NUR HEALTH ASS MEDICAL SURGICAL FINAL EXAM (GRADED A) | GUARANTEED PASS | LATEST UPDATE 2021

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MEDICAL SURGICAL FINAL EXAM 1. Know the assessment techniques A. Inspection= The visual examination -The critical observation of the client for any physical signs that indicate alteration from ... normal -Can be done during hygiene care -Used to assess body surface, shape, size, color, position, and symmetry B. Palpation= Using the sense of touch (DEEP PALPATION IS NOT WITHIN THE SCOPE OF LPN) -Texture of hair -Temperature of skin -Vibration of joints -Size/ Position/ shape/ Consistency/ Texture/ Mobility of masses -Collection of fluid/ Presence of distention -Pulses -Tenderness and Pain C. Percussion= The deliberate striking or tapping of a body part to elicit sounds/vibrations -Direct percussion: striking an area directly with 1 to 3 finger pads or with the pad of the middle finger rapidly -Indirect percussion: striking an object against the area (another finger) -Assesses the size and shape of internal organs (boundaries) -Assesses if the tissue is filled with fluid/ air/ solid D. Auscultation= Listening for sounds produced by the body -Direct: using the unaided ear -Indirect: using a stethoscope -Listen for intensity (loudness of softness of the sound) -Listen for pitch (frequency of vibrations) -Listen for duration (length of the sound; short to long) -Listen for quality (the subjective description of the sound; whistling, gurgling etc.) 2. Difference between normal and adventitious breath sounds Normal Breath Sounds: A. Vesicular= soft, breezy, sighing sound; best heard over periphery/ bases B. Bronchovesicular= blowing sound & large amt. of air through lung tube; best heard over first and second intercostal spaces substernal C. Bronchial= high pitched, harsh, loud sound caused by air moving through the trachea; best heard over anterior trachea, not normally heard over lung tissue. Adventitious Breath Sounds: A. Crackles (rales)= cause by air passing through fluid/ mucous in air passages i. heard on inspiration and is most commonly heard in the bases of the lungs ii. usually do not clear with coughing B. Gurgles (rhonchi)= air passing through narrow air passages as a result of secretions, swelling or tumors. i. clear with cough ii. usually heard over trachea and bronchi iii. best heard during expiration iv. course gurgling, harsh sounds or like snoring C. Wheezes= continuous, high-pitched, musical sound i. caused by air passing through constricted bronchi because of secretions, swelling or tumors. ii. best heard on expiration over all lung fields iii. not usually cleared by coughing D. Friction Rub= grating sound due to inflamed visceral and parietal pleurae rubbing i. usually heard over the anterior lateral chest. ii. can be heard on inspiration and expiration iii. not relieved by coughing 3. Normal heart sounds S1= Closure of the atrioventricular Valve (the “lub”) a. mitral and tricuspid valves close when the ventricles have filled S2= Closure of the Semilunar Valves (the “dub”) a. higher pitched and shorter than S1 b. aortic and pulmonic valves close when the ventricles have emptied Systole= when ventricles are contracted- begins with S1 and ends with the beginning of S2 Diastole= when ventricles relax- starts with S2 and ends with S1 4. Glasgow Coma Scale -Originally used to predict head injury recovery- now used to assess Level of Consciousness -Tests 3 areas: a. Eye response b. Motor response c. Verbal response (Total points= 15; less than 7= comatose) Eye Opening -Spontaneous 4 -To verbal command 3 -To pain 2 -No Response 1 Motor Response -To verbal command 6 -To localized pain 5 -Flexes/ withdraws 4 -Flexes abnormal 3 -Extends abnormal 2 -No Response 1 Verbal Response -Oriented, converses 5 -Disoriented, converses 4 -Uses appropriate words 3 -Makes incomprehensible sounds 2 -No response 1 5. Signs of ETOH Withdrawal -Occurs within 4 to 12 hours after last drink and may last several days after abstinence -Signs: a. coarse tremor of the hands, tongue, or eyelids b. sweating c. N/V d. depressed mood or irritability e. headache f. insomnia g. illusions/ hallucinations in some cases 6. Care of a patient with Obsessive Compulsive Disorder -Obsessions= recurrent and persistent thoughts, urges, or images that are intrusive and unwanted. -Compulsions= repetitive behaviors (hand washing, checking something, etc.) or mental acts (praying, counting, repeating words, etc.) -The obsessions and/or compulsions are aimed at reducing or preventing anxiety or distress or dreaded event or situation. -Treatment= Cognitive therapy, desensitization therapy, SSRIs 7. Care of patient with suicidal ideations -Suicide: often due to anger toward a person or event turned inward -Most common reason: a solution -Stimulus: intense psychological pain, helpless, and/or hopeless -Goal: Relief from emotional pain Interventions: a. Provide a safe environment b. constant supervision- 1:1 direct; no more than arm’s length away c. NEVER leave the patient without relief from a competent staff member- always remember to give report d. be alert at all times, but warm and supportive e. search belongings/ room for items that could be used to attempt suicide- new admits especially f. Remove: belts, shoes laces, sheets, shaving supplies, hangers, cosmetics, mirrors g. conduct regular body searches and check oral cavity after medication administration h. provide a safe environment i. non-judgmental tone/ body language j. create a support system list- family/friends/support groups/ community organizations 8. Care or a patient with Schizophrenia Spectrum Disorder Nursing Care: -Avoid touching patient -Observe for signs of hallucinations -Do not re-enforce the hallucinations- use “the voices” instead of “what are they telling you” or “I understand YOU hear the voices but I do not hear any voices speaking” -Distract the patient from the hallucinations- involvement in interpersonal activities often brings the patient back to reality -Do not argue or deny delusions (false beliefs)- instead “I understand YOU believe this to be true…” -Give positive reinforcement for patient’s voluntary interactions with others- decrease social isolation -Verbal aggression- no direct physical contact made; if possible remove patient to a more isolated area or remove others in the immediate space. -If direct contact is made, result to seclusion or “quiet room” 9. Care of patient with bipolar disorder -Bipolar: characterized by mood swings from profound depression to extreme euphoria (mania), with intervening periods of normalcy. Delusions or hallucinations may or may not be present. Nursing Outcome Criteria: -No physical injury -No harm to self or others -No signs of physical agitation -Eats a well-balanced diet -Verbalizes accurate interpretation of environment -No hallucinatory behavior -Accepts responsibility for own behavior -Does not manipulate others for gratification of own needs -Interacts appropriately with others -Gets 6-8 hours of sleep per night 10. Care of a patient with restraints -Seclusions and restraints should be prescribed for the shortest duration necessary, and only if less restrictive measures are not sufficient (must be documented) a. must monitor every 15 minutes b. must offer bathroom use every 2 hours -NEVER use restraints for: staff convenience, punishment of a patient, patients who are extremely physically or mentally unstable, and clients who cannot tolerate the decreased stimulation. -ONLY used in an emergency when there is an imminent risk of patient physically harming themselves or others -The physician must complete face-to-face assessment within 1 hour of initiation. 11. Care of patient with Pneumonia -Pneumonia= refers to an inflammation of lung parenchyma caused by microbial agents that produce excess fluid S/S: Sudden chills, rapidly rising fever, pleuritic chest pain, tachypnea, SOB, use of accessory muscles, rapid, bounding pulse, orthopnea, SOB while reclining, anorexia, diaphoretic, tires easily, hemoptysis. *Wheezing sound is heard. Nursing Interventions: -Assess RR + Rhythm -Encourage coughing -Ensure proper nutrition -Hydration (2-3 L/day) to liquefy secretions -Humidification to loosen secretions -Administer oxygen as ordered -Bed Rest and avoid exertion -Chest Physiotherapy to mobilize secretions (before meals and position for postural drainage based on lung area to be drained) -Suctioning PRN Prevention: -A pneumonia vaccine called Pneumovax every 5-7 years -TCDB -Incentive Spirometer -Postural drainage -CPT=chest physiotherapy -Vibration and percussion 12. Care of patient with Tuberculosis -Tuberculosis= Infectious disease affecting the lung parenchyma a. mycobacterium tuberculosis is the most frequent (mycobacterium bovis, avium) b. usually involves lungs but may spread to other parts of the body (meninges, kidneys, bones, lymph nodes) c. organism is a bacterium that resembles fungus d. frequently associated with poverty, malnutrition, overcrowding, substandard housing -Sputum Culture is the definitive test to diagnose and suggest active infection -Test is read 48-72 hours after injection -A POSITIVE REACTIONS IS AN AREA OF INDURATION AND ERYTHEMA OF 10mm OR MORE -A positive reaction (10mm or greater) indicates exposure; does not mean active disease Medications: 1. isoniazid (INH) + Vitamin B6 for 8 weeks 2. rifampin (Rifadin)- used to treat the family members exposed 3. pyrazinamide (PZA) 4. ethambutol (Myambutol) *Multiple medications are given to prevent resistance* *If first line does not work, use other drugs such as aminoglycosides and fluoroquinolones* Nursing Interventions: -Promote airway management through the following: a. systemic hydration b. postural drainage -Promote adherence to treatment regimen a. patient must understand that TB is a communicable disease b. compliance with meds is the most effective means of preventing transmission -Provide activity and adequate nutrition since anorexia and weight loss are very common -Prevent transmission of TB infection a. AFB positive b. mask: N95 respirator c. special room for separate ventilation and negative airflow (AIRBOURNE PRECAUTION) 13. Warning Signs of Cancer (C.A.U.T.I.O.N.) C= Change in bowel or bladder habits A= A sore that does not heal U= Unusual bleeding or discharge T= Thickening or lump in the breast or elsewhere I= Indigestion or difficulty in swallowing O= Obvious change in a wart or mole N= Nagging cough or hoarseness 14. Care of a patient receiving radiation therapy Radiation= May be used to cure cancer. It may also be used to control cancer when a cancer tumor cannot be removed surgically or when there is local nodal metastasis. Nursing Intervention: -Assess skin -Assess nutritional status -Assess general feelings of well-being Restrictions for the Patient: -Keep skin dry; do not wash without Dr. order -Wash with warm or cool water, mild soap, rinse and pat dry. NO HOT WATER -Do not remove lines or ink marks -No tape on skin -Avoid powders, lotions, creams, alcohol or deodorants -Wear loose fitting clothes -Use electric razor -No sun or chlorinated pools -Review mucositis precautions 15. Care of Patient with Internal Radiation Implants Brachytherapy= places a radioactive implant at a localized area to target the specific cancer site. This can be done with rods, seeds, beads, ribbons or catheters. Typically placed in a body cavity. CT, MRI or ultrasound is used to guide placement. Can be temporary (high dose) or permanent (low dose). Restrictions for a Patient: -Private room -No pregnant visitors or children -All personnel assisting must wear dosimeter -Post appropriate notices about radiation safety precautions -Limit visits to 30 minutes -Visitors must be 6 ft. from patient -Keep a lead container in the patient's room if the delivery method could allow spontaneous loss of radioactive material. Tongs should be available for placing radioactive material into this container. -Remain in an indicated position to prevent dislodgement of the radiation implant -Call the nurse for assistance with elimination -Radiation precautions needed in the health care and home environment if patient goes home with implant 16. Care of patient receiving chemotherapy -Chemotherapy: Involves the administration of systemic or local cytoxic medications that damage a cell's DNA or destroy rapidly dividing cells -Goal of Chemotherapy: Cure, control or palliation. It is a systemic medication approach that can be combined with surgery and/or radiation. -Most common side effect of chemotherapy: IMMUNOSUPPRESSION -Complication= Stomatitis= Give oral care with mouthwashes and hydration! Nursing Actions for Immunosuppression: -Monitor temperature and WBC count -Fever greater than 100 F should be reported to the provider immediately -Monitor skin and mucous membranes for infection -Cultures should be obtained prior to initiating antimicrobial therapy -If patients WBC drops below 1000, place the patient in a private room and initiate neutropenic precautions Administration of Chemotherapy: -PICC or CVC line, port or pump -Only given by those trained in extravasation management -PO -Infusions -Topical 17. Care of a Patient with Skin Cancer -Three types of Skin Cancer: 1. Squamous cell (epidermis) 2. Basal cell (basal epidermis or nearby dermal cells) 3. Malignant melanoma (cancer of melanocytes) -#1 Cause of Skin Cancer: Overexposure to Sunlight Nursing Care: -Instruct the patient about the importance of using sunscreen a. One ounce of 30 SPF or higher b. Reapply every 2 hours if swimming 18. Care of a patient with Glaucoma Types of Glaucoma: A. Wide-Angle= Usually bilateral, one eye can be worse; anterior chamber is open and appears normal B. Narrow-Angle= Obstruction in aqueous humor outflow due to complete or partial closure of the angle from the forward shift of the peripheral iris to the trabecula. (MEDICAL EMERGENCY) -Glaucoma is often called the “silent thief of sight”. Most patients are unaware that they have the disease until they have experienced visual changes and vision loss. -Life-long therapy needed because there is no cure. Ocular Medications used for Glaucoma: -Miotics -Beta Blockers (DO NOT USE BETA BLOCKERS ON PT’S WITH COPD OR ASTHMA) -Alpha agonists -Carbonic anhydrase inhibitors -Prostaglandins Signs & Symptoms of Glaucoma: -blurred vision - “halos” around lights -difficulty focusing -difficulty in adjusting eyes in low lighting -LOSS OF PERIPHERAL VISION (like blinders on a horse) -aching or discomfort around the eyes and headache Nursing Management: -Assess patient’s knowledge level and adherence -LIFE LONG MEDICATION COMPLIANCE -Teach about the interaction of glaucoma medications with other medications a. For example: the diuretic effect of azetazolamides (Diamox) may have an additive effect on diuretics of other antihypertensive drugs -Loss of peripheral vision impairs mobility the most 19. Administration of Eye Drops and Ear Drops Eye drop administration= 1. Do not instill directly to cornea. 2. Place in conjunctival sac 3. Before instilling eye medication: a. gently wipe away any discharge or drainage along eyelid margins or inner cants b. start in then out 4. Avoid touching the tip of medication bottle or tube to the eye. 5. Do not push on the eyeball or touch the eye when exposing the conjunctival sac. 6. If medication will have systemic effects: a. Apply gentle pressure to nasolacrimal duct for 30-60 seconds. Ear drop administration= 1. Inform client that moving the pinna or triages to instill medications may cause pain 2. warm the medication by rolling container between the hands. (Cold drops cause dizziness) 3. place client on unaffected side 4. keep client side lying after instilling drops. 5. Place a small cotton ball in the ear, avoid packing it tightly 6. remove cotton after 15 minutes. *Pinna up and back for adult* *Pinna down and back for child under 3* 20. Care of a patient with psoriasis Psoriasis= Silver plaques common over the elbows, knees, scalp, lower back and buttocks; periods of remission and exacerbations -Chronic inflammatory multisystem disorder. -Plaque-like lesions, silvery, scaly, flaky appearance -No cure Nursing Management: -support patient -coping strategies -noninfectious condition -do not pick or scratch areas -avoid too frequent washing -use warm water not hot water, pat dry the skin 21. Care of a patient with Vertigo Vertigo= An illusion of motion of the person or surroundings. Patient describes a spinning sensation or say that objects are moving around them. -The dizziness may increase the risk for falls -SAFETY IS IMPORTANT Vertigo Reducing Activities: -restrict movement of head and to change positions slowly -avoid caffeine and alcohol -rest in a quiet and darkened environment -use assistive devices as needed for ambulation -take a diuretic if prescribed, to decrease the amount of fluid in the semicircular canals -space intake of fluids evenly throughout the day 22. Care of a patient with Meniere’s Disease Meniere’s Disease= an inner ear disorder that causes episodes of vertigo; it’s an abnormality in inner ear fluid balance caused by malabsorption in the endolymph sac or a blockage in the endolymphatic duct. Signs & Symptoms: -episodic vertigo: can be severe -tinnitus: ringing in the ears -fluctuating sensorineural hearing loss Dietary Guidelines: -limit food high in salts and sugars!!! -eat meals and snacks in regular intervals to stay hydrated -eat fresh fruits and vegetables, whole grains (limit canned, frozen, and processed food with high sodium content) -drink plenty of fluids, water, milk and low sugar fruit juices 23. Care of a patient with Hypertension Hypertension= elevated blood pressure often called “silent killer” -Commonly accepted criteria: based on two readings on two different occasions a. systolic pressure greater than 140 mmHg b. diastolic pressure of 90 mm Hg or greater c. prehypertension- 120-139 systolic or 80-89 diastolic -Normal blood pressure is 120/80 Patient Education: -Silent killer, damages kidneys, heart, brain and eyes -Greatest challenge = medication compliance - 50% D/C within 1 year -Side Effects of BP meds = cough, periorbital edema, impotence, depression, muscle cramps, weakness, fatigue -Stress not a cure, but improvement of quality of life -Weight loss and exercise -STOP SMOKING -Dietary restrictions of sodium and fat -DO NOT STOP antihypertensive medications abruptly -If you miss a dose, do not double up as this may cause hypotension -Avoid hot baths, exercise and ETOH within three hours of a vasodilator 24. Difference between Left-Side HF and Right-Side HF -There are clinical manifestations of Congestive Heart Failure Left-Sided Heart Failure (L for LUNG) -Pulmonary congestion due to increased pulmonary pressure= causes dyspnea, cough, crackles, and low oxygen saturation -SOB -Orthopnea -Frothy pink tinged sputum -Oliguria -Dizziness (lack of brain perfusion) -Fatigue Right-Sided Heart Failure -Congestion of peripheral system -Edema of lower extremities -Ascites -Nausea -Weakness -Weight gain 25. Care of a patient with Transurethral Resection of the Prostate (TURP) TURP= Surgical instrument is introduced into the urethra and the area(s) of obstruction are cut away. a. most common surgical approach b. allows for shorter hospital stay c. less pain d. may grow back e. no incision -Color of the drainage in the CBI following a TURP should begin reddish pink and clear to light pink within 24 hours. -If bright red blood is present with increased viscosity and numerous clots, call surgeon STAT! -Usually indicates arterial bleeding Nursing Interventions before TURP: -Education on what to expect -Enema night before surgery - Stool softener after -Teach TCDB, SCD or AE hose, care of incision, three-way catheter with CBI (Sterile NS to prevent clot formation) -Administer analgesics -I & O -Obtain lab specimens -Provide emotional support Things to Monitor Post TURP: -Patency of catheter- kinking or clogs can cause distention and/or bladder spasms -Administer analgesics -Provide warm compresses and sitz baths -Administer stool softeners -Monitor bleeding -Monitor for S/S of infection and skin breakdown -Wound care with aseptic techniques -Teach Kegels -AVOID RECTAL TEMP 26. Care of a patient with Continuous Bladder Irrigation (CBI) -A constant flow of normal saline (or other bladder irrigant) through a three-way urinary catheter to keep the catheter patent. -Sterility and patency of CBI system is maintained to avoid infection and occlusions -Saline solution for infusion should be stored and infused at room temperature to avoid bladder spasms. -Strict Intake & Output is recommended for all patients receiving CBI. -If patient complains of pain, make sure there are no kinks or clots in the line. a. empty the bag b. administer pain medication c. notify the doctor 27. Clinical Manifestations associated to Endometriosis Endometriosis= when endometrial tissue (lining of the uterus) is found outside of the uterus. S/S: -Excessive bleeding -Bleeding in between periods -Painful bowel movements (dyschezia) -Painful coitus (dyspareunia) -Dysmenorrhea- aching in lower back, abdomen, vagina without menses and during -Depression -Infertility 28. Nursing Interventions associated with Premenstrual Syndrome (PMS) Physical Symptoms: -accumulation of body fluids -abdominal fullness (bloating) -acne -severe headache -fatigue -lower back pain -engorged/ painful breast Behavioral and Emotional Symptoms: -anxiety -depression -anger -severe mood swings -crying spells -food cravings: chocolate, salt, binge eating Nursing Interventions: -No single treatment -obtain health hx -promote positive coping strategies -encourage activity and relaxation techniques to reduce stress a. meditation b. imagery c. creative activities etc. -teach patient to take medications as prescribed a. Prozac, ibuprofen, oral contraceptives etc. -assess for suicidal, uncontrollable, violent behavior 29. Education on Breast Exam -Performed during general or gynecological exam. -Purpose: to detect breast lumps and thickened areas early on -Self -Breast Examination should be done monthly a. 5-7 days after menstruation begins or on a specific date each month after menopause -Nurses can play a major role in: a. teaching and encouraging women AND men to perform SBE b. teaching s/s of abnormalities 30. Care of a Patient with STI or STD STI= A disease acquired through sexual contact with an infected person. Characteristics include more common in person who engage in high risk sexual behavior. Prevention= Education should include high risk behaviors that can lead to infection Management= Antibiotic Treatment (varies depending on what type of bacterial infection you have; oral or topical) -USE CONDOMS & GET TESTED!!! 31. Care of a patient with Parkinson’s Disease PD is a slowly progressing neurologic movement disorder that eventually leads to disability. -The degenerative or idiopathic form of PD is most common S/S: -head bent forward -fine tremors of hand/ head even at rest -pill rolling of the hands -shuffling propulsive gait -rigid stance -loss of postural reflexes -stooped posture -weight loss -drooling -dysphagia -dementia -confusion -loss of balance -Three Cardinal Signs: RESTING TREMORS, PROPULSIVE GAIT, STOOPED POSTURE Management: Controlling the symptoms by maintaining functional independence Medication therapy: CARIDOPA/LEVODOPA (SINEMET) Nursing Interventions= -Enhance self-care activities by instructing the patient a. to change positions slowly b. allow time to complete task c. use assistive devices -Improve communication -Supporting coping abilities -Improve mobility by teaching walking techniques -Improve nutrition since the patient will have dysphagia and risk for aspiration 32. Care of a patient with multiple Sclerosis (MS) MS= degenerative progressive disease of the nervous system characterized by the occurrence of small patches of demyelination in the brain and spinal cord; causing interrupted nerve impulses. -MS is a chronic illness and there are periods of remission (s/s decrease or disappear) and/or exacerbation (new symptoms occur and existing ones worse) -MRI is the best diagnostic tool- will show multiple plaques S/S: 1. fatigue, weakness 2. visual disturbances 3. cerebellum involvement: ataxia (impaired balance or coordination) *These are three s/s that would be present during an exacerbation state Nursing Interventions: -promote physical mobility: improve gait by minimizing spasticity and contractures a. ROM exercises to prevent contractures -prevent injury with the use of assistive devices -promote bladder and bowel control by setting a schedule -home care considerations a. remove exacerbating factors that may trigger a relapse (fatigue, stress, trauma, infection, surgery, pregnancy, fever, heavy physical exertion) 33. Care of a patient with seizure Seizure= episodes of abnormal motor, sensory, autonomic or psychic activity as a result of excessive discharge from cerebral neurons. Most Common Cause= Abrupt cessation of antiepileptic drugs Most common drug used= Dilantin (Normal Value: 10-20 mcg/mL) Triggering Factors= -not taking meds -overwhelming fatigue -acute alcohol ingestion -excessive caffeine intake -exposure to flashing lights -substances such a cocaine, aerosols, and inhaled glue products Generalized Seizure S/S= -intense rigidity of the body, followed by jerky alterations of muscle relaxation and contractions -epilectic cry -tongue is chewed -patient is incontinent of urine or stool -patient relaxes and slips into a deed coma (post ictal) -the patient is often confused or hard to arouse -may sleep for hours Nursing Care DURING a seizure= -ease pt to the floor -protect the head -loosen constrictive clothing -if there is an aura before the seizure, assist pt back to bed -turn pt to the side -do not use padded tongue blades during a seizure Nursing Care AFTER a seizure= -DOCUMENT THE EVENTS LEADING TO AND OCCURING DURING THE SEIZURE -side lying position which prevents complication of aspiration and further injury -maintain seizure position -STAY WITH THE PATIENT 34. Care of a patient with Stroke Stroke= a sudden loss of brain function resulting from disruption of the blood supply to a part of the brain. S/S= -numbness/ weakness -confusion or change in mental status -trouble speaking or understanding speech -visual disturbances -difficulty with movement/ walking coordination -sudden severe headache Management= Thrombolytic Agents t-PA= dissolves the blood clot that is blocking the blood flow to the brain a. must know when the stroke began b. must be given within 3- 4.5 hours c. use of t-PA must follow a strict eligibility criteria Nursing Interventions= -Assess the patient’s ability to perform ADL’s then proceed in: a. promoting safety b. improving mobility c. patient education d. prevent complications e. achieve communication 35. Care of a patient post Transient Ischemic Attack (TIA) TIA= temporary episode of neurologic dysfunction manifested by a sudden loss of motor, sensory, or visual function *PECURSOR TO A STROKE* S/S= -numbness of the arm (usually unilateral) -difficulty in speaking or slurred speech -dizziness -aphasia (inability to comprehend or formulate language) -vertigo -diplopia (double vision) 36. Care of patient with an amputation Amputation= surgical removal of a body part or limb Main Cause of many amputations= PERIPHERAL ARTERY DISEASE DUE TO DIABETES Post-Op Nursing Care= -monitor VS -check for bleeding/ drainage -bed flat to prevent flexion contractures -elevate first 24 hrs. but after that NO PILLOWS -prone 24-48 hrs. post -assess for bleeding at the surgical site -wound care -wrapping with ace bandage to shape limb Complications= -Hemorrhage: most important -Infection -Skin Breakdown -Phantom Limb Pain a. soon after surgery b. pain, numbness, tingling, muscle cramp, feeling extremity present Nursing Interventions= -pain management -minimize altered sensory perception -promote wound healing -enhance body image -promote self-care -stump desensitization (massages) -achieve mobility 37. Care of a patient post knee and hip replacement Knee Replacement Management= -compression bandage -elevate, ice (to manage edema) -quad sets, active ROM -wound suction (200 mL/24 hr.) -CPM -auto-transfusion -knee immobilizer -weight bearing status -pain control -complications -infections -thrombus formation Hip Replacement Management= -prevent dislocation -monitor wound drainage -prevent DVT -prevent infection -promote home and community-based care -self-care -CMS on surgical leg(s) is priority after surgery -flat position, legs slightly abducted -turn as ordered with abduction pillows -trochanter roll on unaffected leg to prevent external rotation 38. Care of patient with gout -also known as "king’s disease" -purine metabolism; disease of the joints caused by deposit of uric acid crystals in the joints. -foods rich in purines (steak, shell fish, caviar and organ meats) Risk Factors= -obesity -age -alcohol consumption -cardiovascular disease (HTN) -starvation diet -diuretic use -some chemotherapeutic agents -chronic kidney disease S/S= -sudden onset of severe pain the the distal joints, mainly the big toes -toe becomes swollen, red hot, pt becomes febrile -tophi= deposits of uric acid on ear cartilage (seen as bumps on lobes) in peripheral areas Nursing Interventions= -rest to the inflamed joint -if not contraindicated push fluids (help remove the uric acid) -can produce kidney stones if stasis in kidneys -recurrent in patient not compliant with diet 39. Care of a patient with Degenerative Joint Disease Rheumatoid Arthritis= -Small joints first then larger joints -bilateral and symmetrical -insidious onset with periods of remission and exacerbation -Chronic systemic autoimmune disease -Muscles around joints become weak and atrophied due to disuse -Causes deformities with soft, subcutaneous nodules along the tendons - swan neck joints -Tx: Warm shower helps, AM mobility -Methotrexate is the standard Rx treatment -ASA in large doses, NSAID, Steroids, Gold salts, Antimalarial meds, Penicillamines, sulfasalazines Osteoarthritis= -Slow steady progression of destructive changes, thickening of capsule and synovial membrane, thinning of articular cartilage -Not symmetrical, can start at any joint -Caused by injury or abuse to the joints -S/S: Limited joint movement, pain and swelling after exercise, localized, caused by injury or abuse of the joints Heberden nodes - nodules on fingers and knuckles -Tx: Anti inflammatories, splinting, regular exercise for self-esteem and improved physical functioning 40. Care of a patient with Addison’s and Cushing Disease Addison’s Disease= a disorder which the adrenal glands don't produce enough hormones -Adrenal crisis can occur because of sudden withdrawal of steroid therapy; NEVER stop corticosteroids abruptly! -Wear a medic alert bracelet S/S= Muscular weakness Anorexia, emaciation Hypoglycemia N & V, diarrhea Hypotension, fatigue Dry skin and decreased body hair Dark pigmentation of skin and mucous membranes -A blood test on someone with Addison’s Disease would reveal High K+, Low Na+, Low ACTH, Low BP, Low BS Nursing Interventions= -Take V/S because of low BP -Restore fluid balance because of hypovolemia -Risk for falls - hypotension -Daily weight to see if responding to treatment -BS monitoring -Wear a medic alert bracelet -Give patient lots of fluids, protein and reduce sugar and fat -Carry injectable solu-cortef (hydrocortisone sodium succinate) for emergency injections Cushing Syndrome= excess (hyperfunction) of adrenocortical activity that can occur due to one of four things: 1. tumor in the pituitary that produces ACTH and stimulates the adrenal cortex to increase its hormone secretion 2. hyperplasia of adrenal cortex 3. administration of corticosteroids (prednisone) or ACTH 4. ectopic production of ACTH by tumors in other organs such as lungs and pancreas S/S= -Truncal obesity, weight gain -Buffalo hump -Fragile skin -Weakness -Moon face -Hyperglycemia -Increase in masculine traits -Striae abdominal -Diagnostic of Cushing Syndrome= Serum cortisol levels, CT, ultrasound, MRI to detect tumors. -If exogenous corticosteroid excess caused it, it may be reversible -A blood test on someone with Cushing Syndrome would reveal Increased ACTH, High Na+, Low K+, High BS. 41. Care of a patient with Diabetes Mellitus DM= a group of chronic metabolic diseases characterized by increased levels of glucose in the blood resulting from defects in insulin secretion, insulin action or both. -Type 1= Destruction of the pancreatic beta cells leads to inability to produce insulin -Type 2= Type 2 diabetes involves the inability to use insulin properly. There is decreased sensitivity that leads to insulin resistance and increased demand that leads to impaired insulin secretion S/S= -polyuria= excessive urination -polydipsia= excessive thirst -polyphagia= increase in appetite -weakness -ketoacidosis -weight loss Nursing Interventions= 1. control of the blood sugar levels 2. prevention or decrease the effects of the long-term complications Management= -Nutrition -Exercise -Monitoring -Pharmacology -Education *Individual nutrition plan; not the same for everyone -Fats= 20% -Proteins= 20% -Carbohydrates= 60% *You can substitute only within the group, for example: substituting crackers for bread or beans is okay, but not potatoes for carrots. 42. Care of a patient with a hernia Hernia= a protrusion of internal body organs through muscular wall Common Sites= 1. umbilicus: common in children and obesity 2. groin: more common in males 3. hiatal: opening of diaphragm becomes enlarged and stomach moves up through this opening along a healed incision site – where there is weakness in the abdominal wall following surgery. A. reducible B. irreducible C. stangulated -Lifting heavy objects, chronic cough, straining to void or defecate, sneezing can cause hernias. S/S= - “Lump” or local swelling at the same site especially with umbilical/ inigual/ femoral -Pain occurs when peritoneum becomes irritated or with incarcerated and strangulated -Possible intestinal obstruction if intestine becomes blocked by incarcerated hernia 43. Care of patient with Hemorrhoids -Varicosities of the veins of the rectum a. Internal - inside or above the anal sphincter b. External - visible, outside or below the anal sphincter - Eat a high fiber diet for regularity and to prevent straining -S/S= Local pain and itching, bleeding with defecation, swelling (size of marbles) when not inflamed, appear as flat tissue Treatment= -Correct constipation with high fiber, activity, fluids, stool softeners/laxatives -Local application of heat/cold -Sitz bath -Suppositories with anesthetic -Scleopathy- inject solution that makes it dry up -Cryotherapy - freezing to shrivel -Photocoagulation - burning -Hemorrhoidectomy - laser removal that may require a rectal tube -Rubber band ligation Nursing Interventions= -Analgesics -Cold or warm compresses -Sitz bath -Rubber donut -Squeeze buttocks together before sitting -TUCKS pads - in the fridge to keep cool -Stool softeners -High fiber diet -Meticulous hygiene -Every BM - meds, sitz bath and clean well 44. Prevention of Dumping Syndrome -Dumping syndrome - rapid emptying of stomach contents into the small intestine (especially sugar). Occurs when fluids with a high osmolality are given to a patient. -Early dumping= 3 - 45 minutes after meal, fullness, faintness, dizziness, cramping, nausea, weakness, sweating, palpitations, explosive diarrhea -Late dumping= BP falls, profuse sweating, anxiety, H/A, dizziness and drowsiness *Prevent with small frequent meals without fluids* 45. Clinical Manifestations of Dumping Syndrome S/S= feeling of fullness, nausea, diarrhea, abdominal pain, faintness, dehydration, hypotension, tachycardia and diaphoresis 46. Care of patient receiving TPN -Contains dextrose (glucose), amino acids, electrolytes, vitamins, minerals, and insulin. -Blood glucose monitoring with sliding scale coverage -HIGH ALERT!!! -Must be changed q24h -TPN is through a central vein PICC or non-tunneled catheter -CANNOT be discontinued abruptly, must taper related to blood sugar -Change tubing with every new bag -Change dressing using sterile technique q72h -Daily weights -Mouth care -How do you know if it is working? Patient gains weight. -Blood glucose monitor with sliding scale insulin 47. Care of patient with Small bowel obstruction High Intestinal obstruction= -Sharp, brief pains -Increased bowel sounds above obstruction -Vomiting -Rapid dehydration and acidosis -Slight abdominal distention r/t fluid, gas and stomach content accumulation -Can lead to edema, congestion, necrosis, perforation and peritonitis -No feces or flatulence - may have bloody stool or mucous -If complete obstruction, peristalsis will reverse and patient may vomit feces Lower Intestinal obstruction= -Gradual onset - constipation may be only sign -Pains that last several minutes or longer -Marked abdominal extension - bowels may be visible externally -Infrequent vomiting - late sign fecal vomiting -Bowel sounds above obstruction are low pitched and hyperactive -Dehydration is slow because colon absorbs fluids 48. Signs of perforation Perforation= rigid board like abdomen that can refer to the shoulders, sudden severe upper abdomen pain, signs of shock and peritonitis. S/S= distention, tachycardia, pain, rebound tenderness, N&V, rigid abdomen 49. Care of a patient post abdominal surgery -Patient might not have a bowel movement in a couple of days. -Assess bowel sounds post-surgery -No bowel sounds in 3-5 minutes could indicate paralytic ileus= Ileus is a temporary arrest of intestinal peristalsis. -Symptoms are nausea, vomiting, and vague abdominal discomfort. -Any surgery that involves manual manipulation of the bowel, has the risk for paralytic ileus. -The stool seen in paralytic ileus is a liquid seepage. 50. Nursing Interventions associated with endoscopy, colonoscopy, and UGI Endoscopy= -Allow direct visualization of body cavities, tissues, and organs through the use of a flexible, lighted tube for diagnostic and therapeutic purposes. -Check VS and verify allergies -Evaluate clients medical Hx for increased risk of complications -NSAIDs, warfarin, aspirin increase the risk for complications -Ensure the client adhered to the NPO status for the necessary time -Provide bowel prep medications Colonoscopy= -Insertion of a flexible fiber optic colonoscope through the anus to visualize the rectum and sigmoid, descending, transverse, and ascending colon -Moderate sedation -Laying on left side with knees toward the chest -Bowel prep includes: laxatives, clear liquid diet, NPO after midnight, avoidance of aspirin, anticoagulants, and antiplatelet medications. -Monitor for rectal bleeding -monitor VS and respiratory status -Resume usual diet post colonoscopy -Increase the fluid intake post colonoscopy -DO NOT DRIVE OR USE EQUIPMENT FOR 12 TO 18 HRS. AFTER THE PROCEDURE! Upper GI Series= -Series of x-ray films of the lower esophagus, stomach, and abdomen using Barium Sulfate as a contrast medium -It is tasteless, odorless, and completely insoluble (not absorbed) -Detects the anatomical structures and functioning of the upper GI tract -Explain the procedure to the patient -Diet starts with clear liquids and then NPO after midnight- including medication -Laxative may be needed to facilitate removal of barium post procedure (stool may be grey in color until barium is cleared) -Monitor for elimination of the barium -Increase fluids post procedure 51. Care of a patient with Pernicious Anemia Pernicious Anemia= It is the absence of intrinsic factor in the gastric mucosa. It atrophies and stops producing intrinsic factor that is needed to absorb B-12 -ONLY ANEMIA WITH NEURO SYMPTOMS Characteristics= -Macrocytic -Hypochloremia -Hereditary or autoimmune -Anemia - weakness/fatigue, pallor, dyspnea, palpitations -GI- cheilosis, beefy red tongue, weight loss, indigestion, mild diarrhea -Neuro- Tingling, numbness of hands and feet, progressive damage of spinal cord, loss of proprioception -RISK FOR FALLS Diagnostic Tests= -Schilling Test -Requires injection of radioactive B-12 before and after intrinsic factor is administered -Urine collection 24-48 hours -If radioactive B-12 is in urine after intrinsic factor is administered, POSITIVE test and Dx of pernicious anemia Treatment= -Lifetime monthly B-12 IM injections -Can lead to HF in fin treated -Folic acid and iron supplements -Avoid excessive heat or cold -Good mouth care -Small amounts of bland, soft foods -Diet high in protein - B-12 comes from animal sources -Assistance with ADLs -Safety canes, walkers, PT and OT 52. Care of a patient post stem cell transplant Nursing interventions= 1. Bleeding 2. Pain 3. Infection *In that order* 53. Care of patient with Sickle Cell Anemia -Hemolytic anemia -An inherited disease that is autosomal recessive, both parents must have the trait. 1 in 4 chance of getting it or 50% chance of having sickle cell trait. -The RBC become crescent shaped and very rigid. They occlude peripheral tissue and cause small blood clots -Very painful and give rise to sickle cell pain crisis Cause= -HbS > HbA then patient will have signs and symptoms -If HbS is greater than 50%, blood transfusions eould need to be done Management= -Hydration, pain management and blood transfusion -Monitor for infection, reinforce coping mechanisms, ID and correct knowledge deficits -Give supplements of B-12, folic acid, B-6 and iron -Eye exams, vaccines -Hydrea (hydroxyurea) - chemotherapy -Bone marrow transplant may cure -Diagnosed by Hemoglobin electrophoresis. 54. Clinical signs of polycythemia -Increase in blood viscosity -Increase in total blood volume -Congestion of blood in organs -Ruddy complexion -HTN, dizziness, H/A, tinnitus, fatigue, parasthesias, blurred vision, increased uric acid, gout, kidney stones, itching -Thrombus formation - MI, CVA -Enlarged spleen and liver -Bleeding - epistaxis, ulcers, hematuria, intracranial 55. Care of a patient with Acute Leukemia and Multiple Myeloma Leukemia= A group of hematologic malignancies involving abnormal overproduction of leukocytes, unusually at an immature stage in the bone marrow. -Basically, too many WBC that don’t function properly. -Patients are at risk for Infection, bleeding, impaired breathing -WBC overcrowding can result in RBC becoming crowded -This can cause breathing problems because of a lack of O2 carrying ability. S/S= -Anorexia, weight loss -Anemia, fatigue, weakness -Pallor and dyspnea with exertion -Palpitations, tachycardia, orthostatic hypotension -H/A -Bleeding - and prolonged bleeding -Petechiae, ecchymosis -Skin rashes or lesions -Fever and infection -Enlarged lymph nodes, spleen and liver -Bone pain or tenderness, joint swelling r/t hyperactivity of bone marrow Treatment= -Aggressive chemotherapy -Isolation -Antibiotics -Stem cell transplant -RBC and platelet transfusions -Hydroxyurea (Hydrea) Multiple Myeloma= A malignant disease of the most mature form of B-lymphocyte, the plasma cell. -Plasma cells secrete immunoglobulins, proteins necessary for antibody production to fight infections. These become non-functional S/S= -Bone pain that increases with activity and decreases with rest -Back pain/pelvic and spinal fractures r/t bone marrow sites -Hypercalcemia r/t bone destruction -S/S excessive thirst, dehydration, constipation, altered mental status, confusion, coma) -Renal failure -Late disease - anemia, increased blood viscosity and heart failure Nursing Interventions= -Pain management -Assist with mobility/devices -Monitor for hypercalcemia -Monitor renal function -Prevent infection 56. Difference between HIV and AIDS (including stages) HIV= A chronic illness in which an initial viral infection leads to immune compromise due to viral attacks on helper cells (T-lymphocytes and CD4 cells) -The more virus in the blood = the more advanced the disease progression. -Treatment= continued health Stages of HIV= Stage 1= Primary Infection -Period of infection to development of antibodies -Might test negative, highly infectious (viral load is very high) -HIV+ Asymptomatic -May last greater than 10 years -CD4 T cells may or may not decrease Stage 2 = HIV + Symptomatic -Decrease in CD4 T cells (200-499) -May have one or more of certain OI’s or medical conditions relating to HIV or immune dysfunction May have 1 or more opportunistic infections Stage 3= AIDS -Decrease in CD4 T cells (less than 200) -If CD4 cell count is less than 14% of total lymphocyte count= diagnostic of AIDS -Viral Load= Measure how many viral copies are present in each mL of blood -Goal is to be undetectable -Higher the count= Increased Disease Progression!!!! 57. Care of patient with DIC Disseminated Intravascular Coagulation= It is a symptom, not a disease -Normal hemostatic mechanisms are altered so that MASSIVE amounts of tiny clots form in the microcirculation -Initially, coagulation time is normal, but platelets and proteins deplete and then fail and the end paradoxical result of excessive clotting is BLEEDING Risk Factors= -Sepsis -OB complications -Transfusion reactions -Trauma -Shock -Cancer (especially prostate and leukemia) -Allergic reactions Nursing Care= -Monitor V/S -Avoid cough or strain -Avoid invasive procedures -Avoid meds that interfere with clotting/bleeding -Monitor for bleeding risks -Auscultate breath sounds q2-4h (Lungs will be affected first) -Careful oral hygiene and assess skin regularly Medical Management= -Treat the underlying cause -Oxygen r/t low RBC -Fluid replacement r/t kidney assistance -Correct electrolyte imbalance - increased K and Mg from cell lysis -Vasopressor medications - for hypotension and to increase perfusion -Transfusion of blood products 58. Care of a patient post Renal Biopsy -Differentiates whether defect seen on the x-ray is a tumor, stone, or blood clot -cystoscope exam conducted -urethral catheter introduced -biopsy brush inserted through the catheter -lesion brushed to obtain: a. cells and tissue for histologic analysis Post Procedure= -IV fluids administered to prevent clot formation and clear hematuria -hematuria normally clears 24-48 hrs. Complications= -Renal colic a. Administer analgesics 59. Care of patient who is undergoing a CT scan -Noninvasive -With and without contrast: assess for allergies -Ask if patient is allergic to iodine or shellfish -Need to know if patient is taking metformin = can cause renal damage if mixed with contrast -If patient is allergic to iodine, they will premedicate with Zantac or Benadryl -Mucamist is given to premedicate a patient with renal failure 60. Care of a patient post cerebral angiography Cerebral Angiography= an x-ray study of the cerebral circulation after contrast has been injected into a selected artery, usually femoral Pre-Procedure= -Assess for allergies/ renal function/ pregnancy/ if patient is on anticoagulants a. should hold anticoagulants for at least 24-48 hours b. dye is excreted from kidneys c. iodine or shellfish allergies -Clear liquid diet -Have patient void -Explain to patient that they must remain immobile during and probably after the procedure -Tell the patient that they will experience a warm, flushing and metallic taste when injected. Post-Procedure= -Assess for s/s of atrial block so assess for the following: a. changes in Level of Consciousness b. weakness on one side c. motor and sensory disturbances -Assess the injection site (for infection) -Assess peripheral pulses -CMS checks (Circulation, Motor, Sensory) -Fluids are encouraged to flush out the contrast through the kidneys, 61. Signs of cancer of the Larynx -hoarseness is an early symptom (occurs for 2 weeks in duration) -pain and burning when drinking hot liquids, citrus -lump in the neck -raspy voice -persistent cough -pain radiating to the ear -enlarge lymph nodes 62. Care of a patient post thyroidectomy -Semi fowlers with head supported by pillows -Monitor airway - cough, swallowing etc. (around trachea) -Watch for bleeding - especially pooling in back and swallowing could indicate bleeding -Monitor voice quality and changes -Soft diet -Pain medication around the clock -Assess for falling Ca2+ levels (numbness and tingling around the mouth because parathyroid was also removed, can cause dysrhythmias) -Keep calcium gluconate bedside for emergency -HAVE AN EMERGENCY TRACH KIT BEDSIDE 63. Care of a patient post hysterectomy Hysterectomy= is the removal of the uterus. -A bilateral salpingo oophorectomy is the removal of the ovaries and fallopian tubes -Ensure the client has discontinued all anticoagulant meds, aspirin, anti-inflammatory drugs (NSAIDS) and vitamin E. -Rule out pregnancy -Maintain NPO status -Ensure informed consent -Monitor vaginal bleeding post procedure -An indwelling catheter is generally inserted intraoperatively and in place for the first 24 hours Priority Interventions Post Hysterectomy= -Measure VS (fever, hypotension) -Monitor breath sounds (risk of atelectasis; turn, cough, deep breath) -Auscultate bowel sounds (risk of paralytic ileus) -Monitor urine output (call if less than 30 mL/hr) -Assist with IV fluid and electrolyte replacement until bowel sound return -Check incision (infection) -Observe for indications of thrombophlebitis (warm, tenderness, edema) [Show More]

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