exception: Have her put her

watch on her affected side. Whenever she checks the time, she'll be reminded of her left

arm. Encourage a wider visual field. Periodically remind her to move her head from side

to side to scan a wider area. Keep it calm. Keep the environment as calm and quiet as

possible so she can focus on whatever she's doing. Minimize clutter. Minimize clutter so

she can find what she needs and avoid tripping.

39. Seizures

a. Complications: Aspiration is important to watch for; maintain airway during seizure:

turn client on side to aid ventilation. Do not restrain client. Protect the client from

injury during seizure and support head (avoid neck flexion). Document seizure, noting

all data in assessment. Maintain seizure precautions: reduce environmental stimuli as

much as possible, pad sire rails or cribs, have suction equipment and oxygen quickly

accessible, tape oral airway to head of the bed. Do NOT use a tongue blade, padded or

not, during a seizure. It can cause traumatic damage to oral cavity. Administer

anticonvulsant medications as prescribed. Monitor therapeutic drug levels. Teach

family about drug administration: dosage, action, and side effects.

40. Pre-op assessment

a. Data to obtain when taking a preoperative nursing history:

i. Age

ii. Allergies to medications, foods, and topical antiseptics (Patient should wear an

identification band that includes all allergies. Patient with a history of any

allergy responsiveness has a greater potential for demonstrating

hypersensitivity reactions to drugs administered during anesthesia).

iii. Current medications, prescriptions, over the counter, and herbal preparations

iv. History of medical and surgical problems

v. Previous surgical experiences

vi. Previous experience with anesthesia

vii. Tobacco, alcohol, and drug use

viii. Understanding of surgical procedure

ix. Coping resources

b. Cultural and ethnic factors that may affect surgery

41. Pre-op

a. Teaching:

i. Regulations concerning valuables, jewelry, and dentures

ii. Food and fluid restrictions such as NPO after midnight

iii. Invasive procedures such as urinary catheters, IV’s, NG tubes, enemas, douche

iv. Preoperative medications

v. Operating room, transportation, skin preparation, post anesthesia

vi. Postoperative procedures

vii. Respiratory care, such as ventilator, incentive spirometer, deep breather,

splinting

viii. Activity such as ROM, leg exercises, early ambulation, turning

ix. Pain control, such as IM medications, patient controlled analgesia

x. Dietary restrictions

xi. Intensive care unit or post anesthesia care unit orientation

42. Sterile specimen

a. Should be in a sterile container, and refrigerate if not in use.

43. Gonorrhea

a. Most common veneral disease, an infection of the GU tract, however, gonorrhea may

also affect the rectum, pharynx, and eyes, caused by the bacteria Neisseria

gonorrhoeae.

b. MEN: Urethritis w/ dysuria & profuse, purulent urethral drainage 2-5d after infxn;

painful/swollen testicles; symptoms are more obvious & distressing so they usually seek

treatment early on; unusual for men to be asymptomatic.

i. Complications are uncommon but may be prostatitis, urethral strictures &

sterility.

c. WOMEN: Initial urethritis or cervicitits that is often mild enough to remain undetected.

Vulvovaginitis, vaginal discharge, dysuria.

i. Complications PID, Bartholin’s abcess, ectopic pregnancy & infertility.

44. Pneumonia

a. Tachypnea: shallow respirations, often with use of accessory muscles

b. Abrupt onset of fever with shaking and chills (not reliable in elderly)

c. In elderly, symptoms include confusion lethargy, anorexia, rapid respiratory rate

d. Pain and dullness to percussion over the affected lung area

e. Bronchial breath sounds, crackles

f. Chest radiograph indication of infiltrates with consolidation or pleural effusion

g. Elevated white blood cell

h. Arterial blood gas indication of hypoxemia

i. On pulse oximetry, a drop in o2 sat. ( should be >90, ideally >95)

45. Dilutional hyponatremia

a. Common causes: water deprecation, hypertonic tube feeding, diabetes insipidus,

heatstroke, hyperventilation, watery diarrhea, renal failure, Cushing syndrome.

b. S/S: thirst, hyperpyrexia, sticky mucous membranes, dry mouth, hallucinations, lethargy,

irritability, seizures, Na above 145 mEq/l. Confusion, loss of appetite, delusional,

vomiting. Restrict fluids!

46. COPD

a. Postural drainage: is an airway clearance technique that uses gravity to assist in the

removal of secretions from the airways.

i. Teach client to sit upright and bend slightly forward to promote breathing

ii. In bed, teach client to sit with arms resting on over bed table

iii. In chair, teach client to lean forward with elbows resting on knees

iv. Teach diaphragmatic and pursed-lip breathing

47. Finger-nail clubbing

a. Clubbing is seen in individuals who have coexistent pulmonary hypertension (high

pressure inside lung blood vessels), a condition that can result from chronically low

oxygen levels in COPD patients, but the majority of COPD patients do not have suffer

from clubbing.

48. Cataracts

a. Post-op teaching: F.Y.I. After surgery there should be no pain!

i. Warn patient not to rub or put pressure on eye

ii. Teaching that glasses or shaded lens should be worn during waking hours. An

eye shield should be worn during sleeping hours

iii. Teaching to avoid lifting objects over 15 pounds, bending, straining, coughing, or

any other activity that can increase intraocular pressure

iv. Teaching to use a stool softener to prevent straining at stool

v. Teaching to avoid laying on operative side

vi. Teaching the need to keep water from getting into eye while showering or

washing hair

vii. Teaching to observe and report signs

49. Trabeculectomy

a. The last treatment used for wither type of glaucoma (used only after medications and

laser treatments such as a trabeculoplasty have failed to reduce IOP).

b. It is a surgical procedure that removes part of the trabeculum in the eye to relieve

pressure which is caused by glaucoma.

c. This outpatient procedure is most commonly performed under monitored anesthesia

care using a retrobulbar block or peribulbar block or a combination of topical and

subtenon (Tenon's capsule) anesthesia. Occasionally sedation or general anesthesia will

be used.

50. Diabetic retinopathy

a. Many people with early diabetic retinopathy have no symptoms before major bleeding

occurs in the eye. This is why everyone with diabetes should have regular eye exams.

b. Most often, diabetic retinopathy has no symptoms until the damage to your eyes is

severe.

c. Symptoms of diabetic retinopathy include:

i. Blurred vision and gradual vision loss

ii. Floaters

iii. Shadows or missing areas of vision

iv. Difficulty seeing at nighttime

51. PAD (Raynoud’s disease)

a. Raynoud’s disease is a disorder in which the vessels that supply blood to the fingers and

toes contract, causing the fingers and toes to turn white, feel numb, tingle, or burn.

52. Osteoarthritis

a. Pathology: Osteoarthritis (commonly referred to as degenerative joint disease), the

most common form of arthritis, is a chronic condition causing the deterioration of joint

cartilage and the formation of reactive new bone at the margins and subchondral areas

of the joints. It usually affects weight bearing joints (knees, feet, hips, lumbar

vertebrae). The major defect in primary and secondary osteoarthritis is loss of articular

cartilage. It occurs in synovial joints; the joint cartilage deteriorates, and reactive new

bone forms at the margins and subchondral areas of the joints. Cartilage particles within

the joint irritate the synovial lining.

b. S/S: Deep, aching joint pain due to degradation of cartilage, inflammation, and bone

stress particularly after exercise or weight bearing. Stiffness in the morning and after

exercise (relieved by rest). Herberden’s nodules (bony enlargements of the distal

interphalangeal joints), and Bouchard’s nodes (bony enlargements of the proximal

interphalangeal joints), altered gait, decrease ROM.

c. Goal of tx: Is to relieve pain, maintain or improve mobility, and minimize disability.

d. Special considerations: Promote adequate rest, particularity after activity, plan rest

periods during the day, and provide for adequate sleep. Moderation is the key—teach

pt to pace daily activities. Assist with physical therapy and encourage pt to perform

gentle isometric ROM exercises.

53. Documentation

a. Pre-op preparation: The nurse caring for the patient must have basic knowledge. First

the nurse must have the knowledge of the nature of the disorder requiring surgery and

any coexisting disease processes. Secondly, the nurse must identify the individual

patient’s response to the stress of surgery. Third, the nurse must assess the results of

appropriate preoperative diagnostic tests. Lastly the nurse must consider the bodily

alterations and potential risks and complications associated with the surgical procedure

and any coexisting medical problems. The nurse caring for the patient preoperatively is

likely different from the nurse in the OR and PACU, thus communication and

documentation of important preoperative assessment findings are essential to the

continuity of care.

b. All finding of the medication history should be documented and communicated to the

intraoperative and postoperative personnel.

c. The nurse should document and report to the perioperative team if the patient has

problems voiding

d. If the patient has a history of a compromised immune system or takes

immunosuppressive drugs, it must be documented.

e. Caffeine withdrawal headaches could be confused with spinal headaches if the

preoperative data are not documented.

f. JACHO requires that all patients admitted to the operating room have a documented

physical examination (PE) in the chart.

g. The nurse should review the documentation already present on the patients chart

including the review of systems and the physicians PE report, to better proceed with the

examination. All findings must be documented, with any relevant findings immediately

communicated to the surgeon or ACP.

h. All teaching should be documented.

i. The site and side of the anticipated surgery may be marked with an indelible marker by

the patient and documented to indicate agreement with the patient.

54. Grief following CVA

a. Communication: The mental and emotional sequelae of brain trauma are often the

most incapacitating problems. Most patients who have been comatose for more than 6

hours undergo some personality changes. In all cases the family must be given special

consideration. They need to understand what is happening and be taught appropriate

interaction patterns. The nurse must give guidance and referrals for financial aid, child

care, and other personal needs and must assist the family in involving the patient in

family activities whenever possible. The family often has unrealistic expectations of the

patient. In reality the patient experiences reduced awareness and ability to interpret

environmental stimuli. Assisting the patient and family in developing hope and keeping

communication open are strategies perceived as supportive by families. The grieving

process takes time, energy and work. Goals for the grieving process include resolving

emotions, reflecting on the injured/dying person, expressing feelings of loss and

sadness, and valuing what has been shared.

HESI Review 2

55. Diabetes (self-management)

a. Do’s: Monitor your blood glucose at home and record results in a log, take your insulin

as prescribed, obtain hemoglobin H1C blood test ever 3-6 months as an indicator, carry

some form of glucose at all times so you can treat hypoglycemia quickly, Instruct family

members in the use of glucagon admin in the case of emergencies, learn how to

exercise and how food affects your blood glucose levels, begin a medically supervised

exercise program, have an individualized meal plan created by a dietician, follow your

diet eating regular meals at regular times, eat slowly and chew food thoroughly, choose

foods in low saturated fat, limit the amount of alcohol you consume, learn your

cholesterol level, obtain an annual eye examination, obtain annual urine testing for

protein, examine your feet at home, wear comfortable well fitting shoes to help prevent

foot injury, break in new shoes gradually, always carry identification that says you have

diabetes, have other medical problems treated especially high blood pressure and high

cholesterol, know the symptoms of hypoglycemia and hyperglycemia, quit smoking.

b. DONTS: Don’t skip doses of you insulin especially when you are sick, don’t run out of

insulin, don’t enroll in a fad diet, don’t rub the area where insulin was administered,

don’t forget exercise will lower your blood glucose level, don’t exercise if your blood

glucose levels are very elevated- this may lead to a temporary worsening of your blood

glucose level, don’t drink excessive amounts of alcohol bc this may lead to unpredictable

low blood glucose reactions, don’t eat fried food, don’t drink soda or lots of fruit juices,

don’t smoke, don’t apply hot or cold directly to your feet, don’t go barefoot, don’t

ignore symptoms of hypoglycemia and hyperglycemia, don’t put oil or lotion between

your toes.

56. GERD

a. S/S: Heartburn- burning, tight sensation, dyspepsia- pain or discomfort centered in the

upper abd, episodes of hypersalivation, noncardiac chest pain. Burning pain in the

epigastric area possibly radiating to the arms and chest. Pain usually after a meal or

when lying down. Feeling of fluid accumulation in the throat without a sour or bitter

taste due to hypersalivation.

57. Catheriterization

a. Insertion procedure:

i. Preparation: Bring equipment, check lighting, identify client, provide privacy,

cover patient

ii. Procedure: Open STERILE catheter kit, place draper to expose perineum, open

white outer wrap away from sterile package with last turn toward client,

remove sterile absorbent pad and position under pt buttocks- pad creates a

sterile field. Put on sterile gloves, remover sterile articles from tray, pour

antiseptic solution over cotton balls, lubricant- lube catheter tip, if specimen

required open cap, move catheter tray close to pt prep meatus- cleanse, once

you commit non sterile hand don’t move, use sterile hand and grab catheter,

insert about 2 inches (female)/ male 10-12 inches or until urine flow, push extra

inch, inflate balloon, check for resistance. Page 733 potter and perry.

58. Ambulation

a. Gait belt: Ambulation should be done 2-3 times a day for 10 to 15 min. A transfer belt

should be placed around the patient’s waist to provide stability during learning stages.

The nurse should discourage the patient from reaching for furniture or relying on

another person.

59. Fall assessment

a. Check muscle strength on right and left side, ROM, steady gait, coordination etc,

assistive devices. Patients usually begin slow; first dangle feet over bed, second as

strength increases move to sit on commode, then standing and eventually graduating to

walking.

60. IM injections

a. (Information from Smith) 1-5 mL syringe with needle gauge appropriate for muscle site

and fat thickness; deltoid muscle site and fat thickness; deltoid muscle requires 23-25

gauge 1 inch needle; needle size for the vastus lateralis and gluteus muscles vary from

18-23 gauge needle lengths, 1-1.5 inches. Clinical alert: Change needle before

administering intramuscular medication that is irritating to the tissue (e.g. Vistaril)

b. Purpose: to promote rapid absorption of the drug, to provide an alternate route when

drug is irritating to subcutaneous tissue.

c. Injection sites

i. Ventrogluteal injection site (preferred)

ii. Dorsogluteal injection site (least desired)

iii. Vastus lateralis

iv. Deltoid

d. Remember to inject to inject at 90 degree angle and aspirate. If client is obese use a 2-3

inch needle. The Z-track method prevents “tracking” and is used for admin meds that

are irritating to subcu and nervous tissue (e.g. imferon, Vistaril)

e. Time, name of med, dosage, route, injection site, initials, signature

61. IV (pg. 206 in med math)

a. Gtts/min

b. Keep vein open

62. IVPB (pg. 215 in med math)

a. mL/hr

63. Constipation

a. Geriatrics: A detailed acct of the patient’s bowel elimination should be elicited.

Frequency, time of day, and usual consistency should be noted. The use of laxatives and

enemas, and recent change in bowel movement should be noted. The amount and type

of fluid and fiber intake should be determined because they have an important effect on

the frequency and consistency of stool. Causes of constipation include insufficient

dietary fiber, inadequate fluid intake, decreased physical activity, opioids, ignoring

defecation urge and diseases that slow the GI such as diabetes, Parkinson’s and multiple

sclerosis.

b. Overall goals: Increase dietary fiber and fluids, increase physical activity, have the

passage of soft formed stools, not have any complications such as hemorrhoids.

64. Pedal pulse

a. Palpate both dorsalis pedal pulse and posterior tibial pulse.

i. The dorsalis pedis pulse may be felt on the medial side of the doesum of the

foot. Palpate the pulse lateral to the extensor tendon of the great toe, use light

pressure, and repeat the procedure on the other foot, note rate, rhythm,

amplitude and symmetry. Grade the amplitude on a 4 point scale (4 is

strongest).

ii. The absence of a dorsalis pedis pulse may not be indicative of occlusion because

another artery may be supplying blood to this area of the foot. Edema in the

foot will make palpation difficult.

iii. The posterior tibial pulses may be palpated behind and slightly inferior to the

medial malleolus of the ankle, in the groove between the malleolus and the

Achilles tendon (see pic pg 497 assessment book). Palpate the pulse by curving

your fingers around the medial malleolus. Note rate, rhythm, amplitude and

symmetry. Grade the amplitude on a 4 point scale (4 is strongest).

iv. If the artery is difficult to palpate the artery may be occluded

65. Laxative abuse

a. Some patients believe they are constipated if they do not have a daily bowel

movement. This can result in chronic laxative use and subsequent cathartic colon

syndrome- the colon becomes dilated and atonic (lacking muscle tone) and person

cannot defecate without a laxative.

66. Fluid volume deficit (hypovolemia)

a. Hypervolemia causes skin turgor to diminish, there is a lag in the pinching skinfold’s

return to its original state (tenting). The skin may be cool and moist if there is

vasoconstriction to compensate for the decreased fluid volume. Mild hypovolemia

usually doesn’t stimulate this compensatory response; consequently, the skin will be

warm and dry. Volume deficit may also cause the skin to appear dry and wrinkled. These

signs may be difficult to evaluate in the older adults because the pt’s skin may be

normally dry, wrinkled, and non-elastic.

67. Osteoporosis

a. Prevention and treatment of osteoporosis focuses on an adequate diet high in calcium

intake (1000 mg/day in premenopausal women and 1500mg/day in postmenopausal

women who aren’t receiving estrogen). If dietary intake of Ca+ is inadequate,

supplemental Ca+ may be recommended. Foods high in Ca+ are skim milk, yogurt,

turnip greens, cottage cheese, ice cream, sardines, and spinach. Vitamin D is important

in the Ca+ absorption and function and may have a role in bone formation. Increase

intake of protein as well.

68. Bandage extremity

a. When bandaging the extremities the thing to be caution of is circulation, make sure that

the bandages aren’t too tight.

69. Leukotriene modifiers (Singulair)

a. Drugs used to reduce inflammation and ease bronchoconstrication. These drugs are

used as an alternative drug in the management of asthma symptoms. Ex: Singulair is a

PO med and should be taken at night. Singular is ineffective in acute asthma. The

current role of leukotriene modifiers in the management of asthma is for persistent

asthma that cannot be controlled with inhaled corticosteroids or short-acting beta

agonist.

70. Osteoporosis goal

a. To prevent fractures.

b. To decrease pain and promote activities to diminish progression of disease.

71. Osteoporosis

a. Clinical manifestations: Spinal deformity and “dowager’s hump.”

i. Results from repeated pathologic, spinal vertebral fractures.

ii. Gradual loss of height (due to bone loss).

iii. Increase in spinal curvature (kyphosis).

72. Cataracts

a. Cataract is an opacity within the lens. Pts complain of decreased visual acuity or other

complaints of visual dysfunction. Most cataracts is age related, but it can also be

associated with other factors including: blunt, or penetrating trauma, congenital factors

such as maternal rubella, radiation or UV light exposure, certain drugs such as systemic

corticosteroids or long-term topical corticosteroids, and ocular inflammation. Pts with

diabetes mellitus tends to develop cataracts at a younger age then it does with pts

without diabetes.

b. The only way to cure cataracts is surgery; if the cataract is not removed the pts vision

will continue to deteriorate. Post-op meds usually include antibiotic drops to prevent

infection and corticosteroid drops to prevent inflammation. Pt need to avoid activities

that increase IOP; such as bending, stooping, coughing, or lifting.

73. Renal dehydration

a. Urine specific gravity is a laboratory test that measures the concentration of all chemical

particles in the urine. Specific gravity should be between 1.020 to 1.028 and when renal

dehydration occurs the specific gravity increases (specific gravity > 1.028).

74. PVD

a. Peripheral vascular disease is when the veins aren’t pumping the blood back as much as

they should be, so the circulation is the problem. To increase blood flow back to the

heart the pt should keep legs elevated, wear compression stocking, and ambulate for

short distances.

75. HbA1c

a. HbA1c is a test that measures the amount of glycated hemoglobin in your blood. The

doctor may order this test for pts that have diabetes. This test is used to see how the

blood sugar has been over the last 3 months. For diabetes pts they want to keep their

level below 7%, non-diabetic pts below 6.5%.

76. Gastroendoscopy – post-care

a. Gastroendoscopy is a test that is usually done on pts with GERD and it’s a camera that

goes into the mouth and down to the stomach. This procedure is done under local

anesthesia so when the pt gets back for the procedure the pts gag reflex has to be

checked before the pt in able to eat or drink anything.

77. NG tube

a. If a pt has an NG tube and is cyanosis chances are the tube is in the wrong spot and

cutting off the pts airway. If cyanosis occurs the NG tube should be removed

immediately.

78. Reflux cancer disease:

a. Barrett’s esophagitis results from long-term erosion of the esophagus as a result of

reflux of stomach contents 2nd to GERD; this is a precursor to esophageal cancer.

79. AIDS (CD4 < 200)

a. viral disease caused by human immunodeficiency virus (HIV) which destroys T cells

increasing susceptibility to infxn & malignancy; manifested by opportunistic infxns &

neoplasms that may not appear until late in the infxn; malaise, fever, anorexia, night

sweats, weight loss, flu-like symptoms, fatigue, diarrhea, leukopenia, protozoal infxns

(PCP: major source of mortality), fungal/viral/bacterial infxns.

b. Kaposi Sarcoma: Skin lesions that occur in individuals w/ a compromised immune

system; Neoplasm; slow-growing tumor that appears as raised, oblong, purplish,

reddish-brown lesions; tender/non-tender; organ involvement inc: lymph nodes,

airways/lungs, any part of GI from mouth to anus

c. Interventions for Kaposi: Standard precautions, protective isolations if immune system

depressed, prep client for radiation therapy/chemotherapy as prescribed, admin

immunotherapy as prescribed to stabilize immune system

80. Pressure Ulcer

a. Area of tissue damage that occurs as a result of skin & underlying tissue compression

from pressure between a surface & a bony prominence; restricts blood flow to skin =

tissue ischemia, inflammation, necrosis. Can occur anywhere on the body & once it

forms it’s difficult to heal.

i. Stage I: Intact, red & blanch w/ external pressure, may be

painful/firm/soft/warmer or cooler than adjacent tissue

ii. Stage II: Skin not intact, partial thickness loss of dermis, shallow open ulcer w/

red-pink wound bed or as intact or opened/ruptured serum-filled blister

iii. Stage III: Full-thickness loss, extends into dermis & SQ, & slough may be

present, SQ may be visible, undermining & tunneling may/may not be present

iv. Stage IV: Full-thickness loss, present w/ exposed bone/tendon/muscle,

undermining & tunneling may develop

81. Compartment syndrome

a. Pressure increases in a confined anatomical space, leading to decreased blood flow,

ischemia, & dysfunction of these tissues; initial ischemia w/ pain, pallor, paresthesia,

muscle weakness, & loss of pulses may progress to necrosis & permanent muscle cell

dysfunction.

b. Assessment- unrelieved or increased pain in the limb, distal tissue to involved area =

pale/dusky/edematous, pain w/ passive movement, paresthesia, pulselessness (late

symptoms). Call physician if compartment syndrome occurs.

82. Hip replacement

a. Big problem is infection, predisposition to anemia so √ Hct q3-4d, monitor function of

extremity, neurovascular status, I&O every shift, √ skin integrity.

b. Discharge: Rehab planning, encourage fluid intake of @least 3L/d, self-care activities at

max level, get out of bed asap & stay out of bed as much as possible, elevated toilet

seat, chairs w/ high seats, don’t lift leg upward from a lying position or elevate the knee

when sitting as this can pop the prosthesis out of the socket.

c. Dislocation: Abduction pillow, avoid extreme hip flexion (>90º∆), maintain hip & leg in

proper alignment & prevent internal or external rotation, avoid chairs, avoid crossing

legs & bending over.

d. Turn client to the unaffected side & only to affected side as prescribed by physician,

Elevate HOB 30-45º∆ for meals ONLY.

e. Avoid weight bearing on affected leg as prescribed, always refer to prescriptions.

83. Nuero assessment of fracture site

a. Pain/tenderness, decreased or loss of muscular strength or function, obvious deformity,

crepitation, erythema, edema, bruising, muscle spasm, neurovascular impairment.

b. Check movement, strength, sensation, reflexes, cap refill, edema

84. Osteoarthritis

a. Degenerative joint disease; progressive deterioration of the articular cartilage, causes

bone build-up & loss of articular cartilage in peripheral & axial joints, fx weight-bearing

joints & joints that receive the greatest stress (i.e., hips/knees/lower vertebral column,

hands), cause is unknown, risk factors (trauma, aging, obesity, smoking, genetic

changes)

b. naproxen (Naprosyn)- NSAID; reduces inflammation & pain, antipyretic

c. Adverse reactions: Na+ & water retention = peripheral edema, GI bleeding & ulceration,

anaphylaxis or hypersensitivity

d. SDFx: Nausea, vomiting, GI discomfort, bruise easily, peripheral edema, dizziness.

e. Assessments S/S of bleeding (i.e., black tarry stools, bruising, hematemesis, bleeding

gums), drug allergies, C/I conditions (active bleed, renal/liver problems), drug

interactions (dilantin, warfarin).

f. Nursing Implications: May cause GI discomfort which can be decreased by admin w/

food, NSAID induced ulcers may occur (stop!), increases risk for bleeding, esp. during

menses.

g. Teaching: About drug, dosing schedule, C/I, teach to take w/ food to minimize GI

discomfort, encourage to report any Sx’s of increased bleeding/bruising while taking

this, avoid taking ASA & Tylenol & Alcohol

85. Pre-op teaching:

a. Inform about what to expect post-op

b. Notify nurse if any pain is experienced postoperatively & the pain meds prescribed will

be given as needed

c. Inform client to use noninvasive pain relief techniques (guided imagery, relaxation,

distraction) before the pain occurs as soon as pain is noticed

d. Demo use of PCA as prescribed

e. Inform client that requesting an opioid after surgery ≠make them a drug addict

f. Importance of deep breathing & coughing techniques, use of incentive spirometry, &

importance of performing the techniques post-op to prevent development of

pneumonia & atelectasis

g. Do not smoke for @least 24h b4 surgery

h. Leg & foot exercises to prevent venous stasis of blood & to facilitate venous blood

return

i. How to splint an incision, turn, and reposition

j. Inform of any invasive instruments that may needed post-op (NG tube, foley, epidural

catheter, IV, subclavian lines)

k. Instruct not to pull on any invasive devices & they will be removed asap

86. Toradol effects: SEE NAPROSYN

87. Renal pre-op checklist

a. Renal System

i. Acute Renal Failure- abrupt deterioration of the renal system, reversible; when

metabolites accumulate in the body & urinary output changes, 3 major types,

assess history of taking nephrotoxic drugs (i.e., NSAIDs, salicyclates, antibiotics),

alterations in urinary output, edema/weight gain, change in mental status,

assess Na+/K+/Phos/Chloride levels, BUN, creatine, pH, urine specific gravity

ii. Chronic Renal Failure: End Stage Renal Disease- progressive irreversible damage

to nephrons & glomeruli = uremia, as renal function decreased dialysis becomes

necessary; assess family Hx, increased BP, high med use, edema/pulmonary

edema, neurological impairment (weakness/drowsiness), decreasing urinary

function (hematuria, oliguric, proteinuria, cloudy urine, anuric), yellow skin, GI

upset, metallic taste in mouth, ammonia breath, dialysis, previous kidney

transplant, azotemia, increased creatine/BUN, decreased Ca+, elevated

phos/Mg+

b. Assessment: Allergies to latex, HH & physical exam done & document, prescribed labs

documented and in chart.

c. Checklist: Height/weight, ensure client is wear ID bracelet, informed consent forms

signed for procedure/blood trans/disposal of limb/ sterilization procedures, blood

type/screen/cross-match are done, remove jewelry/makeup/hairpins/nail

polish/glasses/prostheses & document valuables (given to family/locked in hospital

safe), document last time client ate/drank/voided, document meds given, (M) vital

signs.

88. Fluid volume: Renal System

a. Maintain acid-base balance

b. Excrete end products of body metabolism

c. Control fluid & electrolyte balance

d. Excrete bacterial toxins, water-soluble drugs, & drug metabolites

e. As fluid flows through the tubules, water, electrolytes & solutes are reabsorbed & other

solutes such as creatine, hydrogen ions, & K+ become urine

f. Water & solutes that are not reabsorbed become urine

g. Process of selective reabsorption determines the amount of water & solutes to be

secreted

h. Homeostasis of Water: ADH primarily responsible for reabsorption of water by the

kidneys, produced by hypothalamus & secreted by posterior pituitary gland (stimulated

by dehydration or high Na+ intake & by a decrease in blood voL); when ADH is lacking =

Diabetes Insipidus & they produce large amounts of dilute urine; treatment is necessary

b/c the client ≠drink sufficient water to survive

i. (M) I&O, labs (serum & urine) especially K+ for Hyperkalemia (ECG changes), LOC,

Weight daily, Kayexalate may be admin for >K+,

j. Assess for sx’s of fluid voL alterations: Excess (dyspnea, tachycardia, JVD,

peripheral/pulmonary edema); Deficit (decreased urine output, reduction in body

weight, decreased skin tugor, dry mucous membranes, HypoTN, tachycardia

k. Assess for Sx’s of Hyperkalemia: dizziness, weakness, cardiac irregularities, muscle

cramps, nausea, diarrhea

89. Hyponatremia

a. Common causes: Diuretics, GI fluid loss, hypotonic tube feeding, D5W or Hypotonic IV

fluids, diaphoresis

b. S/S: Anorexia, nausea, vomiting, weakness, lethargy, confusion, muscle

cramps/twitching, seizures, <135 Na+

c. Treatment: (3% saline or NS) - Hypertonic solution, restrict fluids, if saline solution is

prescribed then administer very slowly (use when fluid restriction not useful).

90. Reproductive

a. Hormone Replacement Therapy (HRT)

i. Osteoporosis: Estrogen replacement therapy to prevent osteoporosis (inhibits

osteoclasts leading to decreased bone reabsorption) and most effective when

combined w/ Ca+ supplements; Salmon calcitonin (Calcimar) inhibits

osteoclastic one resportion by directly interacting w/ active osteoclasts;

Biophosphates like alendronate (Fosamax) inhibit osteoclast-mediated bone

resorption = increasing BMD & must take w/ full glass of water 30min b4

food/other meds & remain upright for @least 30min after taking.

ii. Perimenopause & Postmenopause: Estrogen for women w/o ovaries or

estrogen & progesterone for women w/ a uterus, studies now show that

women who take thee have an increased risk for developing stroke, breast

cancer, heart disease, DVT, pulmonary emboli. But, they have fewer hip fracture

and lower risk of developing colorectal cancer; the lowest dose should be used.

91. Pneumonia

a. Listen to lungs for crackles before doing sputum culture

b. “essential components of nursing care for patients with pneumonia include monitoring

physical assessment parameters, facilitating laboratory and diagnostic tests, providing

treatment, and monitoring the patient’s response to treatment” (p.569, Medical-

Surgical Nursing 7th ed.)

92. Pursed lip breathing (PLB)

a. COPD patients develop increased respiratory rate w/ prolonged expiration to

compensate for obstruction to airflow resulting in dyspnea. PLB decreases dyspnea,

improves oxygenation, and slows respiratory rate by prolonging expiration and thereby

preventing bronchiolar collapse and air trapping.

b. Teach to use PLB before, during, and after any activity causing dyspnea or tachypnea

(sex, alcohol, drugs, exercise…). Teach to inhale slowly through the nose and exhale

slowly through pursed lips. Exhalation should be 3x as long as inhalation. Nurse should

demonstrate so patient can imitate.

c. The following techniques may be used to teach PLB

i. Blow through straw in glass of water to form small bubbles

ii. Blow at a lit candle to bend flame w/o blowing it out

iii. Steadily blow a ping pong ball across a table

iv. Blow a tissue held in hand until it gently flaps

93. Theophylline

a. Methlyxanthine bronchodilator that alleviates early phase of asthma attacks and the

bronchoconstrictive component of the late phase asthmatic response. Not as effective

as beta-adrenergic agonists. Long-acting theophylline administered at bedtime used to

treat pt w/ nocturnal asthma.

b. Serum blood levels should be monitored regularly to determine if drug is w/in

therapeutic range (10 – 20 mcg/mL).

c. Common side effects: vomiting, headaches, nausea, irritability, flushing and palpitations.

Insomnia, GI distress, tachycardia, dysrhythmias, and seizures. Restlessness of caffeine

like jitters.

94. Thick secretions

a. Hydrate, humidified oxygen, chest physiotherapy

b. Chest physiotherapy

i. Perform an hour before meals or 1-3 hr after meals

ii. Admin bronchodilator 15min prior to therapy

iii. Assume pt in correct position for postural drainage for 5-15 min (see 648 of

med-surg textbook for positions)

iv. Observe pt breathing pattern and color changes to face to determine tolerance

v. Have pt take several deep abdominal breaths

vi. Percuss appropriate area for 1-2 min keeping pt’s face in view

vii. Vibrate same area while pt exhales 4-5 deep breaths

viii. Assist pt to cough. Suction if necessary

ix. Repeat same procedure for all necessary positions

x. Monitor hypoxemia and chart effectiveness of treatment by amount of sputum

produced and results of lung auscultation

95. Retinal detachment

a. S/S: Photopsia (light flashes), floaters, and cobweb or ring in the field of vision. Once

the retina has detached, there is a painless loss of peripheral/central vision like a curtain

coming across field of vision. Area of visual loss corresponds to area of detachment

96. HTN

a. Complications: Coronary artery disease, left ventricular hypertrophy, heart failure,

cerebrovascular disease (stroke), PVD, aortic aneurysm, speeds up atherosclerosis,

kidney disease (nephrosclerosis), and retinal damage.

97. PAD and PVD

a. Arterial s/s:

i. Aortic aneurysms: Deep chest pain that may extend to interscapular area,

angina, dysphagia, distended neck veins, edema of head/arms, pulsatile mass in

periumbilical area, bruits, back pain, epigastric discomfort, altered bowel

elimination

ii. Aortic dissection: Chest pain, ALOC, dizziness, weak/absent carotid/temporal

pulse, angina, MI, new high-pitched diastolic cardiac murmur, dyspnea,

orthopnea, different BP readings in left/right arms

iii. PAD of lower extremities: Intermittent claudication (ischemic muscle pain

caused by activity and relieved w/ rest), paresthesia of toes/feet, loss of hair on

lower legs, weak/absent pedal pulse, pallor/blanching of foot in response to leg

elevation, redness of foot (reactive hyperemia) when limb is hung

b. Venous s/s:

i. DVT: Unilateral leg edema, extremity pain, warm skin, erythema, systemic temp

greater than 100.4F, tender calf upon palpation, positive homan’s sign, and

edematous/cyanotic lower extremities.

ii. Varicose veins: Ache/pain after prolonged standing (relieved by walking or

elevating legs), nocturnal calf cramps, and swelling of legs.

98. Gingival hyperplasia

b. May be drug induced with drugs such as dilantin (anticonvulsant), nifedipine (calcium

channel blocker), and ciclosporin (immunosuppressant)

a. Stop medication and notify HCP

b. Thorough oral hygiene after each meal, gum massage, daily flossing, and regular dental

care are essential to prevent or control gingival hyperplasia.

99. Documentation

100. Establish goals

101. Legal – OP

102. HIV/AIDS (complications)

a. Pneumocystis jiroveci pneumonia (PCP)

i. Clinical manifestations: Pneumonia, nonproductive cough, hypoxemia,

progressive SOB, fever, night sweats, fatigue.

103. HIPPA

a. Young adult: A client under the age of 18 is not legally able to give permission for

surgery unless the adolescent is given an emancipated status by the judge.

b. “Once a child reaches the age of majority (typically 18 - 21 years of age), a parent is no

longer entitled to see or amend the child's medical records. If the parent continues to

pay for the child's care, some information may be disclosed so the parent can obtain

payment from the insurer. The physician is allowed to exercise some professional

judgment about when to disclose PHI to the parents without the young adult's

authorization. When in doubt, ask the young adult patient to sign a written

authorization.”