HESI MEDSURG STUDY GUIDE
Please use this guide as such, a guide however remembers to utilize the
basics, the nursing process, ABC’s and prioritize accordingly.
Hematemesis (vomiting blood) – typically upper GI bleed
...
HESI MEDSURG STUDY GUIDE
Please use this guide as such, a guide however remembers to utilize the
basics, the nursing process, ABC’s and prioritize accordingly.
Hematemesis (vomiting blood) – typically upper GI bleed
a. What to assess?
i. Remember ABC’s (pt having difficulty breathing?), check vital
signs first*
ii. Assess stool (blood present? – if so, what color? Dark red=
upper GI bleed, usually more serious)
iii. Check if they are on iron supplements
iv. Worried about hypovolemic shock
1) S/S: restlessness, agitation, HR and RR, cool, pale, sweaty
Open vs Closed Angle GLAUCOMA
a. Def: condition characterized by increase intraocular pressure (OP >
22mmHg) r/t aqueous fluid being inadequately drained from eye
gradual painless vision loss. Generally asymptomatic in early stages
(seen in regular eye exams)
No cure, can be treated pharmacologically an surgically
b. Patient teaching
Develop teaching plan that includes the following
1. Careful adherence to eye-drop regimen can prevent
blindness
2. Vision already lost cannot be restored
3. Lifetime eye drops needed
o Eye drops used to cause pupillary constriction –
movement
4. *** Proper eye-drop installation technique. Obtain a return
demonstration
o Wash hands and external eye
o Tilt head back slightly
o Instill drop into lower lid, touching the lid of the dropper
o Release lid, and sponge excess fluid from lid and cheek
o Close eye gentle, and leave closed for 3.5 mins
o Apply gently pressure on inner canthus to decrease
systemic absorption
o Caution: vision may be blurred for 1-2 hours post admin
and adapt on to dark environment difficult r/t pupillary
constrictions (Fall Risk)
5. Safety measures to prevent injuries
o Remove throw rugs
o Adjust lighting to meet needs
6. Avoid activities that mainly increase IOP
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