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HESI MEDSURG STUDY GUIDE[GRADED A+ VERIFIED100%]

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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 [Show More]

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