HESI Medical-Surgical Nursing PDF

MEDICAL-SURGICAL NURSING HESI HINTS Communication ​ Hint: The SBAR format is used in many institutions during communication processes with other nurses, health care providers, physical therapists, social workers, pharmacists, laboratory technicians, etc. SBAR stands for Situation,...

MEDICAL-SURGICAL NURSING HESI HINTS Communication ​ Hint: The SBAR format is used in many institutions during communication processes with other nurses, health care providers, physical therapists, social workers, pharmacists, laboratory technicians, etc. SBAR stands for Situation, Background, Assessment, and Recommendations. ​ Hint: Nonverbal communication may be more important than verbal communication. Body language, use of personal space, and verbal/oral messages should be congruent. Tone of voice and facial expression are part of body language. An example of positive body language is leaning in toward a client while talking. Recognition of cultural differences regarding personal space is an important component of communication. Most Americans maintain half a meter (1.7 or 11⁄2 feet) distance between people when talking. Body language and verbal/oral communication should also be congruent; state messages in a positive manner even when providing negative feedback. ​ Hint: Clear verbal communication and accurate written records are critical during care transitions. Care transitions include such times as changes of shift, when the client moves from unit to unit, or when the client moves to a new care setting. ​ Hint: Therapeutic communication is necessary in eliciting important information from clients and their families in all nursing interventions and settings, including crisis intervention, cultural awareness/cultural influences on health, religious and spiritual influences on health, family dynamics, and sensory alterations. Health Promotion and Disease Prevention ​ Hint: Changing unhealthy behaviors can modify or even prevent some chronic illnesses. Nurses play a major role in helping clients manage their chronic illnesses and disabilities through behavioral changes. Health teaching and counseling often are the role of the nurse in helping the client focus on improving health habits. ○​ Areas of behavioral change include ​ 1. Physical activity ​ 2. Nutrition ​ 3. Stress ​ 4. Use of tobacco or marijuana ​ 5. Use of alcohol ​ 6. Spiritual perspective ​ 7. Coping skills ​ 8. Support systems ​ Hint: According to the American Lung Association, smoke is harmful to lung health. Burning wood, tobacco, or marijuana releases toxins and carcinogens. Teaching/Learning ​ Hint: To develop a collaborative learning environment between the nurse and the client, nurses must be acutely aware of their own beliefs and values about the teaching–learning process, including client empowerment. Spiritual Assessment ​ FICA: Taking a Spiritual History ○​ Faith, Belief, Meaning: Do you consider yourself spiritual or religious? Do you have spiritual beliefs that help you cope with stress? If the client says no, ask, “What gives your life meaning?”  ○​ Importance: Have your beliefs influenced how you take care of yourself? How does faith or beliefs have a significance in your life? Have your beliefs influenced how you take care of yourself in this illness/situation? ○​ Community: Are you part of a spiritual or religious community? Is this of support to you and, if so, how? Is there a group of people (communities such as friends, church, temple, synagogue, mosque, or support group)? ○​ Address in care: How would you like your nurse to address these issues in your health care? Cultural Diversity ​ Hint: Since the 2000 census, there has been a notable change in the cultural, ethnic, and racial alignment of the United States. Culture influences how clients seek medical attention or treat themselves. Complementary and Alternative Interventions ​ Hint: Reasons why clients use herbal medications: ○​ Cultural influence ○​ Perception that supplements are safer and “healthier” than conventional drugs ○​ Sense of control over one’s care ○​ Emotional comfort from taking action ○​ Limited access to professional care ○​ Lack of health insurance ○​ Convenience ○​ Media hype and aggressive marketing ○​ Recommendation from family and friends Respiratory System Pneumonia ​ Hint: Pneumonia affects people of all ages, especially those 65 or older and infants under age 2 (because their immune systems are still developing). ​ Assessment (important/hallmarks): ○​ Tachypnea ○​ Productive cough with pleuritic pain ○​ Rapid, bounding pulse ○​ Elevated WBC ○​ ABG indication of hypoxemia ​ Hint: Increased temperature also increases metabolism and the demand for O2. Fever can also cause dehydration because of excessive fluid loss due to diaphoresis. ​ Hint: Clients at High Risk for Pneumonia ○​ Altered level of consciousness ○​ Brain injury ○​ Depressed or absent gag and cough reflexes ○​ Susceptible to aspirating oropharyngeal secretions, including alcoholics, anesthetized individuals ○​ Drug overdose ○​ Stroke victims ○​ Immunocompromised ​ Interventions (main ones) ○​ Assess sputum (volume, color, consistency, clarity, and odor) ○​ Assist client to cough productively ○​ Provide fluids up to 3 L/day unless contraindicated (helps liquefy lung secretions). ○​ Assess lung sounds before and after coughing. ○​ Assess respirations (rate, depth, and pattern) ​ Hint: Bronchial breath sounds are heard over areas of density or consolidation. Sound waves are easily transmitted over consolidated tissue. ​ Hint: Hydration ○​ Thins out the mucus trapped in the bronchioles and alveoli, facilitating expectoration ○​ Is essential for client experiencing fever ○​ Is important because 300 to 400 mL of fluid is lost daily by the lungs through evaporation ​ Hint: Irritability and restlessness are early signs of cerebral hypoxia; the client’s brain is not receiving enough O2. ​ Hint: Pneumonia Preventives ○​ Older adults: annual flu vaccinations; pneumococcal vaccination at age 65 or older and younger clients who are at high risk. (Repeat vaccinations may be recommended; avoiding sources of infection and indoor pollutants (dust, smoke, and aerosols); no smoking ○​ Immunosuppressed and debilitated persons: annual flu vaccinations, pneumonia vaccination, avoid infections, sensible nutrition, adequate fluid intake, appropriate balance of rest and activity ○​ Comatose and immobile persons: elevation of head of bed at least 30 degrees for feeding and for 1 hour after feeding; turn frequently. ○​ Clients with functional or anatomic asplenia: flu and pneumonia vaccinations ○​ Common Pattern: flu vaccine and stay away from infection (why make yourself more sick lol) Chronic Airflow Limitation ​ Includes Chronic Bronchitis, Pulmonary Emphysema and Asthma ​ Hint: Exposure to tobacco smoke is the primary cause of COPD in the United States. ​ Hint: ○​ Compensation occurs over time in clients with chronic lung disease, and ABGs are altered. ○​ As COPD worsens, the amount of O2 in the blood decreases (hypoxemia) and the amount of carbon dioxide (CO2) in the blood increases (hypercapnia), causing chronic respiratory acidosis (increased arterial PCO 2), which results in kidneys retaining bicarbonate (HCO3) as compensation. ○​ Not all clients with COPD are CO2 retainers, even when hypoxemia is present, because CO2 diffuses more easily across lung membranes than O2. ○​ In advanced emphysema, due to the alveoli being affected, hypercarbia is a problem, rather than in bronchitis, where the airways are affected. ○​ It is imperative that baseline data be obtained for the client. ​ Hint: Productive cough and comfort can be facilitated by semi-Fowler or high-Fowler position, which lessens pressure on the diaphragm by abdominal organs. Gastric distention becomes a problem in these clients because it elevates the diaphragm and inhibits full lung expansion. ​ ABG Values ○​ pH: 7.35 - 7.45 ○​ PCO2: 35-45 mmHg ○​ PO2: 80-100 mmHg ○​ HCO3: 21-28 mEq/L ​ Chronic Bronchitis ○​ Path: Chronic sputum with cough production on a daily basis for a minimum of 3 months in each of 2 consecutive years ○​ Higher incidence in smokers ○​ Assessment ​ Generalized cyanosis ​ “Blue Bloaters” – nails ​ Right HF ​ Distended neck veins ​ Crackles ​ Expiratory wheezes ○​ Intervention ​ Lowest FiO2 to prevent CO2 retention ​ Maintain PO2 between 55 and 60 ​ S/S of fluid overload ​ Pursed lip breathing and diaphragmatic breathing ​ Tripod positioning ​ Bronchodilators and antiinflammatory agents ​ Emphysema ○​ Assessment ​ “Pink Puffers” ​ Barrel Chest ​ Pursed Lip Breathing ​ Pulmonary blebs on radiograph ○​ Intervention ​ Same as Chronic Bronchitis ​ Asthma ○​ Assessment  ​ Dyspnea, wheezing, chest tightness ​ Assess precipitating factors (what triggered the asthma attack – allergies, stress, environment, exercise) ○​ Intervention ​ Administer bronchodilators (BFF: albuterol) ​ Education (causes, medication regimen) ​ Hint: Overinflation of the lungs causes the rib cage to remain partially expanded, giving the characteristic appearance of a barrel chest. The person works harder to breathe, but the amount of O2 taken in is not adequate to oxygenate the tissues. Insufficient oxygenation occurs with chronic bronchitis and leads to generalized cyanosis and often right-sided heart failure (HF; known as cor pulmonale). ​ Hint: Cells of the body depend on O2 to carry out their functions. Inadequate arterial oxygenation is manifested by cyanosis and slow capillary refill (4 L/min or delivered directly to the trachea. If given at 1 to 4 L/min or by mask or nasal prongs, the oropharynx and nasopharynx provide adequate humidification. Cancer of the Larynx ​ Hint: With cancer of the larynx, the tongue and mouth often appear white, gray, dark brown or black and may appear patchy. ​ Hint: Tracheostomy care involves cleaning the inner cannula, suctioning, and applying clean dressings. ○​ Key Points ​ Suction ​ Suction when adventitious breath sounds are heard, secretions at endotracheal tube, and gurgling sounds ​ Aseptic/sterile technique ​ Never suction >10 to 15 seconds, pass the catheter only three or fewer times ​ Oxygenate with 100% O2 for 1 to 2 minutes before and after to prevent hypoxia ​ Hint: Air entering the lungs is humidified along the nasobronchial tree. This natural humidifying pathway is gone for the client who has had a laryngectomy. If the air is not humidified before entering the lungs, secretions tend to thicken and become crusty.  ​ Hint: A laryngectomy tube has a larger lumen and is shorter than the tracheostomy tube. Observe the client for any signs of bleeding or occlusion, which are the greatest immediate postoperative risks (first 24 hours). ​ Hint: Always have suction equipment available at the bedside for new and chronic tracheostomy clients. ​ Hint: Fear of choking is very real for laryngectomy clients. They cannot cough as compared to previously because the glottis is no longer present. Teach the glottal stop technique to remove secretions (take a deep breath, occlude the tracheostomy tube momentarily, cough, and simultaneously remove the finger from the tube). ​ Intervention ○​ PreOp ​ Allow client and family to observe and handle tracheostomy tubes and suctioning equipment. ​ Explain how and why suctioning will take place after surgery. ​ Plan for acceptable communication methods after surgery. ○​ PostOp ​ Simple communication ​ Keep call light within reach ​ Ask yes/no questions ○​ Promote respiratory functioning ​ Assess respiratory rate and characteristics every 1 to 2 hours. ​ Keep bed in semi-Fowler position at all times. ​ Keep laryngeal airway humidified at all times. ​ Auscultate lung sounds every 2 to 4 hours. Pulmonary Tuberculosis ​ Assessment ○​ Often Asymptomatic ○​ Fever with night sweats ○​ Cavitation or calcification as evidenced on chest radiograph ○​ Positive sputum culture is positive for M. tuberculosis ○​ Recurring upper respiratory infections (URIs) ​ Hint: Tuberculin skin test (TST) (also called the Mantoux test): A positive tuberculosis (TB) skin test in a healthy client is exhibited by an induration 10 mm or greater in diameter 48 to 72 hours after the skin test. Anyone who has received a bacillus Calmette-Guérin (BCG) vaccine will have a positive skin test and must be evaluated with an initial chest radiograph. A health history with signs and symptoms form may be filled out annually until signs and symptoms arise; then another radiograph is required. Chest x-rays are required on new employment; employer may require an x-ray every 5 years depending on exposure risk. CDC guidelines indicate that the QuantiFeron-TB Gold test, a new blood test, is more reliable for TB skin testing. Nucleic acid amplification (NAA) testing may be recommended when a client has signs and symptoms of TB. TST in clients who have received BCG vaccination may cause a false-positive reaction to the TST, which may complicate decisions about prescribing treatment. ​ Intervention ○​ Teaching ​ Cough into tissues and dispose of immediately into biohazardous waste bags. ​ Take all medications as prescribed daily for a minimum of 9 to 12 months. It is essential that the client take the medications as prescribed for the entire time. Skipping doses or prematurely terminating the drug therapy can result in a public health hazard. ○​ Refer client and high-risk persons to local or state health department for testing and prophylactic treatment. ○​ Collect sputum cultures as needed; client may return to work after three negative cultures. Lung Cancer ​ Assessment: ○​ Persistent dry, hacking cough early, with cough turning productive as disease progresses ○​ Hemoptysis; rust-colored or purulent sputum ○​ Positive sputum for cytology and for pleural fluid ○​ Dyspnea ○​ Diminished breath sounds, occasional wheezing ​ Intervention ○​ Place client in semi-Fowler position. ○​ Teach pursed-lip breathing to improve gas exchange. ○​ Decrease pain to manageable level by administering analgesics as needed (within safety range for respiratory difficulty). ​ Hint: Some tumors are so large that they fill entire lobes of the lungs. When removed, large spaces are left. Chest tubes are not usually prescribed with these clients because it is helpful if the mediastinal cavity, where the lung used to be, is allowed to fill with fluid. This fluid helps to prevent the shift of the remaining chest organs to fill the empty space. ​ Hint: If the chest tube becomes disconnected, do not clamp! Immediately place the end of the tube in a container of sterile saline or clean water until a new drainage system can be connected. If the chest tube is inadvertently dislodged from the client, the nurse should cover with a dry sterile dressing taped on three sides. If an air leak is noted, tape the dressing on three sides only; this allows air to escape and prevents the formation of a tension pneumothorax. Notify the health care provider. ​ Hint: NCLEX-RN Content on Chest Tubes ○​ Fluctuations (tidaling) in the fluid will occur if there is no external suction. These fluctuating movements are a good indicator that the system is intact; they should move upward with each inspiration and downward with each expiration. If fluctuations cease, check for kinked tubing, accumulation of fluid in the tubing, occlusions, or change in the client’s position, because expanding lung tissue may be occluding the tube opening. When a chest tube is connected to suction, continuous bubbling is an indication of an air leak between the drain and the client. Renal System Acute Kidney Injury ​ Hint: Normally, kidneys excrete approximately 1 mL of urine per kg of body weight per hour. ○​ For adults, total daily urine output ranges between 1500 and 2000 mL depending on the amount and type of fluid intake, amount of perspiration, environmental or ambient temperature, and the presence of vomiting or diarrhea. ​ Hint: GFR is a test used to check how well the kidneys are working. Specifically, it estimates how much blood passes through the glomeruli each minute. Glomeruli are the tiny filters in the kidneys that filter waste from the blood. ​ Hint: Electrolytes are profoundly affected by kidney problems (a favorite NCLEX-RN topic). ○​ There must be a balance between extracellular fluid and intracellular fluid to maintain homeostasis. A change in the number of ions or in the amount of fluid will cause a shift in one direction or the other. Sodium and chloride are the primary extracellular ions. Potassium and phosphate are the primary intracellular ions. ​ Diagnostic findings in the oliguric phase ​ 1. Increased blood urea nitrogen (BUN) and creatinine ​ 2. Increased potassium (hyperkalemia) ​ 3. Decreased sodium (hyponatremia) ​ 4. Decreased pH (acidosis) ​ 5. Fluid overload (hypervolemic) ​ 6. High urine specific gravity (>1.020 g/mL) ​ Diagnostic findings in the diuretic phase ​ 1. Decreased fluid volume (hypovolemia) ​ 2. Decreased potassium (hypokalemia) ​ 3. Further decrease in sodium (hyponatremia) ​ 4. Low urine specific gravity (100 bpm) ​ 2. Bradycardia: slow rates ( 200 mg/dL ○​ Oral glucose tolerance test (OGTT) > 200 ​ Hyperglycemia ○​ Three P’s (Polydipsia, Polyuria, Polyphagia) ○​ Blurred vision ○​ Weakness ○​ Weight loss ○​ Syncope ​ Hypoglycemia ○​ Headache ○​ Nausea ○​ Sweating ○​ Tremors ○​ Lethargy ○​ Hunger ○​ Confusion ○​ Slurred speech ○​ Tingling around mouth ○​ Anxiety, nightmares ​ Hint: Why do clients with diabetes have trouble with wound healing? High blood glucose contributes to damage of the smallest vessels, the capillaries. This damage causes permanent capillary scarring, which inhibits the normal activity of the capillary. This phenomenon causes disruption of capillary elasticity and promotes problems such as diabetic retinopathy, poor healing of breaks in the skin, and cardiovascular abnormalities. ​ Hint: Glycosylated Hgb (HbA1c) ○​ Indicates glucose control over previous 90 to 120 days (life of red blood cells [RBCs]) ○​ Is a valuable measurement of diabetes control ○​ Informs diagnosis of diabetes and prediabetes ​ Hint: The body’s response to illness and stress is to produce glucose. Therefore, any illness results in hyperglycemia. ​ Hint: If in doubt whether a client is hyperglycemic or hypoglycemic, treat for hypoglycemia. ​ Hint: Teach self-monitoring of blood glucose (SMBG) ○​ Uses techniques that are specific to each meter ○​ Frequency of monitoring based on treatment regimen, change in meals, illness, and exercise regimen ○​ Requires recording results and reporting results to health care provider at time of visit ○​ Results of monitoring used to assess the efficacy of therapy and to guide adjustments in MNT, exercise, and medications to achieve the best possible blood glucose control Musculoskeletal System Rheumatoid Arthritis ​ Hint: A client comes to the clinic complaining of morning stiffness, weight loss, and swelling of both hands and wrists. Rheumatoid arthritis is suspected. Which methods of assessment might the nurse use, and which methods would the nurse not use? Use inspection, palpation, and strength testing. Do not assess range of motion (ROM); this activity promotes pain because ROM is limited. ​ Hint: In the joint, the normal cartilage becomes soft, fissures and pitting occur, and the cartilage thins. Spurs form and inflammation sets in. The result is deformity marked by immobility, pain, and muscle spasm. The prescribed treatment regimen is corticosteroids for the inflammation; splinting, immobilization, and rest for the joint deformity; and NSAIDs for the pain. Synovial tissues line the bones of the joints. Inflammation of this lining causes destruction of tissue and bone. Early detection of rheumatoid arthritis can decrease the amount of bone and joint destruction. Often the disease goes into remission. Decreasing the amount of bone and joint destruction reduces the amount of disability. Lupus Erythematosus ​ Hint: NCLEX-RN questions often focus on the fact that avoiding sunlight is key in the management of lupus erythematosus; this is what differentiates it from other connective tissue diseases. ​ Nursing Assessment ○​ Dry, scaly rash on face or upper body (butterfly rash) Osteoarthritis (OA) (Formally Known as Degenerative Joint Disease [DJD]) ​ Degeneration of cartilage, a wear-and-tear process ​ Occurs asymmetrically Osteoporosis ​ Classic dowager’s hump, or kyphosis of the dorsal spine ​ Hint: Postmenopausal, thin, white women are at highest risk for development of osteoporosis. Encourage exercise, a diet high in calcium, and supplemental calcium. Tums are an excellent source of calcium, but they are also high in sodium, so hypertensive or edematous individuals should seek another source of supplemental calcium. The main cause of fractures in older adults, especially in women, is osteoporosis. The main fracture sites seem to be hip, vertebral bodies, and Colles fracture of the forearm. ​ Hormone replacement therapy (HRT) has been used as primary prevention strategy for reducing bone loss in the postmenopausal woman. ​ Medications ○​ Bisphosphonates (Alendronate, -dronate) + Selective estrogen receptor modulator ​ Dual-energy x-ray absorptiometry (DEXA), which measures bone density in the spine, hips, and forearm, as a baseline after menopause. Fracture ​ Hint: An intracapsular fracture heals with greater difficulty, and there is a greater likelihood that necrosis will occur because the fracture is cut off from the blood supply. The risk for the development of a fat embolism, a syndrome in which fat globules migrate into the bloodstream and combine with platelets to form emboli, is greatest in the first 36 hours after a fracture. It is more common in clients with multiple fractures, fractures of long bones, and fractures of the pelvis. The initial symptom of a fat embolism is confusion due to hypoxemia (check blood gases for PO 2). Assess for respiratory distress, restlessness, irritability, fever, and petechiae. If an embolus is suspected, notify physician stat, draw blood gases, administer O2, and assist with endotracheal intubation. Clients with fractures, edema, or casts on the extremities need frequent neurovascular assessment distal to the injury. Skin color, temperature, sensation, capillary refill, mobility, pain, and pulses should be assessed. In clients with hip fractures, thromboembolism is the most common complication. Prevention includes passive ROM exercises, use of elastic stockings, elevation of the foot of the bed 25 degrees to increase venous return, and low-dose heparin therapy.  ​ Hint: Assess the 5 Ps: pain, paresthesia, pulse, pallor, and paralysis. ​ Hint: NCLEX-RN questions focus on safety precautions. Improper use of assistive devices can be very risky. When using a nonwheeled walker, the client should lift and move the walker forward and then take a step into it. The client should avoid scooting the walker or shuffling forward into it; these movements take more energy and provide less stability than does a single movement. Joint Replacement ​ Hint: Orthopedic wounds ooze more than other wounds. A suction drainage device usually accompanies the client to the postoperative floor. Check drainage often. ​ Hint: NCLEX-RN questions about joint replacement focus on complications. A big problem after joint replacement is infection. ​ Hint: Fractures of bone predispose the client to anemia, especially if long bones are involved. Check Hct every 3 to 4 days to monitor erythropoiesis. ​ Hint: After hip replacement, instruct the client not to lift the leg upward from a lying position or to elevate the knee when sitting. This upward motion can pop the prosthesis out of the socket ​ Hint: Immobile clients are prone to complications: skin integrity problems, formation of urinary calculi (client’s milk intake may be limited), and venous thrombosis (client may be on prophylactic anticoagulants). Amputation ​ Hint: The residual limb (stump) should be elevated on one pillow. If the residual limb (stump) is elevated too high, the elevation can cause a contracture. Neurosensory System Glaucoma ​ Hint: Glaucoma is often painless and symptom free. It is usually detected as part of a regular eye examination. ​ Hint: Eye drops are used to cause pupil constriction because movement of the muscles to constrict the pupil also allows aqueous humor to flow out, thereby decreasing the pressure in the eye. Pilocarpine is commonly used. Caution client that vision may be blurred for 1 to 2 hours after administration of pilocarpine and that adaptation to dark environments is difficult because of pupillary constriction (the desired effect of the drug). Cataract ​ Hint: When the cataract is removed, the lens is gone, making prevention of falls important. Remember that client safety is always the nurse’s priority. Eye Trauma ​ [text] Detached Retina ​ [text] Hearing Loss ​ Conductive Hearing Loss ○​ Hint: The ear consists of three parts: the external ear, the middle ear, and the inner ear. Inner ear disorders, or disorders of the sensory fibers going to the central nervous system (CNS), often are neurogenic in nature and may not be helped with a hearing aid. External and middle ear problems (conductive) may result from infection, trauma, or wax buildup. These types of disorders are treated more successfully with hearing aids. ​ Sensorineural Hearing Loss ○​ [text] ​ Hint: NCLEX-RN questions often focus on communicating with older adults who are hearing impaired. Neurologic System Altered State of Consciousness ​ Hint: Use of the Glasgow Coma Scale eliminates ambiguous terms to describe neurologic status, such as lethargic, stuporous, or obtunded. ​ Hint: Nursing care: A client with an altered state of consciousness is fed via enteral routes because the likelihood of aspiration is high with oral feedings. Residual feeding is the amount of previous feeding still in the stomach. The presence of 100 mL of residual in an adult usually indicates poor gastric emptying, and the feeding should be withheld; however, the residual should be returned because it is partially digested. ​ Hint: Paralytic ileus is common in comatose clients. A gastric tube aids in gastric decompression. ​ Hint: Any client on bed rest or immobilized must have ROM exercises often and very frequent position changes. Do not leave the client in any one position for longer than 2 hours. Any position that decreases venous return, such as sitting with dependent extremities for long periods, is dangerous. ​ Hint: Safety features for immobilized clients include the following: ○​ Prevent skin breakdown by frequent turning. ○​ Maintain adequate nutrition. ○​ Prevent aspiration with slow, small feedings or NG feedings or enteral feedings. ○​ Monitor neurologic signs to detect the first signs that ICP may be increasing. ○​ Provide ROM exercises to prevent deformities. ○​ Prevent respiratory complications; frequent turning and positioning provide optimal drainage. ​ Hint: Restlessness may indicate a return to consciousness but can also indicate anoxia, distended bladder, covert bleeding, or increasing cerebral anoxia. Do not oversedate and report any symptoms of restlessness. Head Injury ​ Hint: The forces of impact influence the type of TBI. They include acceleration injury, which is caused by the head being in motion, and deceleration injury, which occurs when the head stops suddenly. Helmets are a great preventive measure for motorcyclists and bicyclists ​ Hint: Even subtle behavior changes, such as restlessness, irritability, or confusion, may indicate increased ICP. ​ Hint: CSF leakage carries the risk for meningitis and indicates a deteriorating condition. Because of CSF leakage, the usual signs of increased ICP may not occur. ​ Mannitol - to dehydrate brain and reduce cerebral edema ​ Steroids - Dexamethasone (Decadron) ​ Hint: Try not to use restraints; they only increase restlessness. Avoid narcotics because they mask the level of responsiveness. Spinal Cord Injury ​ Hint: Physical assessment should concentrate on respiratory status, especially in clients with injury at C3 to C5, because the cervical plexus innervates the diaphragm. ​ Hint: It is imperative to reverse spinal shock as quickly as possible. Permanent paralysis can occur if a spinal cord is compressed for 12 to 24 hours. ​ Hint: Keeping the bladder emptied assists in avoiding bacterial growth in urine that has stagnated in the bladder. Brain Tumor ​ Hint: Benign tumors continue to grow and take up space in the confined area of the cranium, causing neural and vascular compromise in the brain, increased ICP, and necrosis of brain tissue. Even benign tumors must be treated because they may have malignant effects. ​ Hint: Corticosteroids to reduce swelling include the following: ○​ Agents and osmotic diuretics to reduce secretions (atropine, glycopyrrolate) ○​ Agents to reduce seizures (phenytoin) ○​ Prophylactic antibiotics Multiple Sclerosis (MS) ​ Hint: Symptoms involving motor function usually begin in the upper extremities with weakness progressing to spastic paralysis. Bowel and bladder dysfunction occurs in 90% of cases. MS is more common in women. Progression is not “orderly.” ​ Hint: Nursing implications for administration of these drugs should focus on the prevention of infection. Myasthenia Gravis ​ Nursing Assessment ○​ Diplopia (double vision), ptosis (eyelid drooping) ○​ Masklike affect: sleepy appearance due to facial muscle involvement ​ Hint: In clients with myasthenia gravis, be alert for changes in respiratory status; the most severe involvement may result in respiratory failure. ​ Hint: Myasthenic crisis is associated with a positive edrophonium (Tensilon) test, whereas a cholinergic crisis is associated with a negative test. Parkinson Disease ​ Tremor at rest, increased muscle tone (rigidity), slowness in the initiation and execution of movement (bradykinesia), and postural instability (difficulties with gait and balance) ​ Hint: NCLEX-RN questions often focus on the features of Parkinson disease: tremors (a coarse tremor of fingers and thumb on one hand that disappears during sleep and purposeful activity; also called “pill rolling”), rigidity, hypertonicity, and stooped posture. Focus: safety! ​ Hint: The pathophysiology involves an imbalance between acetylcholine and dopamine, so symptoms can be controlled by administering a dopamine precursor (levodopa). Guillain-Barre Syndrome ​ Preceded by a (viral) respiratory or GI infection 1 to 4 weeks Stroke/Brain Attack: Cerebral Vascular Accident ​ Hint: CNS involvement related to cause of stroke includes the following: ○​ Hemorrhagic: caused by a slow or fast hemorrhage into the brain tissue; often related to HTN ○​ Embolic: 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). ​ Hint: Atrial flutter and fibrillation produce a high incidence of thrombus formation after dysrhythmia caused by turbulence of blood flow through all valves and heart. ​ 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 tries to cope with the stroke. Mood swings can be expected during the recovery period, and bouts of depression and tearfulness are likely.” ​ Hint: Words that describe losses in strokes include the following: ○​ 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 ​ Hint: Steroids are administered after a stroke to decrease cerebral edema and retard permanent disability. H2 inhibitors are administered to prevent peptic ulcers. Hematology and Oncology Anemia ​ Hint: Physical symptoms occur as a compensatory mechanism when the body is trying to make up for a deficit somewhere in the system. For instance, cardiac output increases when Hgb levels drop below 7 g/dL. ​ Hint: Use only normal saline to flush IV tubing or to run with blood. Never add medications to blood products. Two registered nurses should simultaneously check the physician’s prescription, the client’s identity, and the blood bag label. Leukemia ​ [text] Hodgkin Disease ​ Hint: Hodgkin disease is one of the most curable of all adult malignancies. Emotional support is vital. Career development is often interrupted for treatment. Chemotherapy renders many male clients sterile. May bank sperm before treatment, if desired. General Oncology Content ​ [text] Reproductive System Benign Tumors of the Uterus ​ Hint: Menorrhagia (profuse or prolonged menstrual bleeding) is the most important factor relating to benign uterine tumors. Assess for signs of anemia. Uterine Prolapse, Cystocele, and Rectocele ​ Hint: What is the anatomic significance of a prolapsed uterus? When the uterus is displaced, it impinges on other structures in the lower abdomen. The bladder, rectum, and small intestine can protrude through the vaginal wall. Cancer of the Cervix ​ Hint: Prevention: American College of Obstetricians and Gynecologists (ACOG) 2016 recommendations: Pap smears. In women aged 30 to 65 years, annual cervical cancer screening should not be performed (level A evidence). Clients should be counseled that annual well-woman visits are recommended even if cervical cancer screening is not performed at each visit. Every three years is the recommended time frame for Pap smears. Women ages 30 to 65 years should have a Pap smear with an HPV test every 5 years. Women over 65 do not need a Pap smear. Pap smears should not be performed for any woman under age 21 regardless of onset of sexual activity. Ovarian Cancer ​ Hint: The major emphasis in nursing management of cancers of the reproductive tract is early detection. Breast Cancer ​ Hint: The presence or absence of hormone receptors is paramount in selecting clients for adjuvant therapy. Testicular Cancer ​ Hint: Prevention: All males should do testicular self-examination (TSE) regularly at the same time every month after age 14. Cancer of the Prostate ​ [text] Sexually Transmitted Disease (STDs) ​ Hint: STDs in infants and children usually indicate sexual abuse and should be reported. The nurse is legally responsible to report suspected cases of child abuse. ​ Hint: Chlamydia is the most commonly reported communicable disease in the United States. ​ Hint: Complications - Pelvic inflammatory disease (PID) involves one or more of the pelvic structures. The infection can cause adhesions and eventually result in sterility. Manage the pain associated with PID with  analgesics. Bed rest in a semi-Fowler position may increase comfort and promote drainage. Antibiotic treatment is necessary to reduce inflammation and pain and should be effective for Neisseria gonorrheae and Chlamydia trachomatis. ​ Hint: A client comes into the clinic with a chancre on his penis. What is the usual treatment? IM dose of penicillin (such as benzathine penicillin G, 2.4 million units). Obtain a sexual history, including the names of his sex partners, so that they can receive treatment. Burns ​ Hint: Infection is a life-threatening risk for those with burns. ​ Hint: Preexisting conditions that might influence burn recovery are age, chronic illness (diabetes, cardiac problems, etc.), physical disabilities, disease, medications used routinely, and drug or alcohol abuse.