Kaplan Med-Surg - to review

Generalized tonic-clonic seizures

- Typically begin with a loud cry - change in LOC - body stiffening, alternating between muscle spasm, relaxation - Tongue biting, incontinence, labored breathing, apnea, cyanosis - On wakening, possible confusion, difficulty talking - Drowsiness, fatigue, headache, muscle soreness, weakness

When should iron supplements be taken?

1 hour before meals; best absorbed on an empty stomach

Precautions for brachytherapy

1. visitors should maintain 6 foot distance from radiation source 2. tell patient that the use of radiation means that special precautions must be taken to protect the health care personnel (so pt does not think they are being ignored) 3. Provide pt with emotional support about the upcoming process

What is the therapeutic level of prothrombin time for a patient on Warfarin?

1.5-2 times the control

How much iron does a person need daily?

15-18mg daily (women) 10 mg daily (men) Average diet 12-15 mg/day

How much fluid is typically removed from a patient during paracentesis?

2-3 L - Document amount, color, characteristics of drainage obtained, assess pressure dressing for drainage, positioning in bed until VS stable

During discharge teaching for a patient receiving warfarin, the nurse realizes further teaching is required if the client says: A. I should look for yellow-tinged complexion B. I will wear a medic-alert bracelet C. I should tell the health care provider if I have black stools D. I should consult the healthcare provider before taking any medications

A. I should look for yellow-tinged complexion This is a symptom of hepatitis, not a side effect of warfarin. - Medic-Alert bracelets should be worn, s/s of bleeding should be watched out for - Black stools indicates bleeding, this should be told to the physician - OTC meds may contain aspirin

A nurse observes a staff member entering the patient's room wearing a protective respiratory device. The nurse determines care is appropriate if the staff member is caring for which of the following patients? A. Patient with varicella B. Patient with mumps C. Patient with vancomycin-resitant Enterococcus (VRE) D. Patient diagnosed with pneumonia

A. Patient with varicella (chickenpox) Protective respiratory device is for pathogens transmitted by airborne route; need private room with negative air pressure, keep door closed, keep mask on patient when transporting

Glaucoma

Abnormal increase in intraocular pressure leading to visual disability or blindness S/S: cloudy or blurry vision or loss of vision, artificial lights appearing to have rainbows or halos around them, decreased peripheral vision, pain, HA, N/V NI: instruct on correct usage of prescribed medication (miotics), avoid tight collars, danger signs of glaucoma brow arching, halos around lights, blurry vision, diminished peripheral vision, HA or eye pain

Nursing Interventions for appendicitis

Administer IV fluids to prevent dehydration, NO cathartics, NO enemas because they might rupture the appendix - NOTHING by mouth, administer analgesics "judiciously" because they may mask symptoms of rupture - Place patient in Fowler's position to reduce pain, NO HEAT to lower right abdomen, NO palpation - can cause rupture - If sudden loss of pain, indicates perforation, this is an EMERGENCY

Treatment for patient having a cerebrovascular accident (CVA) or ischemic stroke, who does not receive t-PA

Administer anticoagulants (IV heparin or low-molecular weight heparin) - Maintain cerebral perfusion by assessing cerebral hemodynamics - Take preventative measures to reduce ICP - osmotic diuretic (Mannitol), maintain partial pressure of carbon dioxide (PaCO2) within range of 30-35 mmHg - Promote venous drainage, lower increased ICP by elevating head of the bed - Establish patent airway, if necessary, by intubation - Perform hemodynamic monitoring - Perform neurologic assessment to determine evolution of stroke, acute complications

What are nursing considerations for patient with presbycusis?

Age-related hearing loss caused by inner ear changes - decreased ability to hear high sounds NI: position self directly in front of client, provide well-lit, quiet room, get client's attention, move close to better ear, speak slowly and clearly when appropriate but do not shout, keep hands and other objects away from mouth when speaking - have client repeat statements, using appropriate hand motions, writing messages down if client is able to read

Complex partial seizures

Altered LOC Amnesia

What is the purpose of isometric exercises

Alternate contraction/relaxation of muscle without moving the joint - Maintains strength when joint is immobilized (Ex. in a cast) Resistive isometric exercise is done when a client pushes or pulls against manual or mechanical resistance, contracting muscles and increasing their strength (Ex. pushing against a wall or pressing hands together)

Warfarin

Anticoagulant; interferes with synthesis of Vitamin K-dependent clotting factors, has prolonged action of 2-5 days AE: hemorrhage, alopecia NI: Monitor PT (1.5-2 times the control is therapeutic level), observe for petechiae, bleeding gums, bruises and dark stools

Buck's traction

Application of pulling force to part of the body to reduce, align, immobilize fractures, relieve muscle spasms - Skin traction-pulling force is applied to the skin NI: maintain straight alignment of ropes and pulleys, assure the weights hang free, frequently inspect skin for breakdown areas - If no fracture, may turn to either side, with fracture, turn to unaffected side, elevate food of bed for counter traction, use trapeze for moving, don't elevate knee hatch

What are symptoms of hypoxia?

Apprehension, restlessness, dizziness, confusion, fatigue, tachycardia, hyperpnea, dyspnea NI: Use pillows to avoid being flat, ease breathing; medications, oxygen, physical reconditioning, relaxation techniques

When observing a patient removing PPE coming out of a patient's room, when should you intervene? A. If a staff member removes the gloves by pulling off inside out B. The staff member holds onto the outer surface of the face mask while pulling mask away from face C. The staff member unties the gown, removes it without touching the outside of the gown D. The nurse performs hand hygiene for 15 seconds

B. The staff member holds onto the outer surface of the face mask while pulling mask away from face Do not touch the outer surface of the mask - untie the top mask string, then the bottom string, pull mask away from face and drop into trash receptacle

Which diet best meets the need of a person with multiple wounds? A. high-protein, low fat, high-iron diet B. high vitamin c, high protein, high carb C. high vit A, high calcium, high fat D. high vit B, high protein, low carb

B. high vitamin c (wound healing), high protein (tissue growth), high carb (energy) - Also, vit A, E, and minerals like zinc

What are good sources of iron?

Beef, lamb, liver Absorbed BETTER when taken with vitamin C (ascorbic acid) - beans, leafy green vegetables, raisins, molasses

Absence seizures

Brief changes in LOC blinking or rolling of eyes, blank stare slight mouth movements

Myoclonic seizures

Brief involuntary muscular jerks of the body or extremities

What is peritoneal dialysis?

Catheter surgically inserted into abdominal cavity, excessive fluid and waste products that are usually removed by the kidneys are removed through the peritoneal cavity 1-2 liters of fluid infused by gravity into peritoneal space via sterile technique, fluid stays for approx 20 minutes, then fluid is drained by gravity NI: taking VS, checking for respiratory distress, pain, discomfort, checking abdominal dressing around the catheter for wetness Complications: peritonitis, abdominal pain, insufficient return of fluid, infection

Meniere's disease

Caused by dilation of endolymphatic system - disease of inner ear - too much endolymph fluid in membranous labyrinth - hearing loss, vertigo S/S: tinnitus, unilateral sensorineural hearing loss, vertigo Treatment: salt and fluid restriction to decrease amount of endolymphatic fluid, antihistamines, anti emetics, surgery

Epilepsy

Characterized by recurrent seizures - paroxysmal events associated with abnormal electrical discharges in the brain

Nursing considerations for asthma

Chronic inflammatory disease of the airways, caused by increased responsiveness of tracheobronchial tree to various stimuli NI: assess respiratory status, administer meds, instruct about use of peak flow meter, use of metered dose inhaled, triggers to avoid

Lidocaine

Class 1 antidysrhythmic Suppresses dysrhythmia formation by blocking flux of sodium ions across cell membranes AE: hypotension, tremors, double vision, tinnitus, confusion, blurred vision, drowsiness, dizziness NI: administer oxygen, keep resuscitation equipment available, use infusion pump for IV administration, place pt on cardiac monitor

vancomycin-resitant Enterococcus (VRE) requires what kind of precautions?

Contact precautions - clean, sterile gloves when entering room, change gloves after patient contact, wash hands

One day post-op, a patient develops a fever. The nurse auscultates crackles bilaterally in the lower lobes. Which of the following complications of surgery is probably developing? A. Heart failure B. Thrombophlebitis C. Pulmonary embolism D. Atelectasis

D. Atelectasis (complete or partial collapse of lung) - secretions block bronchioles and the alveoli collapse, causing hypoventilation

Emergency treatment for status epilepticus

Diazepam, Lorazepam, fosphenytoin, phenobarbital 50% dextrose IV, thiamine IV

What kind of diet should a patient with Addison's disease try to follow?

Diet that maintains sodium, potassium balance

Dysarthria

Difficulty speaking

Pneumonia requires what kind of precautions?

Droplet precautions

Mumps requires what kind of precautions?

Droplet precautions Private room or patient with like infection, maintain spacial separation of 3 feet, can keep door open

Nursing care for femoral angiogram

Dye injected into arteries and x-rays are taken of vascular system: client will feel warmth as the dye is injected NI: Check for history of allergies, symptoms of allergic reaction including dyspnea, N/V, sweating, tachycardia, numbness of extremities Treatment: Epi, antihistamines, steroids, assess femoral/popliteal/posterior tibial, dorsalis pedis pulses

Nursing care for enteral tube feedings

Elevate head of bed at least 30 degrees, ensure feeding is at room temperature, verify tube placement, check for gastric residual, return residual to stomach unless greater than 100 mL, flush tubing with 30mL water, initiate feeding, flush tubing with 30 mL water

Meningitis care for family

Ensure that family members and other contacts of pt with bacterial meningitis are evaluated promptly for post-exposure antibiotic prophylaxis (can be viral or bacterial)

Hemoptysis

Expectoration or coughing up of blood from respiratory tract, including larynx, trachea, bronchi or lungs

Nursing care for MRI's

Explain procedure Assess client for claustrophobia Remove metal jewelry and metal objects, ask if client has metal implanted in body - pacemaker, clips

Body mechanics

Face direction of moving, rather than twisting Avoid lifting when possible Push rather than pull Alternate periods of rest and activity

Treatment for MS

Focused on alleviation of symptoms, avoidance of conditions that hasten progression of disease Nonpharm: avoid fatigue, emotional stress, viral infections, extreme temperatures, eat a healthy diet, get adequate sleep, maintain physical strength Pharm: Drugs that interfere with immune response, subdue MS during relapses, slow progression - Interferon B, Glatiramer acetate, Mitoxantrone, Methotrexate, Cyclophosphamide, Cyclosporine Drugs that relieve symptoms of MS: Diazepam, Dantrolene for spasticity, cholinergic drugs to control incontinence, antidepressants, to relieve depression

What kind of diet is advised for a patient on peritoneal dialysis?

High protein, lots of fiber to prevent constipation - Expected protein losses with continuous peritoneal dialysis

Where is bone marrow biopsy taken from?

Iliac crest and sternum, local anesthetic used NI: cleanse site with alcohol to remove providone iodine, apply pressure with sterile gauche pad for several minutes to control bleeding, apply sterile pressure dressing Possible complications: bleeding, infection

Nursing care for pre-op patients

Instruct client about exercises to be performed postoperatively Instruct client to practice deep breathing and coughing, leg exercises, how to move in bed, how to use an incentive spirometer

Appropriate diet for chronic renal failure

Low protein, low potassium, low sodium

Oxygen delivery systems

Low-flow oxygen delivery system: nasal cannula - 24-28% Simple face mask Partial rebreather Nonrebreather mask High flow oxygen delivery system: Venture mask Aerosol mask, face tent, tracheostomy collar (24-100%)

What kind of diet should someone with Meniere's disease follow?

Low-sodium, high potassium (pt probably taking diuretics, need to counteract potassium loss in urine)

Clear liquid diet

Maintains fluid balance, for surgical patients or patients experiencing acute vomiting/diarrhea; used to empty GI tract to prevent aspiration Ex. gelatin, popsicle, tea with lemon, ginger ale, bouillon, fruit juice without pulp NO: fruit juices with pulp, MILK!

Name 4 diseases that would warrant airborne precautions

Measles (rubeola) M. tuberculosis Varicella (chickenpox) Disseminated zoster (shingles)

How is urine for a culture and sensitivity (C&S) obtained?

Midstream or sterile method Sterile (port of indwelling catheter used, clamp below port to withdrawing sample)

What is a low residue diet used for?

Minimizing intestinal irritation and activity by reducing fiber and cellulose; if a patient has recently had lower bowel surgery or diverticulitis/Crohn's disease, ulcerative colitis - foods that require LESS energy for digestion Ex. roast lamb, buttered rice, sponge cake, white processed foods BAD: whole wheat, corn, bran, raw fruits and veggies, seeds

Addison's disease

Most typical form of adrenal hypo function - Adrenal crisis: profound weakness and fatigue, shock, severe N/V, hypotension, dehydration, occasionally, high fever - If receiving meds, watch for cushingoid signs, fluid/electrolyte imbalance, especially if receiving mineralocorticoids

Treatment for detached retina

NI: maintain bedrest, patch affecter or both eyes, position so area of detachment is in dependent position, teach client to take precautions to avoid bumping head, moving eyes rapidly or rapidly jerking head - Instruct client to avoid hair washing for 1 week, strenuous activity for 3 months, bending down or straining at stool

Trigeminal neuralgia (Tic Douloureux)

One or more branches of 5th cranial nerve - infections of sinuses, teeth, mouth or irritation of the nerve from pressure Indications: stabbing or burning facial pain that is excruciating, unpredictable, paroxysmal: twitching, grimacing of facial muscles NI: Identify, avoid stimuli that exacerbates the attacks, administer carbamazepine (Tegretol) and analgesics, avoid rubbing eye, chew on opposite side of the mouth

Nursing indications for increased intracranial pressure

Osmotic diuretics (Mannitol), Lasix, steroids, antihypertensives, anticonvulsants, hyperventilation, surgery for decompression or shunt NI: Maintain airway by suctioning, elevate head of bed 30 degrees, keep head in midline position, administer fluids as ordered

Heparin therapy requires what lab test?

Partial thromboplastin time (1.5-2 times the control means anticoagulation is effective) Antidote: Protamine sulfate

Commonly prescribed drugs for generalized tonic-clonic, complex seizures

Phenytoin, Carbamazepine, Phenobarbital, Primidone

Maslow's Hierarchy of Needs

Physiological (lowest) - must be met first Safety/security Love and belonging Esteem Self-actualization (highest)

What is the purpose of a chest tube?

Placed in pleural space, used to drain air and blood so lung can re-expand

Chest tubes

Placed so that air and blood drain, lung can re-expand 1. water-seal chamber - observe for constant bubbling which indicates there's a leak - should bubble ONLY during forced expiration 2. chest tube dislodged: apply pressure over insertion site with a dressing that is tented on one side to allow for escape of air 3. if tube is disconnected from drainage system, cut contaminated tip off using sterile scissors, immerse end of the chest tube in 2 cm sterile water until system can be re-established

What is the emphasis for care after death?

Preventing damage to the body from skin damage, skin discoloration, muscular contraction, making the body look comfortable and natural for family viewing - Remove tape carefully - Elevate head to prevent discoloration, blood pooling, prevent disfigurement from rigor mortis within 2-4h - Close eyelids, insert dentures, close mouth, body positioned naturally - Remove tubing - ID tags AFTER family has viewed body

Cold therapy

Promotes vasoconstriction, increases blood viscosity, decreases metabolism of tissues, has local anesthetic effect - Decreases muscle tension - should not be applied for longer than 20 minutes or reflex vasodilation can occur

Heat therapy

Promotes vasodilation, decreases blood viscosity, increases metabolism of tissues, increases capillary permeability - should not be applied for longer than 20-30 minutes, or reflex vasoconstriction and tissue congestion can occur

What is a pulse deficit?

Radial pulse is slow than apical pulse (left 5th intercostal space at midclavicular line) due to ineffective contractions failing to send pulse waves to periphery: cardiac dysrhythmias may be present

Autonomic dysreflexia

Reaction of autonomic (involuntary) nervous system to over-stimulation - occurs in clients with spinal cord lesions ABOVE level of T6 after spinal shock has subsided Indications: pounding HA, profuse sweating, especially of forehead, nasal congestion, piloerection, hypertension NI: Place client in sitting position, catheterize or irrigate existing catheter to re-establish patency, check rectum for fecal mass, administer IV antihypertensive agent slowly

Cystic fibrosis

S/S: wheezing, crackles Hereditary dysfunction of exocrine glands, causing obstruction of flow of thick mucus NI: postural drainage, chest physiotherapy, breathing exercises, expectorants, mucolytic agents, replacement of pancreatic enzymes, aerosol therapy with bronchodilators, mucolytics assist in loosening secretions, relief of bronchospasm

Treatment for Meniere's disease

Salt/fluid restriction to decrease amount of endolymphatic fluid, antihistamines, anti emetics, surgery, diuretics

Simple partial seizures

Sensory (Flashing lights, smells, auditory hallucinations) Autonomic (sweating, flushing, pupil dilation) Psychic (dream states, anger, fear)

What are nursing considerations for thoracentesis?

Take vital signs, shave area around needle insertion site, position patient sitting with arms on pillow or overbid table or lying on side in bed, teach client to expect stinging sensation with injection of local anesthetic, as well as pressure when needle is inserted Post-procedure: auscultate breath sounds frequently, monitor VS frequently, check for leakage of fluid, location of puncture site, client tolerance, sterile dressing on puncture site

Most common type of headache:

Tension headache Indications: mild to moderate pressure or tightness, bilateral, discomfort worse with activity NI: careful assessment of onset of symptoms, triggers, instruct about analgesics, relaxation techniques, massage, moist hot packs to neck

What does a positive Homans' sign indicate?

Thrombophlebitis (swelling/inflammation) of a vein caused by a blood clot Positive Homans' sign: pain in calf on forceful and abrupt dorsiflexion of the patient's foot at the ankle while the knee is extended

What is the purpose of elastic anti embolism stockings?

To decrease risk of thrombus formation by exertion external pressure on lower extremity muscles and superficial leg veins, preventing stasis and promoting venous return in lower extremities by maintaining external pressure NI: apply in morning before client arises, do not apply if skin lesions, gangrene present, must be properly sized and applied, clean, dry and smooth, must be removed and reapplied at prescribed intervals Watch for skin irritation, breakdown

Mantoux test

Tuberculin skin test of purified protein derivative (PPD) given intradermally in the forearm and read after 48-72 hours Positive: induration (hard area under skin) > 5 mm in HIV infected persons, recent contact of person with TB, or persons with fibrotic changes on chest radiograph consistent with prior TB, with organ transplants, immunosupressed induration > 10mm considered positive in recent immigrants from high-prevalence countries, IV drug uses, residents/employees of high-risk congregate settings, mycobacteriology lab personnel with clinical conditions at high risk, children less than 4 years, infants/children/adolescents exposed to high risk adults induration > 15 mm considered positive in ANY person, including person with NO known risk factors for TB

Bell's Palsy

Unilateral facial paralysis involving 7th cranial nerve, usually temporary Indications: Inability to close eye, decreased corneal reflex, increased lacrimation, drooping mouth, speech difficulty, eating difficulty NI: Protect head from cold and drafts, administer analgesics, assist with electrical stimulation, teach isometric exercises for facial muscles, gentle massage and warm packs, prevent corneal abrasions, sunglasses in day, eye patch at night, reassure client that they haven't had stroke, emotional support for altered body image

Brachytherapy

Use of implants that are radioactive at the treatment site (usually malignant lesion) - internal radium implants, internal radiation NI: save all dressings, bed linens until source is removed, then discard dressings and linen as usual - done to assure no radiation source is IN the linen or dressings - Urine, feces, linen are not radioactive - Nurse should NOT stand close to or in line with radioactive source - Organize care so limited time is spent in client's room - Encourage client to do own care - Client must remain on bed rest while implant is in place - Position of source of radiation is verified by radiography

What is standard measurement for central venous pressure?

Used as a guide for fluid replacement; need central line, water manometer with 3-way stopcock, IV fluids, reading taken at highest level of fluctuation of fluid in manometer (fluctuates with respirations) Normal: 3-11cm water > 11: hypervolemia or poor cardiac contractility, symptoms of fluid overload < 3: hypovolemia, pneumothorax, air embolism, infection at insertion site

Commonly prescribed drugs for absence seizures

Valproic acid, clonazepam, ethosuximide

What is the antidote for Warfarin?

Vitamin K

When are neutropenic precautions initiated?

WBC <1000

What is important to tell patients who are going to have EEG - recording of brain?

Withhold tranquilizer, cigarettes, stimulants according to institution policy - Patient may be asked to hyperventilate 3-4 minutes, watch bright flashing light, eat regularly scheduled meals

What is the time limit between onset and diagnosis for which a patient must receive thrombolytic agents for stroke?

Within 3 hours Recombinant t-PA - dissolve obstructive blood clots, decrease stroke severity - Withhold anticoagulants for the next 24 hours - Monitor VS, especially BP to lower risk of intracranial hemorrhage - Every 15 min for first 2 hours, every 30 for next 6 hours, every following hour until 24 hours after treatment

Multiple Sclerosis

autoimmune disease - attacks the CNS by destroying the myelin sheaths that surround the nerve fibers

Fat embolism syndrome

blocking of small blood vessels by fat globules subsequent to a fracture, especially one of long bones or pelvis I (when emboli are deposited in lungs): anxiety, agitation, acute confusion, fever >103, chest pain, dyspnea, tacky, tachypnea, thick white sputum, petechiae (on chest, neck, shoulder, axillae, flank, abdomen), sudden onset, 24-72 hrs after fracture NI: High Fowler's position, oxygen in high concentrations, possibly with positive/expiratory pressure, corticosteroids, vasoactive meds to prevent hypotension and shock, fluid replacement guided by accurate I & O

Parkinson's

fine, slow spreading tremors, muscular rigidity, altered gait NI: finger exercises, ROM as appropriate, ambulation modification, refer to physical therapy

Bronchovesicular breath sounds

harsh sounds heard over main stem bronchi

A patient with a hip fracture will present with:

leg shortened, adducted, externally rotated, pain, hematoma, ecchymosis - flex hip only to 45 degrees, never cross legs!

Bronchial breath sounds

loud, coarse, blowing sound heard over trachea

Signs of miningeal irritation (4)

nuchal rigidity (neck stiffness), Kernig's sign (flex hip and knee, if patient feels back pain, it is positive), Brudzinski's sign (flex patient's head toward chest - if hips and legs flex involuntarily, this is positive for meningitis), opisthotonic position (severe hyperextension, spasticity in patient's head, neck and spinal column, bridging or arching position)

Normal urine values for urinalysis

pH: 4.6-8.0 color: pale yellow-amber turbidity: clear specific gravity: 1.010 - 1.030 RBC's: 0-2 glucose: none ketones: none protein: 0-8 mg/dL

Vesicular breath sounds

soft, low pitched, breezy sounds heard over most of peripheral lung fields

Thrombolytic therapy for MI

streptokinase alteplase anistreplase reteplase

Shock

systemic pressure is too low to carry necessary oxygen, nutrients to vital organs and cells NI: ensure patent airway, maintain breathing and circulation, restore circulating blood volume, insert indwelling catheter, I's & O's every 15-30 minutes, determine cause of shock, lab tests, elevate feet slightly, meds prescribed, maintain body temp, avoid too much heat