Medsurg Hesi Topics.docx[VERIFIED100%]

Medsurg Hesi Topics 1. Nursing process-Stroke TIA: Med-Surg book p930-945 lot of pages just hitting the highlights.........TIA = Transient ischemic attack. TEMPORAY neurologic dysfunction resulting from a brief interr ...

Medsurg Hesi Topics 1. Nursing process-Stroke TIA: Med-Surg book p930-945 lot of pages just hitting the highlights.........TIA = Transient ischemic attack. TEMPORAY neurologic dysfunction resulting from a brief interruption in cerebral blood flow. Typically resolves in 30 to 60 min. Treatment focuses on preventing another TIA or stroke: Reducing high BP, the most common risk factor for stroke, by adding or adjusting drugs to lower BPTaking aspirin or another antiplatelet drug to prevent strokes (Plavix) Controlling diabetes and keeping blood sugar levels in a target range, typically 100-180mg/dl Promoting lifestyle changes such as quitting smoking, eating heart-healthy foods, and being more active Ensure that the pt taking antiplatelet drugs is aware of precautions and actions to take if bleeding occurs. A Stroke - Is a medical emergency, and it should be treated immediately to reduce permanent disability. It is caused by an interruption of perfusion to any part of the brain. Recommend a diet high in fruits and veggies and low in saturated fats. Light to moderate alcohol consumption may reduce the risk for stroke, but a higher consumption may increase it. NCLEX purple book p225, 937-939 1.In clients with hemorrhagic strokes, the head of the bed is usually elevated to 30 degrees to reduce intracranial pressure and to facilitate venous drainage. 2.For clients with ischemic strokes, the head of the bed is usually kept flat 3.Maintain the head in a midline, neutral position to facilitate venous drainage from the head. 4.Avoid extreme hip and neck flexion; extreme hip flexion may increase intrathoracic pressure, whereas extreme neck flexion prohibits venous drainage from the brain ALERT! A critical factor in the early intervention and treatment of stroke is the accurate identification of stroke manifestations and establishing the onset of the manifestations. Stroke screening scales may be used to quickly identify stroke manifestations. Box 66-17 Neurological Assessment in Stroke: Changes in level of consciousness Signs of increasing intracranial pressure Assessment of cranial nerves V, VII, IX, X and XII Cranial nerve V: Difficulty with chewing Cranial nerve VII: Facial paralysis or paresis Cranial nerve IX and X: Dysphagia Cranial nerve IX: Absent gag reflex Cranial nerve XII: Impaired tongue movement Review box 66-18 Assessmnet findings in a stroke HESI green book p 144-146HESI HINT– CNS involvement related to cause of stroke: Hemorrhagic: caused by a slow or fast hemorrhage into the brain tissue; often related to HTN Emoblic: Caused by a clot that has broken away from a vessel and has lodged in one of the arteries of the brain, blocking the blood supply. It is often related to atherosclerosis (so it may occur again). HESI HINT– Atrial flutter and fibrillation produce a high incidence of thrombus formation following dysrhythmia caused by turbulence of blood flow through all valves and heart chambers. HESI HINT– A woman who had a stroke 2 days earlier has left-sided paralysis. She has begun to regain some movement in her left side. What can the nurse tell the family about the client’s recovery period? The quicker movement is recovered, the better the prognosis is for full or improved recovery. She will need patience and understanding from her family as she tried to cope with the stroke. Mood swings can be expected during the recovery period, and bouts of depression and tearfulness are likely.See table 4-35 Location of disruption in the brain p145 HESI HINT– Words that describe losses in strokes: 1.Apraxia: inability to perform purposeful movements in the absence of motor problems 2.Dysarthria: difficulty articulating 3.Dysphasia: impairment of speech and verbal comprehension 4.Aphasia: loss of the ability to speak 5.Agraphia: loss of the ability to write 6.Alexia: loss of the ability to read 7.Dysphagia: dysfunctional swallowing HESI HINT– Steroids are administered after a stroke to decrease cerebral edema and retard permanent disability. H2 inhibitors are administered to prevent peptic ulcers 2. Vitamins and herbs, outcomes/nursing action/constipation-diarrhea: 3. Operative nutrition/ healing: Hesi green book p169, 170 8. Provide proper nutrition (BURN patients):a.Maintain NPO status until bowel sounds are heard and then advance to clear liquids as prescribed b.Provide a diet high in protein, carbohydrates, fats and vitamins c.Monitor caloric intake *** Monitor hydration status: Record urinary output hourly (30/100 mL/hr is normal range). Maintain IV fluids titrated to keep urine output at 30 to 100 mL/hr. accurately record I&O. Weigh daily. *** 5. Provide adequate nutrition. a. Provide high-calorie (up to 5000 calories/day), high-protein, high-carbohydrate diet.b. Give national supplements via NG tube feeding at night if caloric intake is inadequate. c. Keep accurate calorie counts. d. Administer all medications with either milk or juice. e. May require total parenteral nutrition (TPN). f. Weigh daily. NCLEX purple book p83,84 Monitoring of enteral feedings and the client’s ability to tolerate feedings Monitoring of nutritional intake and oral hydration P572 ALERT! – Avoid the IM or SubQ medication route for meds administration because absorption through the soft tissue is unreliable when hypovolemia and large fluid shifts occur. Nutrition a.Proper nutrition is essential to promote wound healing and prevent infection. b.The basal metabolic rate is 40 to 100 times higher than normal with a burn injury c.Maintain NPO status until bowel sounds are heard, and then advance to clear liquids as prescribedd.Nutrition may be provided via enteral tube feeding or parenteral nutrition through a central line e.Provide a diet high in protein, carbohydrates, fats, and vitamins f.Monitor calorie intake Med-Surg book p486, 487 Nutrition requirements for a patient with a large burn area can exceed 5000 kcal/day. Not meeting this need leads to very rapid weight loss. In addition to highcalorie intake, a diet high in protein is needed for wound healing. Work with the dietitian and the patient to plan additions to standard nutrition patterns. Encourage pts who can eat solid food to ingest as many calories as possible. Offer frequent high-calorie, high-protein supplemental feedings. Keep an accurate calorie count for foods and beverages that are actually ingested by the pt. P542 Nutrition with pts who had head and neck cancer surgery: A nasogastric, gastrostomy, or jejunostomy tube is placed during surgery for nutrition support while the head and neck heal. After the intestinal tract is motile, nutrients can be given via the feeding tube. The nutrition support team or dietitian assesses the pt before surgery and is available for consultation after surgery. Replacement of calories, protein, and water loss is calculated carefully for each pt. The feeding tube usually remains in place for 7 to 10 days after surgery. Before removing the tube, assess the pts ability to swallow if nutrition is to be given by mouth. Aspiration CANNOT occur after a total laryngectomy because the airway is completely separated from the esophagus. Stay with the pt during the first few swallowing attempts. Swallowing may be uncomfortable at first, and analgesics may be needed. ** review Chart 29-3 Prevention of Aspiration during swallowing on p543 P436 Table 25-2 Causes of Impaired wound healing: Nutritional deficiencies –Calories Protein Vitamins Minerals Water P438 Nutrition for preventing pressure ulcers: Ensure a fluid intake between 2000 and 3000 mL /day Help the pt maintain an adequate intake of protein and calories P440 High risk pts, impaired mobility: Nutrition status is a critical risk factor or pressure ulcer development and for successful healing. Tissue integrity and would healing depend on a positive nitrogen balance and adequate serum protein levels. Draining wounds contribute to protein loss and require aggressive intervention. Nutrition is considered inadequate when the serum pre-albumin level is less than 19.5 g/dL, albumin level is less than 3.5 g/dL, or the lymphocyte count is less than 1800/mm3. P446 Nutrition Therapy: Severe protein deficiency inhibits healing and impairs host infection defenses. SEE Table 60-2 p1239 Manifestations of Nutrient Deficiencies ********** This table would be great for HESI TOPIC #2!!!! As it says which vitamin causes what deficiency ********** P1239,1240 Providing high-calorie, nutrient-rich foods (milkshakes, cheese, supplements, drinks like Boost or Ensure. A feeding schedule of six small meals may be tolerated better than three. ** Review chart 60-3 Promoting Nutrition Intake ** P1325 Regarding the Diabetic patient : Pts requiring clear of full liquid diets should receive about 200 g of carbohydrate daily in equally divided amounts at meals and snack times. After surgery, food intake is initiated as quickly as possible with progression from clear liquids to solid foods occurring as rapidly as tolerated. Returning to a normal meal plan as soon as possible after surgery promotes healing and metabolic balance. If TPN is used after surgery, severe hyperglycemia may occur. Monitor blood glucose often to determine the need for supplemental insulin. 4. Cirrhosis / edema: It is extensive, irreversible scarring of the liver, usually caused by chronic reaction to hepatic inflammation and necrosis. Common causes are alcoholism, viral hepatitis, nonalcoholic steatohepatitis, bile duct disease, and genetic diseases. Ascites is the collection of free fluid within the peritoneal cavity caused by increased hydrostatic pressure from portal hypertension. It causes a type of 3 rd spacing which has edema and hypovolemia. Ascites is considered edema. Hesi 106-108 Saunder 695