Hesi MEDICAL SURG 203

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Hesi MEDICAL SURG 203 Hesi MEDICAL SURG 203 1. Math- IM-mg/ml 2. Basic Nursing Skills/Nutrition-DASH diet- [med surg page 715-716] Plan emphasizes fruits, vegetables, fat-free or low-fat mil... k and milk products, whole grains, fish, poultry, beans, seeds, and nuts. Compared with the typical American diet, the plan contains less red meat, salt, sweets, added sugars, and sugar-containing beverages. The DASH eating plan significantly lowers BP, and these decreases compare those achieved with BP-lowering medication. Additional benefits also include lowering of low-density lipoprotein (LDL) cholesterol. 3. Basic Nursing Skills/Nutrition- Esophageal Varices Other students’ notes: • No red foods or red dyed foods • No pointy foods like crackers • No hot beverages • Luke warm broth, popsicle [Lewis book pg. 1019] F.Y.I. Esophageal Varices are a complex of tortuous veins at the lower end of the esophagus, which are enlarged and swollen as a result of portal hypertension. Page 1022: the main therapeutic goal for esophageal and gastric varices is to prevent bleeding and hemorrhage. The patient should avoid ingesting alcohol, aspirin, and NSAIDS. So make sure you choose a diet that prevent bleeding or hemorrhage, so think SAFETY 4. Basic Nursing Skills/Safety-Hemodialysis-Low BP Other student’s notes and also in book Lewis page 1122 • Hypotension occurs as a result of rapid removal of vascular volume, decreased cardiac output, decreased systemic vascular resistance. S/S: lightheadedness, vomiting, seizures, vision changes, CP and cardiac ischemia. Treatment is a bolus of 0.9% NS and slowing the volume being removed. • Stop dialysis • Notify MD • Lay them flat raise feet higher than head- Trendelenburg 5. IV-ml/hour-heparin 6. GI/Hepatic/Oncology- Colon cancer-intestinal polyps Other student Notes: Polyps increases the risk for colon cancer. [Lewis book pg. 985] Adenomatous polyps are neoplastic. They are closely linked to colorectal adenocarcinoma. The risk increases with polyp size. 7. Integumentary-Shingles-Chronic pain Other student notes: • Unilateral clustered skin vesicles along peripheral sensory nerves on the trunk, thorax or face. Fever malaise, burning, pain, paresthesia, pruritus. Assess for s/s of infection and skin necrosis, neurovascular status, Bell’s palsy is a complication. • Asses patient’s pain first [Lewis book 436] Linear disturbance along a dermatome of grouped vesicles and pustules on erythematous base resembling chickenpox. Usually unilateral on trunk, face, and lumbosacral areas. Burning, pain, and neuralgia preceding outbreak. Mild to severe pain during outbreak. Treatment: Symptomatic: antiviral agents such as acyclovir, famciclovir, and valacyclvir within 72 hr to prevent postherpetic neuralgia. Wet compresses, silver sulfadiazine (Silvadene) to ruptured vesicles. Analgesis. Mild sedation at bedtime. Gabapentin (Neurontin) to treat postherpetic neuralgia. Usually heals without complications, but scarring and postherpetic neuralgia possible. Vaccine (Zostavax) to prevent shingles is available for adults’ ≥ 50 yr. 8. ACS- unrelieved chest pain also on 743 in Lewis book Other student notes: Unrelieved chest pain-severe, immobilizing chest pain not relieved by rest, positioning change or nitrates, is hallmark sign of MI Treatment for ACS (acute coronary syndrome) • Nitroglycerin q 5min up to 3 times • Call 911 if does not resolve after first one. • Take blood pressure • If unrelieved by Nitro OANM therapy (oxygen, Aspirin, Nitro, Morphine) • Three ways to get the artery open: Cath lab for stent or angioplasty, TPA not if they are a bleeding risk, CABG 9. HF-lab value also Lewis page 772 Student Notes: BNP-Brain natriuretic peptides- normal less than 100pg/ml: the higher the BNP the more sever the heart failure. If the BNP is elevated dyspnea is due to HF, if the BNP is normal the dyspnea is due to a pulmonary problem. 10. Cardiovascular- MI-Female Student Notes: Postmenopausal increases risk of MI (estrogen protects against MI) s/s: L arm pain, substernal pressure of pain, radiates to left arm and jaw, SOB, sense of impending doom. Woman may experience atypical discomfort, SOB, fatigue, GI discomfort. Lewis Book pg. 748 Woman may experience atypical discomfort, SOB, or fatigue Hurst Book page 77 Women usually present with GI signs and symptoms, epigastric complaints or pain between the shoulders, an aching jaw or a choking sensation. 11. Cardiovascular-PAD-Ulcer Nclex book pg. 806: Assess for signs of ulcer formation or signs of gangrene Lewis book page 835: Arterial (ischemic) ulcers most often occur over bony prominences on the toes, feet, and lower legs. Non-healing arterial ulcers and gangrene are the most serious complications. 12. Cardiovascular/Endocrine- Pheocromocytoma-HA Lewis page 1215 Notes: The complication is hypertensive crisis including hypertensive retinopathy and neuropathy, cardiac enlargement, dysrhythmia HF, MI, stroke. Avoid stimuli that can precipitate a hypertensive crisis such as increased abdominal pressure and vigorous abdominal palpation. Manifest- episodic HTN, severe HA, tachycardia with palpitations, profuse sweating. Really High BP= HA (check BP) 13. Cardiovascular/Operative-DVT-prevent postop Lewis 849-850 Lewis Book: Change position every 2 hours, flex and extend feet, knees, and hips every 2-4 hours while awake. Ambulate 4-6x/day as tolerated and sit in chair for meals. TED hose, SCDs, LMWHs. Ambulation is key Notes: • Get them up and walking • SCD (Sequential compression devices) • TED (Thromboembolic deterrent) hose- Elastic compression (Antiembolism) stockings • LMW heparin • Lovenox 14. Endocrine- DKA Notes: • Priority for DKA person with foot ulcer is fluids. Do not let foot ulcer distract. • Immediate interventions: Mental stupor the person is going into a coma. Top priority for DKA- come in with very high blood sugars they are spilling lots of sugars into the urine and cause polyuria, so they are losing lots of fluids • Administer fluids first • Check potassium • Hang insuling drip (insulin only) • Check blood sugars every 15-60 minutes • Infection is the common issue that triggers DKA and undiagnosed, missed insulin dose. They have Kussmals respirations they are trying to blow off Co2 to compensation. • Diabetic coma end result if untreated • Monitor for ICP if the blood glucose level falls before the brain has time to equilibrate water is pulled from the blood into the CSF in the brain causing ICP. Notify MD if they cannot take food or fluids in a period of 3-4 hours. • F.Y.I: Hurst book- IVFs- start with NS... then when the blood sugar gets down to about 300, switch to D5W to prevent throwing the client into hypoglycemia. 15. Endocrine-SIADH-thirst Notes: Fluid restriction- give hard candies Lewis Book page 1193-1194 • Restrict fluids to no more than 1000ml/daily • Use of ice chips and sugar less gum helps decrease dry mouth from thirst 16. GI/Hepatic-Coffee ground emesis page 945 in Lewis as well Notes: • Foul smelling • Upper/Lower GI bleed that has been in contact with acid • Noted with ulcers • Testing • Treatment PPI (omeprazole, protonix etc..) • Test for H-pylori by stool, blood, breath test (urea) (culture) • Treatment for H-Pylori positive (Antibiotic, flagyl,PPI) • Testing for coffee ground emesis (EDG) • Nursing care for EDG consent, gag reflex return • Sometimes the hematocrit is normal after they have had a GI bleed because the percentage of blood volume is the same, not until you start giving fluids do you see the hemoglobin drop. • Pg. 945- Biopsy of the antral mucosa and testing for urease (rapid urease testing) is considered the gold standard for diagnosis of H.pylori infection. 17. GI/Hepatic-GI surgery-analgesia Notes: • Make sure they are well medicated for splitting and deep breathing • They slow GI motility Hesi Book 104 • Opiate drugs tend to depress gastric motility. However, they should be given with caution, Nurse should assess for abdominal for abdominal distention; abnormal pain; abdominal rigidity; signs and symptoms of shock- increased HR; decreased BP, indicating possible perforation/GI bleed. • Also refer to Lewis book 358 18. GI/Hepatic/Immune/Hematology-GI bleeding Notes: • Big tarry stools- Hemoglobin and hematocrit 19. GI/Hepatic/Immune/Hematology- Travelers diarrhea Notes: • Defined as 3 stools in 24 hours in a travelers • E-coli highest percentage • Destination is the most importance is the distance traveled like undeveloped countries • Worry about immunocompromised people • Use bottle water and boiled water • Avoid ice this was probably not treated • Avoid green lettuce because could have been washed with unsafe water • General principles of taking care of people with GI disorders (hydration is a high priority) • Fluroqulone antibiotic treatment of choice • Anti-diarrheal drugs can delay the time to get the infectious agent out of your system. So these should be avoided. (Loparmide/Imodium). • Travelers Diarrhea = Yellow Sclera = Jaundice 20. Immune/Hematology-Abscess-rash 21. Immune/ Hematology-SLE-nephritis Page 1582 med surg • Systemic lupus erythematous (SLE) is a multisystem inflammatory autoimmune disease(FYI remember butterfly rash on face) • Lupus nephritis occurs in approximately 40% of pt. with SLE • Manifestations of renal involvement vary from mild proteinuria to rapidly progressive glomerulonephritis (purple book says to monitor for protein and cast in urine page 1001) • Scarring and permanent damage can lead to end-stage kidney disease • Primary goal in treating lupus nephritis is to slow progression of nephropathy and preserve renal function by managing the underlining disease. • Corticosteroids, cytotoxic agent, and immunosuppressive agents 22. Hematology/ Integumentary/musculoskeletal/ Physical Assessment/Respiratory- Muscular Dystrophy-skin page 1544 med surg • Muscular dystrophy- is a group of genetic diseases characterized by progressive symmetric wasting of skeletal muscles without evidence of neurologic involvement. In all forms of MD an insidious loss of strength occurs with increasing disability and deformity • Gradual decrease in respiratory function often lead to the use of CPAP, eventually a tracheostomy and mechanical ventilation are necessary to sustain respiratory function • Remember skin color provides clues to respiratory status (page 486) • Keep this pt. active as long as possible to prevent skin break down and respiratory complications 23. Immune/ hematology/ neurological- restless leg syndrome- iron and ferritin page 1427 Med surg • A serum ferritin may be order • If serum ferritin is low or pt. has iron deficiency iron supplement may be considered as part of treatment. 24. Immune/ Hematology/ operative- OR- banana allergy Page 216 Med Surg • Because some proteins in rubber are similar to food proteins, some foods may cause an allergic reaction in people who are allergic to latex. This is called latex-food syndrome • Foods- banana, avocado, chestnut, kiwi, tomato, water chestnut, guava, hazelnut, potato, peach, grape, and apricot • In people with latex allergy, most have a positive allergy test to at least one related food • This should be included in pre op assessment 25. Integumentary-Eczema-moisturizing creams Notes: • Hydrate the affected area • Give antihistamine, corticosteroids- thin layer (lube skin) • Avoid excessive bathing and washing • cool wet compresses • Water should be tepid • Keep nails short • Associated with allergies and asthma 26. Integumentary/Oncology-Radiation therapy-avoid sun • Avoid the Sun 27. Musculoskeletal-external fixation device-perfusion • Asses Pin sites • Check 5 P’s [Pulse, pain, pallor, paresthesia, paralysis] in extremity • Circulation • Tissue perfusion 28. Musculoskeletal- Osteomalacia priority • Safety or injury • Vitamin D or calcium deficiency causes (same as Rickets’ in children). Softening of bones. Causes bone pain, difficulty walking. • Safety is an issue. Needs sun light, Vitamin D, encourages eggs, milk, and weight bearing exercises 29. Neurological-CVA-expressive aphasia- on page 1394 as well Lewis book • Damage to brocas area of the frontal brain. • Client understands what is said but unable to communicate verbally. • Left brain damage • Use pictures/picture broad to communicate 30. Neurological- Meningitis-action also refer to page 1382 • Put in isolation 1st to prevent spread • Transmission of meningitis is by direct contact including droplet spread. Maintain respiratory isolation for client with pneumococcal meningitis. Seizure precautions, s/sx of increased ICP, cranial nerve assessment, urine and stool precautions, elevate HOB 30 degrees, and avoid neck flexion and extreme hip flexion, prevent stimulation • Culture first then Broad spectrum antibiotics 31. Neurological-Multiple sclerosis-fall in Lewis page 498 • Do neuro checks • At high risk for falls • Assessment decreased perceptive pain, blurred vision, weakness • Avoid scatter rugs and use assistive devices 32. Neurological/Respiratory-ALS-lungs Lewis book Page 1439 • Typical symptoms of ALS are limb weakness, dysarthria, and dysphagia. Muscle wasting and fasciculation’s result from the denervation of the muscles and lack of stimulation and use. Other symptoms include pain, sleep disorders, spasticity, drooling, emotional lability, depression, constipation, and esophageal reflux. Death usually results from respiratory tract infection secondary to compromised respiratory function. • Nursing interventions include: facilitating communication, reducing risk of aspiration, facilitating early identification of respiratory insufficiency, decreasing pain secondary to muscle weakness, decreasing risk of injury related to falls and providing diversional activities such as reading and companionship 33. Oncology-Bone pain management • Give opioid/non-opioid together • Risk for fracture • Pain medication as ordered because the pain is severe • Multiple myeloma oncological blood disorder cause bone pain • Lewis page 674: The patient often does not manifest symptoms until the disease is advanced, at which time skeletal pain is the major manifestation. Pain in the pelvis, spine, and ribs is particularly common and is triggered by movement. Analgesics, such as NSAIDs, acetaminophen, or an acetaminophen/opioid combination, may be more effective than opioids alone in diminishing bone pain. Braces, especially for the spine, may also help pain. 34. Operative-Preop support-goal NCLEX pg. 208 box 19-4 • Cough and deep breathe • Leg exercises • Informed consent-surgeon is responsible for obtaining. Minors need a legal guardian • Nurse must ensure the patient understand what the surgeon explained • NPO the night before • IV line large enough for blood products if required • Bowel preps if ordered • Clean with antibacterial soap the night before • Don’t smoke 24 hours • Teach about surgical procedure and what to expect • Cultural aspects into consideration • Splint incision • Verify the client and surgical operative site is crucial 35. Operative/Renal-Nephrectomy-Postop Lewis book page 1095 • Urine output- measure and record the urine output at least every 1 to 2 hours. The total urine output should be at least 0.5 mL/kg/hr. Observe and monitor the color and consistency of urine. • Weigh patient daily. Change in daily weight can indicate retention of fluids, which places the patient at cardiovascular risk for developing heart failure. Retention of fluids can increase the work required of the remaining kidney to perform its functions. • Respiratory Status. Performed through a flank incision just below the diaphragm. Postoperatively, it is important to ensure adequate ventilation. The patient is often reluctant to turn, cough, and deep breathe because of incisional pain. Give adequate pain medication to ensure the patient’s comfort and ability to perform coughing and deep breathing exercises. Incentive spirometer are used every 2 hours. Early and frequent ambulation. • Abdominal Distention. Present to some degree. Most commonly due to paralytic ileus. Oral intake is restricted until bowel sounds are present (usually 24 to 48 hours after surgery). IV fluids are given until the patient can take oral fluids. Progression to a regular diet follows. 36. Operative/Respiratory-Thoracotomy sub cut emphysema WEB • Air can leak out of the pleural space through an incision made for a thoracotomy to cause subcutaneous emphysema Page 549 Med Surg • Thoracotomy- is a surgical incision into the chest(thorax) to gain access to the heart, lungs , esophagus, thoracic, aorta, or anterior spine • Subcutaneous emphysema- is when gas or air is in the layer under the skin. • Nursing care postoperative assesses respiratory function, including rate, effort, sputum volume and color, breath sounds and chest tube drainage function. Also page 609 purple book 37. Physical assessment/ reproductive- gonorrhea-male Page 1262 • Initial site of infection is the urethra • S/S= dysuria, and profuse purulent drainage 2-5 days after infection, painful swollen testicles • Men usually seek care earlier in infection because their symptoms are usually obvious and distressing • Unusual for me not to have symptoms 38. Renal-Acute kidney injury Acute Kidney Description • The rapid loss of kidney function from renal cell damage • Signs and Symptoms caused by retention of nitrogenous waste (urea), retention of fluids, and inability of kidneys to regulate electrolytes Causes • Prerenal - volume depletion, hypotension (decreased CO, decreased SVR etc) • Intrarenal- ATN, nephrotoxic drugs, intrarenal infection, prolonged renal ischemia • post renal- bladder neck obstruction, bladder cancer, calculi, post renal infection Phases of acute renal failure and interventions Onset • Begins with precipitating event Oliguric phase (8-15 days) • Sudden decrease in urine output (< 400 ml/day) • Signs of excess fluid volume- hypertension, edema, pleural and pericardial effusions, dysrhythmias, CHF and pulmonary edema • Signs of Uremia- is the illness accompanying kidney failure (also called renal failure), in particular the nitrogenous waste products associated with the failure of this organ. (anorexia, N/V, pruritis)/azotemia- is another word that refers to high levels of urea, but is used primarily when the abnormality can be measured chemically but is not yet so severe as to produce symptoms. • Signs of neurologic changes • Signs of metabolic acidosis- Kussmauls • Signs of pericarditis- friction rub, chest pain with inspiration, low grade fever • Laboratory analysis- Box 62-4 (NCLEX book this is the reference she use)- Oliguric phase: increased BUN, Cr, Sp Gr, K, Phos, Mg, low calcium, nl or low sodium, decreased GRF and Cr Cl, hypervolemia. Diuretic phase: improving GFR, Cr and BUN; low K, low Na, hypovolemia What are some common nephrotoxic drugs? • Nephrotoxic drugs: NSAIDS, aminoglycoside antibiotics, vancomycin remember that ACE-I delay progression of CKD but also cause potassium retention- monitor K+ Assessment • Assess objective and subjective data noted in the phases of acute renal failure Interventions • Monitor urine, input and output, urine color, characteristics • Restrict fluid and Na during oliguric phase, administer Lasix • Monitor daily weight (same time, same clothes etc) • Monitor for signs of infection • Monitor lungs for wheezes, rhonchi, and edema • Administer prescribed diet (low protein, high carbohydrate, restrict K) • Administer medications as prescribed (may need decreased doses) • Prepare client for dialysis if prescribed 39. Renal-AGN-diet instructions Low-sodium diet Other Notes: • Restrict protein based on the degree of protein in urea • High quality nutrient rich foods • Sodium is restricted • Potassium is restricted during periods of oliguria 40. Respiratory-Bronchoscopy-prep Other Notes: • Informed consent • Don’t eat until gag reflex return • NPO • Blood tinged mucus is normal [Lewis Book pg. 490-492] • Flexible Fiberoptic scope is used for diagnosis, biopsy, specimen collection, or assessment of changes. It may also be done to suction mucous plugs, lavage the lungs, or remove foreign objects. • Instruct patient to be NPO status for 6-12 hr. before the test. Obtain signed permit. Give sedative if ordered. After procedure, keep patient NPO until gag reflex returns. Monitor for recovery from sedation. Blood-tinged mucus is not abnormal. If biopsy was done, monitor for hemorrhage and pneumothorax. 41. Respiratory-COPD & infection Other Notes: • Infections triggers COPD exacerbation • Notify provider for change in sputum • Centers around recognizing an infection early on • Avoid respiratory infection [Lewis Book page 586] • The primary causes of exacerbations are bacterial or viral infections. Exacerbations are signaled by an acute change in the patient’s usual dyspnea, cough, and/or sputum (i.e., something different from the usual daily patterns). Assess patients for the classic signs of exacerbation such as an increase in dyspnea, sputum volume, or sputum purulence. • Teach clients proper hand-washing, disposing of respiratory secretions properly and receiving vaccines to assist in preventing spread of infection. Use pursed lip breathing with COPD. 42. Respiratory-Influenza-Sputum [Other Notes] • Most common complication is pneumonia with secondary bacterial pneumonia. Clients usually experience gradual improvement of symptoms then worsening cough and purulent sputum. • Tamiflu given if caught in first 24-48 hours. Flu vaccine contraindicated with Gillian-Barre 43. Respiratory-Laryngectomy-trach care [Other notes] Leave old ties on until new ties are secured • Air way is important • Communication is important • Use the voice stimulator • Do not suction longer than 10 minutes • Stoma guard of shield • Avoid aerosol spray • Loose fitting high collared shirt • Increase fluids to 3000 to decrease trach plugs • Trach care includes cleaning inner cannula, suctioning, and applying clean dressing. Keep Laryngeal airway humidified at all times. 44. Respiratory- Suctioning page 509 • Assess the need for suctioning q2hr (assessment crackles or rhonchi over large airway, moist cough, increase peak inspiratory pressure on mechanical ventilator, and restlessness) • Don’t suction routinely • Don’t suction if pt. can cough and clear secretions • Dial reads 120 to 150 pressure with tubing occluded • Assess O2 and HR to obtain baseline for detecting change • Wash hands and wear goggles • Use sterile technique • Preoxygenate 30 seconds • Suction intermittently while withdrawing catheter in a rotating manner • Limit suction to 10 seconds • Re assesses Repeat until clear • Return O2 to prior setting • auscultate 45 Sensory- Cataract Surgery Light housework [Other Notes • Warn not to rub or put pressure on the eye, teach that glasses or shaded lens should be worn during waking hours, an eye shield should be worn during sleeping hours, avoid lifting over 5lbs, bending, straining, couching or otherwise increasing IOP, use stool softener, avoid laying on operative site, keep water out of eye. When cataract is removed the lens is gone, making prevention of falls important. 45. cataract surgery (nclex book): types of surgery extracapsular extraction, intracapsular extraction, partial iridectomy or lens implant. With extracapsular extraction the lens is lifted w/o removing the lens capsule, this may be done with phacoemulsification in which the lens is broken up by ultrasonic vibrations. with intracapsular extraction the lens and capsule are completely removed. With partial iridectomy ( removing part of the IRIS) may be done with the lens extraction to prevent secondary glaucoma. PRE-OP: teach the client about the post-op instructions to prevent or decrease intraocular pressure such as bending over, coughing,straining, and rubbing eyes. Stress to client that care after surgery reuires instillation of eye drops several times a day for 2-4 weeks. Give meds preoperatively including mydriatics (e.g.tropicamide) promotes dilation and reduce muscle spasm and cycloplegics (e.g. cyclogyl) this drug paralyzes the ciliary muscle and thus the power of accommodation. post –op : elevate the head of the bed 30-45 degrees and position the client on the back or the nonoperative side to prevent the development of edema at the operative site. maintain eye patch and orient pt to the environment. Position client belongings on the nonoperative side. use side rails for safety and assist with ambulation. Client education: no eye straining. Instruct client that itching and mild discomfort is normal for a few days after surgery. Avoid rapid eye movements, coughing , sneezing, bending over, vomiting and don’t lift more than five pounds. prevent constipation( stool softners) follow instructions for meds and dressing changes, wipe drainage with a sterile wet cotton ball from inner canthus to outer canthus. Eye shield at bed time. If lens implant is not performed, accommodation is affected and glasses should be worn all the time. Cataract glasses will magnify objects to appear closer than they really are so the client needs to judge distance and climb stairs carefully. Contact lenses provide sharp acuity but dexterity( skillful with hands) is needed to insert them. Contact the HCP for severe pain, discharge, increase redness, or decrease vision. 46. Diabetes Mellitus/physical assessment of poor compliance(lewis): soft sunken eye balls, vitreal hemorrhages, cataracts. Skin will be dry, warm, inelastic, pigmented lesions(on legs),ulcers(mainly on feet),loss of hair on toes, acanthosis nigricans( dark velvety patches on skin), rapid deep respirations(kussmaul respirations),hypotension, weak rapid pulse, vomiting, fruity breath, altered reflexes ,restlessness, confusion, stupor, coma, muscle wasting. Labs: fasting glucose >126 oral glucose tolerance test > 200 ,random glucose >200. Leukcytosis and increase in BUN,creatine,triglycerides,cholesterol, LDL,VLDL, decrease in HDL(good cholesterol), A1C >6%, glycosuria,ketonuria,albuminuria,acidosis. Note: diabetes is a disorder of glucose metabolism related to the absent or insufficient insuln supply and/or poor utilization of the insulin that is available. Exercise: brisk walking can control glucose exercising don’t have to be vigorous, proper foot wear is important and workouts should have warm up and cool down periods. Start exercises at a low level and gradually increase. if glucose is < 100 eat a 15g carb snack before exercise. Do not work out if <100, check glucose in between exercising (15-30 mins later). 47. Transfusion reaction process( lewis 676): types of transfusion reactions are Acute and Delayed. With acute the reaction usually developes in the first 15mins w/ chills, fever, low back pain, flushing, tachycardia, hypotension, vascular collapse, hemoglobinuria, acute jaundice, dark urine ,bleeding, acute kidney injury, shock, cardiac arrest, DIC death. Examples of acute reactions are febrile, anaphylactic, allergic, circulatory overload, sepsis, TRALI(acute lung injury reaction) massive blood transfusion reaction. Delayed: occurs as early as 3 days or as late as several months but usually 5-10 days posttransfusion as the result of destruction of transfused RBC’s by alloantibodies not detected during crossmatch. Patient could present with fever, mild jaundice, and decresed hemoglobin. Examples of delayed reactions are hepatitis B/C, iron overload, herpes virus, Epstein-barr virus, malaria, cytomegalovirus. Steps to take before the transfusion process: take vitals before so you have a base line. If patient has a fever before the transfusion then contact the HCP. Give the blood as soon as it is brought to the patient. do not refrigerate the blood on the nursing unit. If the blod isn’t used within 30 mins then return it to the bank. During the first 15 mins or 50ml transfusion remain with the patient. The rate at this time should be no more than 2ml/min. rapid infusion of cold blood may cause the patient to become chilled. Take vitals after the first 15mins then observe the patient periodically (e.g. Q 30 mins) the transfusion should be in withing 4 hours to decrease the risk of bacterial growth. Blood that is unrefrigerated for 4 hours or longer should not be used and returned to the bank. If an acute reaction happens take the following steps: 1 stop the infusion. 2 maintain patent iv line with saline. 3 notify blood bank and HCP. 4 recheck ID tags and numbers. 5 monitor vitals and output. 6 treat symptoms. 7 send blod and tubing back to the bank. 8 collect required blood and urine specimens. 9 document on transfusion form and patient chart. Key points: do not use dextrose or LR for administarion. Do not give any meds through the same tubing unless it has been cleared with NS solution. Blood is usually administerd with a 19 guage needle. 48. burns-cultural/spiritual: address individual spiritual and cultural needs. They both have a role in treatment decisions and recovery. pastoral care may be helpful resource for patient and family. Encourage the burn care team to remain culturally aware and sensitive to the patient and caregiver cultural needs. 49.BPH nsg problems(lewis/nclex): BPH is the enlargement of the prostate gland. Complications of BPH are urinary obstruction, acute urinary retention, UTI, calculi, renal failure, pyelonephritis, and bladder damage if urinary retention tx is delayed. Objective data would be distended bladder on palpation; smooth, firm, elastic enlargement of the prostate on rectal examination. Diagnostic finding: vesicle neck obstruction on cystoscopy; redidual urine with postvoiding catherization; white blood cells,bacteria,or microscopic hematuria with infection; increase serum creatine with renal involvement. TURP is the gold standard surgical tx for BPH: this procedure is performed under a spinal or general anesthetic and requires 1-2 days of hospital stay. postop complications could include bleeding,clot retention, and dilutional hyponatremia associated with irrigation. Since bleeding is a common complication patient must discontinue anticoagulants and aspirin days before the surgery. Interventions: encourage fluids 2000-3000 ml daily. Urinary catheter to prevent distention. Avoid meds that cause urinary retention like anticholinergics, antihistamines, decongestants, and antidepressants. Give meds as prescribed and have client to decrease caffeine ,artificial sweetners, spicy, and acidic foods. follow a time voiding schedule. Drug therapy: finasteride(proscar) * may cause hypotension if used with ED drugs. Tamsulosin helps relieve the symptoms and restore urine flow. Note that finasteride can take up to 6 months to be affective. Home care include: catheter care. Managing urinary incontinence. Fluid intake. Managing for S/S. preventing constipation. Lifting 10lbs or less. No driving or intercourse after surgery.beaware of the possibility of retrograde ejaculation. 50. chronic back pain post-op: Conditions related to low back pain are intervertebral disc disease. Types of surgeries for back pain are diskectomy, percutaneous diskectomy, spinal fusion, laminectomy, artificial disk replacement. Post-op care focuses on maintaining proper body alignment of the spine until healed. Depending on the extent of the surgery and the surgeons preference the patient may be able to dangle legs at the bed side,stand or even ambulate the same day of surgery. With lumbar fusion: place pillows under the thighs of each leg when supine and between the legs when inside lying position to ensure alignment. sufficient staff may be needed to move the patient. The first 24-48 hrs post op the pt may be on morphine with a PCA pump. once fluids are taken in the patient may be switched to oral drugs like vicodin or oxycodone. Diazepam are used to relax the muscles. With the lumbar fusion the spinal canal has been entered so report any signs of severe headache or leakage of CSF. Monitor peripheral neurologic signs every 2 hrs for the first 48 hrs and make sure to compare with the assessment before surgery.bladder emptying may be altered because of the opiods,anesthesia or reduce activities. Patient teaching for back problems: DO’s : place a foot on a step or stool when prolonged standing. Sleep in side slying position w/ knees and hip bent.sleep on back with lift under knees and legs or back with 10inch pillow under knees to flex hip and knees. Regularly exercise 15mins in the morning and evening and begin with a 2-3 min warm up period.carry light items close to the body.maintain proper body weight. Use local heat and cold applications.use a lumbar roll or pillow for sitting. Complementary therapies like yoga,biofeedback,and acupuncture can help relieve pain. Don’t : lean forward without bending knees. Lift anything above level of elbows.stand in oneposition for a prolonged time. Sleep on abdomen or back or side with legs straight.exercise without without talking to HCP if in severe pain.exceed prescribed amount of exercise without HCP approval. Avoiding tobacco products can help prevent pain( nicotine decreases circulation to the intervertebral disk) 51. exopthalmos-poc: pylthiouracil (ptu) and methimazole(tapazole) are the first line antithyroid drugs used. “” do not abruptly discontinue the meds because a return of hyperthyroidism can occur. Propranolol and atenolol are used to control the effects of hyperthyroidism such as tachycardia, irritability, tremors, and nervousness. PTU can be used for pregnant women and radioactive iodine therapy is the D.O.C. for nonpregnant women. When the radioactive therapy is used a possible side effect of thyroiditis and parotiditis can occur and cause dryness and irritation of the mouth and throat. Instruct the patient that sips of water,ice chips,or salt and soda gargle 3-4 times a day can give relief. Nutrition therapy: high calorie, high protein, and high carb with small frequent meals.instruct patient to avoid caffeine like coffee,tea,and cola. Nursing implementation: apply artificial tears as needed. Salt restriction to reduce orbital edema.elevate patient head to promote drainage from the periorbital area.patient should sit upright as much as possible. Dark glasses to reduce glare and prevent irritation from smoke. If eye lids won’t close the tape them shut. Exercise the intraocular muscles by turning them in a complete range of motion. Steroids and radiation are used in severe cases. 52. glaucoma teaching(lewis): Give meds as prescribed to lower eye pressure. Instruct the client on the need for life long medication use. Patient to wear a medical bracelet. Avoid anticholinergic meds. Have client report eye pain,halos around the eyes,and changes in vision to the HCP. Instruct the client that if maximum medication therapy fail that surgery will be needed. Contact the HCP before taking any meds including OTC. After eye surgery: proper hygiene and eye care techniques to insure wound is not contaminated.teach S/S of infection. Importance of head positioning (no bending),coughing,and valsalva maneuver. Teach how to instill eye meds using aseptic technique. Report pain not relieved by meds. Follow up with all appts. DRUG ALERT: miotics such as carbachol, arkapine, pilocar,carpine will decrease visual acuity. Elderly: all B-adrenergic blocking glaucoma agents are contridicated in patients with heart problems,COPD,and asthma. 53. glucose monitoring(nclex): Monitoring requires a finger prick to obtain a drop of blood for testing.alternative testing sites are the forearm, upper arm, abdomen, thigh, calf. Test must be done carefully in diabetic neuropathy patients. Urine testing for glucose is not a reliable indiacator for blood glucose and is not used for monitoring purposes.urine ketone testing should be performed during illness and whenever the client with type 1 diabetes has glucose levels over 240. Client instructions for monitoring: use the proper procedure to obtain sample. Perform the procedure precisely for accurate results.follow manufacture instructions for glucometer. Calibrate the monitor.check the expiration on the test strips. If results don’t seem reasonable redo the test and recheck the equipment and expiration dates. Hypoglycemia actions to take: check the level.give 10-15g of carbs like juice.take vitals.retest glucose level. Give client complex carbs (peanut/cracker). Document complaints,actions taken and outcome. 54.raynaud self care: Raynauds phenomenon is a vasospastic disorder most often involving the fingers and toes. Signs and symptoms are color changes of the fingers,toes,ears,and nose. decreased perfusion causes pallor and rubor when blood flow is restored. Teach patients to wear loose,wam clothing as protection from the cold including wearing gloves when handling cold objects. At all times avoid extreme temperatures.immersing hands in warm water will decrease vasospasm. The patient should stop using tobacco and avoid caffeine and other drugs that has vasoconstrictive effects( cocaine,amphetamines,ergotamine,pseudoephedrine) also the patient should avoid emotional upsets. Alternative treatments include calcium channel blockers (procardia) to relax smooth muscles. side,loosening clothes,ease patient to the floor if seated. Do not restrain the patient or place anything in the mouth. [Show More]

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