Med Surg - ATIR

Albumin

determines the amount of protein the liver produces in the body

TSH

determines thyroid function

condition that is risk for developing vascular disease

diabetes mellitus bc they have greater risk for developing cardiovascular and peripheral vascular disease

parkinsons disease diagnosis

diagnosed by clinical manifestations such as shuffling gate

bells palsy diagnosis

diagnosed by clinical manifestations such as weakness and paralysis of facial muscles

trigeminal neuralgia diagnosis

diagnosed by pt clinical manifestations such as severe facial pain

pt teaching for doing own peritoneal dialysis at home

dialysate outflow should be clear in color, cloudy outflow is an indication of peritonitis, use sterile technique when connecting dialysis tubing, pt should warm dialysate fluid before instillation, pt can move around during well time

myasthenia gravis

disorder that involves muscles and nervous system

nursing care for pt having chemo with sores in her mouth

eat several small portioned meals daily bc small amounts at once are usually tolerable, cold foods are usually tolerated better bc they emit less odor, rinse with a solution of water and 0.9% sodium chloride or water and backing soda (glycerin or alcohol based mouth wash can lead to irritation and burning)

phosphorus

electrolyte that aids in the production of calcium and bones

Acute Pancreatitis

elevated serum amylase level, hypotension, tachycardia, increased leukocyte count

interventions for pt with deep partial thickness burns over 60% of body surface

encourage pt to increase caloric intake to meet increase energy needs, increase oral fluid intake to maintain adequate hydration, increase intake of protein to meet increased energy needs

physical change from graves disease

exophthalmos

nursing care for pt with hearing impairment

face the pt while speaking to allow the pt to see who is speaking and have visual cues by observing facial expressions, avoid high pitched tones bc they are difficult to understand and distort both vowels and consonants, use gestures which can enhance communication by providing visual cues, rephrase rather than repeat misunderstood conversation

pt teaching for TB

family members who have been in contact with the pt should be tested, nurse should collect sputum cultures every 2-4 weeks after initiation of medication, pt should take meds for 2-3 consecutive weeks to make sure they can't transmit the bacteria to others, airborne precautions are not necessary for family members bc they have already been exposed

prevent aspiration

give pt liquids with increase viscosity (thickened liquids), tilt neck forward while swallowing

diltiazem pt teaching - hypertension med

headaches are expected adverse effect due to the medications vasodilatory effects, do not take 2 tablets at once if you miss a dose

furosemide

high ceiling loop diuretic used to treat heart failure

auscultate pericardial friction rub

high-pitched scratchy sound over the heart, for a pt who has pericarditis

suctioning a trach pt

hyperoxygenate before - ask the pt to take 3-4 deep breaths or apply a resuscitation bag that is attached to oxygen and manually give the pt 3-4 breaths to minimize hypoxia, perform suctioning 10-15 secs (longer suctioning can cause further hypoxia and bronchospasms), do not increase suction pressure bc it can cause hypoxia and trauma to the mucosa, the amount of suction for an adult is between 80-120 mm Hg

thyroid storm

hypertension, tachycardia, restlessness & tremors which can progress to seizures

lordosis

increase in curvature of the spine

crohns disease

inflammatory bowel disease

Vaccine timeline

influenza - once a year, hep b - series of 3 and only requires a booster after a titer indicates a need, pneumococcal - every 3-5 years, tetanus - every 10 years

prednisone

inhibits the production of cortisol from the adrenal cortex which can lead to adrenal crisis if the client abruptly discontinues the med

discharge teaching for esophageal varices

instruct pt to consume foods high in fiber to prevent risk of straining and bleeding due to constipation, avoid taking any over the counter meds (including nsaids & multivitamins) that decrease cell replication and can result in bleeding, elevate the head of the bed while sleeping to prevent aspiration of blood from the varices or shortness of breath from the pressure of ascites

promote restful night sleep

offer snack at bedtime

acute glomerulonephritis

periorbital edema due to fluid retention, dry itchy skin (not diaphoresis), hypertension

penrose drain

place precut gauze snugly around the drain

care for pt after above the knee amputation

place the pt in prone position for 30 min 3-4 times per day to prevent hip flexion contractures, perform frequent range of motion exercises to prevent flexion contractures, reapply wrapping every 4-6 hours to reduce edema, provide pt with firm mattress to prevent flexion contractures

discharge teaching for multiple sclerosis

plan to exercise daily - maintains physical well-being, include fiber in diet to maintain bowel function, avoid excessive heat (hot showers) bc it can lead to increase in muscle weakness

anxiety before surgery

priority - determine the clients understanding of the procedure. this allows you to provide necessary teaching which can help manage anxiety

nurse action for pt with sepsis

priority - initiate oxygen per dr order to promote adequate perfusion,

dumping syndrome interventions

provide a low fiber diet, encourage high fat diet, encourage pt to eliminate fluids with meals, eat high protein diet

thrombophlebitis

pt reports throbbing, burning at iv site along with red line up his arm. pain, warmth, and red streak up arm are s/s

pt who is easily fatigued and dyspneic - interventions

pt should alternate activities and rest periods throughout day to conserve energy (do not complete all personal hygiene activities in the morning), call for assistance when ambulating, have someone cut food into small pieces to conserve energy, use pursed lip breathing when short of breath

positioning for head injury

pt should be in low-fowler's position with pt head in the midline position, this promotes venous drainage and reduces the risk of increased intracranial pressure

priority intervention for frost bite pt

put pt foot in a water bath at 40 degrees Celsius (104 F) bc the greatest risk is further damage of tissue due to the hypothermic effect / other interventions - elevate extremity to promote circulation, administer opiod, immunize with tetanus toxoid bc pt is at risk for tetanus

plan of care for pt with TB

put pt in negative pressure airflow room to filter the air and prevent transmission of micro-organisms, visitors should follow transmission precautions, pt should wear a surgical mast when transporting outside of the room, initiate airborne precautions

pt teaching for mitral valve disease

"I will call my doctor if my ankles swell", this indicates heart failure and should be reported to provider

normal bowel sounds

5-30 gurgles and clicks per minute

lab values to check before cardiac cath

BUN- indicates kidney function which should be checked to determine if the pt can tolerate the iv contrast dye during the procedure

lab values to monitor for methotrexate toxicity

CBC bc methotrexate toxicity can result in bone marrow suppression,

post-op gastrectomy actions to decrease episodes of dumping syndrome

put pt in supine position after meals to decrease rapid gastric emptying, instruct pt to consume no fluids with meals to allow for ingestion of foods high in protein, offer pt 6 small meals per day

ABG results for COPD pt

PaCO2 56 mm Hg - above expect reference range. during acute exacerbation of copd hypercpnia (an elevated PaCO2) in expected

abdominal adhesions in upper gastrointestinal tract

adhesions and scar tissue can create a mechanical intestinal obstruction so the nurse should expect to hear hyperactive bowel sounds above the point of the intestinal obstruction

pancreatic enzymes

administer to pt with pancreatitis before meals

intervention after gastrectomy

administer vit b12 injections to prevent dumping syndrome

alcohol withdrawal

agitation and diaphoresis, if pt doesn't get treatment the manifestations of alcohol withdrawal will worsen and can become life threatening *priority intervention for these s/s is to ask how much alcohol pt drinks a day

methimazole

antithyrod hormone used to treat hyperthyroidism

injection sites for thrombocytopenia

apply firm pressure to prevent bleeding

menieres disease - caloric test

ask pt to lie supine while irrigating with a cold and then warm solution in each ear. an expected response for a pt who has menieres disease is vertigo, nausea, and vomitting

metoprolol

beta-adrenergic antagonist used to treat hypertension.

physical change from Addison's disease

bronze skin

anticoagulant med

can cause excessive bruising for a client with mitral valve disease but bruising is not a direct result of the disease

corticosteroids

can increase susceptibility to infection by suppressing host defenses, can cause sodium and water retention resulting in decrease urination, can increase appetitie

what to ask to find out if pt has bowel obstruction

can you describe the odor of your vomit? - pt has n/v and constipation,

nurse action for pt reporting pain/swelling at IV site

check the iv site for infiltration, if infiltration is found stop the infusion to prevent vein and tissue damage, once infusion is stopped remove the iv catheter, elevate the affected extremity to decrease swelling, notify charge nurse

preventing spread of hepatitis A to others

client can contract hep a by ingesting foods handled by an infected individual therefore hand washing can prevent spreading the virus, pt can never donate blood

post op care for amputation of lower extremity

compression dressing should be changed 3 times daily and any time the dressing becomes loose - promotes proper fit of prosthesis and reduces edema, elevate the limb no more than 24 hours to prevent contractures of the hip joint, anchor the residual limb dressing at the nearest joint proximal to the amputation, cleanse residual limb with mild soap and then carefully rinse dry

iv venous spasms

cramping at or above the insertion site and numbness

lab finding that needs to be reported to provider before CT

creatnine 1.9 mg/dL puts the pt at risk for developing contrast induced nephropathy

peripheral arterial disease (PAD) interventions

dangle extremities off the side of bed to aid in reducing pain and swelling caused by decreased circulation, avoid applying heat to the pt extremities to prevent injury due to decreased sensation, avoid massaging pt lower extremities due to poor blood circulation and could also dislodge a clot formation, avoid applying support stocking to lower extremities as this interferes with arterial blood flow to lower extremities

pneumocytstis jirovecii (carinii) pneumonia treatment - pentamidine isethionate, nebulizer treatments with albuterol, iv fluids

decreased exertional dyspnea indicates therapeutic regimen is effective

pt teaching for radiation therapy

irradiated tissues are extremely sensitive to ultraviolet sun rays so the radiation site should be covered in sunlight, to protect skin the pt should wear loose cotton clothing over radiation site, do not remove ink markings until the completion of radiation, pt should not apply moisturizing lotion to the radiation site bc it can irritate the skin, pt should not use a wash cloth to cleanse the radiation site, pt should gently cleanse the site with his hand

nursing care for pt receiving continuous enteral feedings

irrigate the tube using at least 30ml of water every 4 hr to decrease clogging, elevate head of bead to a 30 degree angle to prevent aspiration, auscultate for bowel sounds, change tubing and feeding bag every 24 hr, never mix medications into tube feeding bag

Jackson pratt suction

keep the device compressed to maintain suction

bucks traction intervention

keep the skin dry and free from perspiration, prolonged moisture on skin will result in skin breakdown

indicates risk for delayed wound healing

lab value - prealbumin 12mg/dL, it is below the expected reference rand which indicates the clients protein status is inadequate

pt positioning for retinal detachment in right eye surgery

left side lying - promotes drainage of fluid under the detached retina and adherence of the retina to underlying tissue

pt teaching with left arm cast

lifting casted extremity over the head keeps the affected arm above the level of the heart which can help prevent stiffness of the affected arms shoulder joint in addition to promoting mobility and circulation, elevating cast with a fabric covered pillow provides support and reduces swelling, using a sling provides support and helps prevent fatigue from the weight of the cast, pt can apply ice to the cast for the first 24-48 hours to decrease edema and promote mobility

Interventions - neutropenia

limit visitors to healthy adults - minimizes the pt risk of exposure to infection, discourage fresh fruits and vegetables bc the skins of them can contain bacteria which can increase the risk for infection,

bronchial breath sounds

listen over the trachea, loud and high pitched sound

bronchovesicular breath sounds

listen to the anterior chest over the first and second intercostal spaces lateral to the sternum, medium intensity and medium pitched sound

vesicular breath sounds

listen to the anterior chest over the peripheral lung fields, soft and low pitched sound

hyperactive bowel sounds

more than 30 gurgles and clicks per minute

indicative of meningitis

nuchal rigidity

pt reports pain at fracture site during bucks traction

realign the pt - if body is out of alignment muscle spasms develop causing increased pain, do not remove weights without order or loosen ropes bc this can affect the weight applied to the traction

dehydrated pt caused by n/v

report heart rate of 120 bpm to provider which is elevated and indicates the pt therapy is not effective

post op discharge teaching for wound care

report purulent drainage to provider bc this is a sign of infection, administer an analgesic prior to wound care for discomfort, irrigate wound with sterile 0.9% sodium chloride irrigation, avoid using cotton tipped application to cleanse wound bc the fibers can become embedded in the wound causing infection and delaying wound healing

indicates psoriasis

round and reddish purple skin lesions

lab value to monitor for malnourishment

serum albumin

lab value to monitor for liver disorder

serum bilirubin, serum ammonia

lab value to monitor after MI

serum troponin - pt will have elevated serum troponin indicating myocardial damage, the level begins to elevate 4-6 hours after the MI and typically remains elevated for up to 10 days

indicates moles

skin lesions - small, brown and located randomly over the body

indicates melanoma

skin lesions - variegated color and irregular borders

epoetin alfa for kidney failure

stimulates the production of erythropoiten and RBC's, resulting in an increase hemoglobin level, hemoglobin level of 11 g/dL indicates effectiveness,

iv hematoma

swelling and bruising

iv infiltration

swelling and cool skin

nursing plan for blood transfusion

take the pt vital signs immediately before transfusion to get baseline and immediately after procedure for signs of transfusion reactions, obtain 0.9% sodium chloride to administer with blood, administer blood through tubing that has a filter specifically for blood products, 18 gauge needle is acceptable

manifestations of dehydration

tenting of skin/poor skin turgor, increased respiratory rate, urine output 20ml/hr (decreased urine output)

interventions for pt receiving intermittent enteral feedings through ng tube

test the ph of gastric contents to verify tube placement bc this is the most reliable nonradiologic method to verify placement, raise the head of the bead at least 30 degrees to reduce risk of aspiration, change feeding bag and tubing every 24 hour, check gastric residual volume every 4hr to ensure pt is tolerating and absorbing the feeding

pt teaching for testicular self examination

testicular cancer is typically painless therefore pt should report any lump that is not painful, perform exam after warm shower, do exam monthly, consider pea sized lumps an unexpected funding and report to provider

indicates normal age related skin change

thick and scaly skin lesions

metoclopramide

treatment for gastroesophageal reflux, administer 30 min prior to meals and at bedtime

physical changes from cushing's syndrome

truncal obesity due to redistribution of fat,

prevent skin breakdown

use tepid water with mild soap

pt teaching about genital herpes

viral shedding and spreading of the infection can occur even when lesions are not present, avoid sexual activity when lesions are present bc lesions can occur anywhere in the perineal area and condoms will not provide adequate protection, genital herpes lesions have a vesicular appearance and occur in clusters, its incurable and recurring viral disease

nurse role when checking othostatic hypotension

wait 3-5 mins after the pt changes positions before getting the next blood pressure reading, check for systolic decrease of at least 10-15 mm Hg after the pt sits at the side of the bed, observe for a heart rate increase of 10/min, leave blood pressure cuff on pt to maintain the cuff in the same position for each blood pressure check

abdominal bruit auscultation

whooshing sound that indicates impaired blood flow through an artery