Medsurg HESI 🩺
Food DECREASES symptoms -> HELPS Mid-epigastric pain beneath xiphoid Bloating, nausea, vomiting & fullness
Duodenal ulcers
1. *Do not want patient to sit there and let fluid buildup* a. Prevent pneumonia/atelectasis b. If patient refuses to ambulate -> SCDs (sequential compression devices)
Early ambulation for patients
- Check feet everyday; make sure you dry your feet - Wear proper shoes - Don't want them walking around bearfoot - Make sure bath water isn't too hot
Education needed regarding foot care on diabetic patients.
-Immediately post-op you don't take off the first one until the doctor does (never take off the first one) - Look at drainage & reinforce the dressing
Nursing duties for post-op surgical dressing changes
Show pictures of charts to communicate
What to do when a patient is experiencing expressive aphasia?
a. Increase fluid intake to 3L/day if tolerated b. Intake can be IV or PO
What to do when a patient needs to expectorate thick lung secretions?
-> treatment of High K+ levels a. Watch for DIARRHEA (pulls out potassium and excretes through the bowels) b. If question asks what to look for INITIALLY à Diarrhea c. If diarrhea has already passed, look for POTASSIUM levels or EKG changes
Kayexalate
Crackles, dyspnea, orthopnea, paroxysmal nocturnal dyspnea
Left ventricular diastolic failure signs and symptoms:
-Going to back up into the lungs (respiratory system) -SOB -dyspnea -wheezing -pulmonary edema -crackles -coughing (coughing up pink tinged secretions) -fatigued/weak
Left ventricular diastolic function S/S:
Decreased course crackles
Which assessment finding would you expect to see in a patient who had recently been suctioned via endotracheal tube? A. Increased course crackles B. Decreased course crackles C. Decreased fine crackles D. Increased fine crackles
- Monitor glucose - Check amylase & lipase levels - May have to put an NG down & put it to suction - *one of the most common causes of pancreatitis is alcohol abuse, so talk about that* - * They will always be NPO* - Ultrasound
List all nursing interventions for a patient diagnosed with pancreatitis:
apply oxygen by non-rebreather mask (too much carbon dioxide cause respiratory acidosis)
After reviewing ABG's the patient is in respiratory acidosis. What is the nurses's primary intervention? A. apply oxygen by non-rebreather mask B. sedate w/ ativan 1mg/kg C. Administer bicarb 1 amp D. Administer a bronchoocnstrictor
a. Anticoagulants for lifetime b. Antibiotics for dental work c. Soft bristle toothbrushes d. 2g Na diet, low fat/cholesterol e. If on coumadin à LIMIT vitamin K (green leafy vegetables)
Mechanical valve replacement teaching:
Sinus Bradycardia
<60 bpm
The patient's sclera is yellow (inflammation b/c of gallstones, the stones can get lodged in the bile duct, which backs up & causes damage in the liver)
Which assessment information will be most important for the nurse to report to the health care provider about a patient with cholelithiasis? A. The patient's urine is bright yellow B. The patient's sclera is yellow C. The patient has increased pain after eating D. The patient complains of chronic heartburn
A. Diet & exercise regimen (least invasive) (metformin would be the next; first drug of choice)
A 36 year old male is newly diagnosed with type 2 diabetes. Which of the following treatments do you expect the patient to be started on initially? A. Diet and exercise regimen B. Metformin BID by mouth C. Regular insulin subcutaneous D. None, monitoring at this time is sufficient enough
Alternate IV & IM medications
A 73 year old patient with end stage cancer is in the hospital for pain control and rates pain at a "12" on the numeric rating scale of 0 to 10. What is the appropriate method of pain control for this patient? A. Alternate acetaminophen & ibuprofen B. Only give PO medications on a scheduled basis C. Alternate IV & IM medications D. Wait for patient to request medication each time
extravasation ( a vesicant irritates the vein)
A client on the oncology unit is receiving a vesicant chemotherapy agent. What is your priority nursing concern? A. Extravasation B. Dehisence C. Evisceration D. Fistula E. Hemorrhage
Place the client in high Fowler's position. (They are in respiratory acidosis) Primary assessment: respiratory (listen to lungs, rate & depth)
A client with pneumonia presents with the following arterial blood gases of pH 7.28, PaCO2 of 74, HCO3 of 28 meq/L, and PO2 of 45. Which of the following is the most appropriate nursing intervention? A. Administer a sedative B. Place client in left lateral position C. Place client in high-fowlers position D. Assist the client to breathe into a paper bag What would be your primary assessment for this patient?
A. Establish IV access
A drug abuse client is being admitted to your unit with the diagnosis of cellulitis from a needle stick injury. What is the nurse's primary action for this client? A. Establish IV access B. Monitor urine output C. Administer the first dose of pain medication D. Consult case management for rehab placement
F,H are incorrect
A nurse is assessing a client who has a seizure disorder. The client reports he thinks he is about to have a seizure. Which of the following actions by the nurse are incorrect? (Select all that apply) A. Monitor for prolonged apnea B. Ease the client to the floor if standing C. Move furniture away from the cient D. Loosen the clients clothing E. Protect the clients head with padding F. Restrain the client G. Turn on side H. Place tongue blade in clients mouth I. Record the time & document details of seizure J. Document details of the seizure
Decreased cardiac ouput
A patient arrives to the ER with the diagnosis of sinus bradycardia. What is the primary nursing diagnosis for this patient? A. Risk for infection B. Decreased cardiac output C. Ineffective health maintenance D. Risk for injury
Sit the patient in high fowler's Priority nursing assessment: respiratory (listening to what their lungs sound like)
A patient diagnosed CHF present to the ER with SOB, dyspnea, rhonchi, dry cough, and tachycardia. What is the RN's first response? A. Complete chest percussions on bilateral lungs B. Push 1 amp o fmetoprolol C. Place the patient in trendelenburg D. Sit the patient in high fowler's What is the priority nursing assessment?
C. Weak cough
A patient is admitted to the ER with amyotrophic lateral sclerosis. Which nursing assessment warrants immediate intervention? A. Muscle spasms B. Severe constipation C. Weak cough D. Slow urine stream
C. Use picture charts to communicate (they can point out what they are trying to say)
A patient is admitted to the ER with expressive aphasia. To further assess the patient, the nurse should include which of the following techniques: A. Speak slower to communicate B. Speak louder to communicate C. Use picture charts to communicate D. Type on computer screen to communicate
Bowel sounds in all 4 quadrants complication that can occur after abdominal surgery: - they can get an ileus (a painful obstruction of the ileum or other part of the intestine) - blocked bowel after surgery (important to get them up & giving stool softeners; dont feed until you hear bowel sounds)
A patient who received an emergency appendectomy 2 days ago is now experiencing abdominal pain on the med-surg unit. What shoud the RN consider to be the primary assessment? A. Pedal pulses B. Jugular vein distention C. Bowel sounds in all 4 quadrants D. Urinary output of 30 cc per hour
Set patient up on a fixed pain med schedule q 4 hrs
A patient with stage IV bone cancer has no pain relief with the first dose of IV pain medication. What is the most appropriate nursing intervention for long term relief? A. Administer ibuprofen 400mg PO B. Set patient up on a fixed pain med schedule q 4 hrs C. Alternate rearranging pillows and cold cloth applications D. Support assisted suicide as the patient's advocate
Looking for a bowel movement (they are going to have massive liquid diarrhea b/c Kayexalate causes potassium to exchange from sodium in the intestines & potassium goes out via BM)
A renal failure client with a potassium level of 5.5 mEq/L is to receive sodium polystryene sulfonate (kayexalate) orally. What do you want to monitor for immediately after this medication is given?
atelectasis (parital full collapse of lung/alveoli; one of the most common breathing complications after surgery) this is why we're doing turn cough deep breathe, incentive spirometer
A surgical protocol states that all post operative patients must participate in early ambulation to prevent: A. Bed sores B. Atelectasis C. Contractures D. Dehiscence and eviscertion
Let's discuss your risk factors for continued living.
An older adult client comes to the clinic for his annual physical. His primary concern is increased fatigue. Which response by the nurse would be the most appropriate? A. Have you looked into a nursing home placement? B. Decrease your level of activity throughout the day. C. Increase your level of activity throughout the day. D. Let's discuss your risk factors for continued living.
Assess immediately and hourly thereafter (something has changed; this is different from their norm)
An older adult client who is predominantly argumentative and combative becomes calm & sleeps through the night. What is the nurse's priority intervention? A. Assess immediately and hourly thereafter B. Call the MD C. Document the client is resting D. Allow the patient to rest and document a round every 4 hours
Assess potassium level (when you're giving insulin & dextrose it pulls K+ out of cells too; it will drop) (check glucose BEFORE meals, not after)
An order is given to the RN to administer dextrose + insulin combined as a one time stat dose. What will be most important to include in this patient's plan of care? A. Assess range of motion B. Assess oxygen level C. Assess potassium level D. Assess glucose readings after each meal
-RBC count: 4.2-6.1 (Anemia) -Urinalysis: UTI (checking for WBC, blood, RBCs) for Diabetics we may be checking for ketones or protein -Na level: 135-145 (Conjestive Heart Failure; checking for electrolyte imbalance; Also check BNP for HF) -WBC count: 5,000-10,000 (infection, wound, or sepsis) BUN: 10-20 (Kidney/Renal Failure)
Normal lab values & primary diagnosis: A. RBC count B. Urinalysis C. Na Level D. WBC count E. BUN
Bedside prep: Sterile saline, tape, gloves, dressing that has been order When changing the wound you are looking for signs of infection (redness, swelling), dehiscence (make sure that it is still together), also evisceration (make sure there is good tissue)
Bedside prep for a post op wound: Primary concerns:
melena
Black tarry stool
1. *Blood should not transfuse more than 4 hours* ALWAYS ON A PUMP a. Itching b. Flank/chest pain c. Swelling d. Decrease BP; INCREASE RR, HR, & temp
Blood transfusion reaction
a. Ambulation (first) b. SCDs (2nd) c. Low-molecular weight heparin (Lovenox) / anti-thrombolytics, coumadin PO
Decrease clotting formation
TLS (tumor lysis syndrome) -Can put them into acute renal injury -They'll have hyperurecemia, hyperphosphatemia, hyperkalemia, hypocalcemia
Describe TLS and rationales for going into TLS
a. Check POTASSIUM b. *Rationale: insulin pulls K+ out with glucose c. *Add D5 or D10 when BS reaches a level of 250 mg/dL DKA: pH decrease, acidosis (fruity breath) TYPE 1 HHS: no acidosis, BS >600 TYPE 2
Dextrose + insulin combined
a. Pursed lips b. Barrel chest (increase anteroposterior diameter) c. Tripod positioning d. Use of accessory muscles e. ALSO: chronic cough, sputum production, dyspnea, wheezing f. Medications: bronchodilators, incentive spirometer, CPT, O2
COPD S/S
- Expect to see no BP or sticks in that arm - Cannot use right away b/c it has to have time to heal - Auscultate to bruit - Palpate for thrill
Care of a newly inserted AV fistula
No heavy lifting or bending over at the waste (nothing that will increase IOP ) Wear bandage or shield to protect the eye Eyes will feel like scratchy sand-like feeling in their eyes Need to have someone to drive for them 1st 24 hrs after surgery, they just need to relax (they can watch TV & read; nothing that will cause pressure) Don't want patient rubbing or pressing on their eye Shouldn't drink alcohol for at least 24 hours
Cataract extraction surgery education
a. No lifting/straining/bending b. No driving for > 2 days c. No contacts d. No alcohol for >24 hours e. No rubbing or pressing on eyes f. No bright lights
Cataract surgery education
a. Check cultures (blood, sputum, urine) before starting antibiotics b. Give antibiotics if culture answer is NOT an option c. Establish IV access
Cellulitis from needle stick (worried about infection)
-ambulation -compression hose (leg stockings) -give Heparin, Lovenox (but least invasive first)
Nursing action to decrease clot formation
a. Manage airway!!! b. Decrease BP *MUST STAY LOW* à if ruptures, can bleed easily c. Coughing up blood (red or coffee grounds) d. Avoid acidic/spicy foods & aspirin, alcohol, NSAIDS e. Use beta blockers to keep BP low f. If bleeding occurs: Manage airway (suction) à stabilize the patient à IV therapy (octreotide [sandostatin] or vasopressin)
Esophageal varices: **COMMIN IN LIVER CIRRHOSIS** -> medical emergency
people that like to drink (alcohol)
Esphogeal varices are very common in __
Review their dietary log (check what they have been eating & keep up with what foods are causing the adjustments)
For patients with blood sugar ranges fluctuating high and low, what should be the nursing intervention? A. Increase the patients short acting insulin B. Decrease the patients long acting insulin C. Draw a serum glucose D. Review their dietary log
Food INCREASES symptoms -> EXACERBATES Burning or gaseous
Gastric ulcers
- Prep the room & make sure you've got all the equipment - They help with transfering & positioning the patient for surgery - Anybody needs anything, they go and get it - *They are responsible for calling the surgical TIME-OUT* (primary role)
Goal of the surgery circulating nurse:
30 minutes before (give it time to kick in; once someone gets nauseated with chemo, it's hard to catch it)
How many minutes prior to chemotherapy do you give antiemetic drugs? A. 15 B. 30 C. 45 D. 60
a. Increased protein in the blood; decrease serum albumin b. Edema/swelling/abdominal edema c. Increase weight gain
Indicators of nephrotic syndrome
massive protein in urine hypoalbunemia (low protein in the blood) hyperlipidemia edema (anasarca; in ankles in feet) Weight gain make sure to do daily weights monitor edema in lower legs and in abdomen (ascites occurs commonly w/ nephrotic syndrome)
Indicators of nephrotic syndrome
Cellulitis
Infection of skin cells
a. Increase water intake to 3L / day b. DECREASE calcium, struvite (uric acid: gout), infections (bacterial: UTIs) c. Strain urine (shows composition of the stone) d. Increase ambulation *Foods to AVOID: calcium (milk, dairy, green leafy vegetables) & caffeine (coffee, tea, soda, chocolate); spinach nuts, wheats, brans, *Take thiazide diuretics to prevent calcium stones; allopurinol or colchicine to prevent uric acid stones; and antibiotics for bacteria (struvite) *S/S: male over ager 40, N/V, pain radiates to flank area, hematuria
Interventions for patient with renal calculi:
Safety risk factors: - Changes to be made in the home include: colored step strips (yellow), tub and toilet grab bars, stairway hand rails, unclutter floor space, increase lighting and use of night lights Quality of life: - Depression can occur due to diagnoses, loss of self-esteem, life situations (retirement, loss of spouse, etc.); pain, insomnia, lethargy, agitation, weight loss, and dementia are associated with depression - Encourage older adults with depression to seek treatment
Older Adults
a. NPO!!!! b. NG suction c. Abdominal ultrasound d. Amylase/lipase levels e. AVOID alcohol
Pancreatitis interventions
a. NEVER remove 1st dressings à HCP must remove because it may pull off the clot/skin b. Mark if oozing; if it spreads, reinforce
Post-op dressings
a. Place patient in high fowlers (allows better oxygen) b. Check RR, respiratory depth, and O2 sat c. Use nonrebreather to keep O2 and release CO2 d. pH decreased; PaCO2 INCREASED; HCO3- normal or increased (compensation) e. NORMALS: *pH:7.35-7.45 PaCO2:35-45 HCO3:22-26*
Respiratory acidosis (CO2 excess)
a. Age b. Alcohol - Limit to 1 a day for females and 2 a day for males c. Tobacco use (smoking) - Increases risk for cardiovascular disease d. Diabetes mellitus - Common in patients with HTN - Complications are more severe when these coexist e. Elevated serum lipids (Coronary artery disease) - Increased cholesterol and triglycerides are primary risk factors for atherosclerosis - Common in people with HTN f. Excessive dietary sodium - Sodium intake can contribute to HTN and decrease antihypertensive med g. Gender - Prevalent in men in young adulthood - After 64 - more prevalent in women h. Family history - First relatives increase risk i. Obesity - Weight gain is associated with increased frequency of HTN - BMI: 1. 18.5-25 -> normal 2. 25-30 ->OVERWEIGHT 3. >30 ->OBESE j. Ethnicity - African Americans k. Sedentary lifestyle l. Socioeconomic (greater in lower socioeconomic areas) m. Stress
Risk factors for HTN
*Obesity* *Smoking* *Diabetes* *Cholesterol* Stress
Risk factors for hypertension
Risks: Diabetes, Smoking, Hypertension, Diet (fatty foods/high cholesterol), Family History Interventions: Diet and Exercise
Risk for developing Coronary Artery Disease: What interventions do you instruct the patient to slow progression of CAD?
- check for increased HR, respirations, & temp - BP will drop - May have hemolytic rash & be itching - May see flushing - Chest or flank pain - Blood has to run off on a pump TIME FRAME FOR GIVING BLOOD HAS TO BE LESS THAN 4 HOURS; IF STILL BLOOD IN AFTER 4 HOURS, YOU HAVE TO TAKE IT DOWN
S/S of blood transfusion reaction?
- Stool will be red (bloody diarrhea) (lower) - rectal bleeding - Blood count may show low H&H, may be anemic
S/S of ulcerative colitis
D, C, A,B Once you confirm that it's in place, you would listen to bowel sounds
Sequence the procedure for verifying feeding tube placement: A. Measure the pH of aspirate, compare the color of the strip with the color on the chart provided by the manufactor B. Discard used supplies, remove gloves and discard, and perform hand hygiene C. Draw back on syringe & obtain 5 to 10 mL of gastric aspirate observe appearance of aspirate D. Perform hand hygiene. Apply clean gloves, draw up 30 mL of air into syringe, then attach to end of feeding tube, flush tube with 30 mL of air
-Sudden excruciating pain in or around the eye with N/V -Colored halos, blurred vision, & ocular redness
Teaching for closed-angle glaucoma
-Report if they are coughing up blood -Recognize if there is a rupture, there will be bleeding & immediate action needs to be taken -No spicy foods!! -To prevent pressure, you have to control their high blood pressure Majority of people who come in w/ esophogeal varices are alcoholics
Teaching for esophageal varices
a. Black dome vision "Tunnel vision" ->LOSE PERIPHERAL VISION -> 1ST symptom!!!! b. Pressure eyedrops - lifetime medication c. Check surroundings
Teaching for open angle glaucoma:
- No heavy lifting (no excess pressure) -Will always have to use eyedrops for the rest of their lives -S/S of open angle glaucoma: will have decreased peripheral vision, also it happens very slowly, you use lose vision before you ever even know there is a problem (Chronic)
Teaching plan for the client with open angle glaucoma
Melena
The client with a duodenal ulcer may exhibit which of the following findings on assessment? A. Hematemsis B. Malnourishment C. Melena D. Pain with eating
Evisceration
The displacement of organs outside of the body.
- Smoking - Spicy foods - Alcohol - *Milk/Milk products* - Caffiene, Coffee, Tea, Chocolate
Things to avoid with duodenal ulcers
a. Metabolic EMERGENCY b. Rapid release of components due to chemo & radiation into system à renal failure, hyperkalemia, hyperuricemia, hyperphosphatemia, HYPOcalcemia *hypocalcemia means that the body tries to pull calcium out of the bones, which leads to brittle bone syndrome
Tumor lysis syndrome
(UC is lower GI) a. Abdominal pain b. Bloody diarrhea / rectal bleeding à main s/s!!! c. Low H & H à anemia
Ulcerative colitis S/S
Hand hygiene/gloves -> Draw 20-30 mL air ->attach tube -> push air -> listen for bubbles -> aspirate pH -> observe aspirate ->measure pH (should be <5) -> discard supplies
Verify tube placement
a. Check IV site every hour b. Vesicant drugs: vancomycin, Levaquin, chemo agents (doxorubicin/adriamycin = red devil) c. IF INFILTRATED: stop infusion, apply ice, Call MD
Vesicants -> watching for extravasation (swelling, redness, pain)
Increase water/fluid intake Decrease calcium Limit coffee, tea, & cola
What are dietary considerations for renal calculi?
-W/ a mechanical valve, they will always have to take blood thinners (Coumadin/any anticoagulant the doctor prescribes) for the rest of their lives -Using soft tooth brushes -Being careful not to cause any bleeding -They will always hear a clicking w/ mechanical valves
What are your priority teaching points for a patient being discharged with having a mechanical valve replacement?
a. Weak cough b. Speaking, swallowing, drooling
What calls for an immediate ALS (amyotropic lateral sclerosis) intervention? **RESPIRATORY** (MS lose cognitive function)
a. Yellow sclera, jaundice (because backing into the liver) b. Avoid fatty/spicy foods and alcohol c. S/S: - RUQ pain - Tachycardia/ diaphoresis - Pain 3-6 hours after a high fat meal or when laying down d. Management: - NPO with NG tube - IV fluids - Low fat diet iv. Fat soluble vitamins
What do you report to the HCP with cholelithiasis?
Decrease calcium (milk, cheese, tofood) Want them to get up and ambulate to get those stones down Increase water/fluid intake Strain urine
What interventions do you plan to include w/ a pt who has renal calculi?
first thing to do is to stop the infusion & start flushing
What is nursing priority when a transfusion reaction is suspected? A. vital signs B. call the MD C. administer benadryl D. stop the infusion
Administer nausea medication
What is the primary nursing action for a patient with chemo induced nausea? A. Take a blood pressure B. Apply a cold cloth to forehead C. Document amount of emesis D. Administer nausea medication
Increase fluid intake to 3L/day if tolerated
What is the priority nursing intervention in helping a patient expectorate thick lung secretions? A. Humidify the oxygen as able B. Administer cough suppressant Q24HR C. Teach patient to splint the affected area D. Increase fluid intake to 3L/Day if tolerated
Dyspnea Barrel chest Tripod position Pursed-lip breathing
What physical assessment findings would a nurse expect to find in a client with COPD?
a. Aspirin b. Spicy/fatty/acidic foods c. Alcohol d. DAIRY à exacerbates symptoms e. Coffee **Wait 2-3 hours after eating before laying down** **Common finding with duodenal ulcers: melena**
What to avoid w/ duodenal ulcers
amyotrophic lateral sclerosis (ALS)
condition of progressive deterioration of motor nerve cells resulting in total loss of voluntary muscle control; symptoms advance from muscle weakness in the arms and legs, to the muscles of speech, swallowing, and breathing, to total paralysis and death; also known as Lou Gehrig disease
esophagel varices
enlarged, swollen, varicose veins at the lower end of the esophagus
cholelithiasis
gallstones in the gallbladder
Extravasation
leakage of intravenously (IV) infused, and potentially damaging, medications into the extravascular tissue around the site of infusion
Metformin (oral diabetes medicine that helps control blood sugar levels)
medication used for type 2 diabetes
expressive aphasia
slurred speech or inability to speak; they're unable to get out what they want to say
RLS (restless leg syndrome) (unable to control the urge to move their legs) (typically happens at night/evenings; can occur whether you are sitting or lying down)
unpleasant sensations (itching, twitching, tingling, crawling) in the lower legs; irresistible urge to move the legs temporarily relieving the sensation but not disurbing sleep.
popped, twisted, enlarged veins -legs ache, painful, feel heavy (S/S)
varicose veins
hematemesis
vomiting blood
