Key Concepts Med Surg 2024 PDF

Med Surg Review of Key Concepts Dr. Lopez 1 Spiritual Distress Example of spiritual distress is when clients state: "I do not understand why this happened to me" This indicates that the client is not accepting of the consequences of their health p...

Med Surg Review of Key Concepts Dr. Lopez 1 Spiritual Distress Example of spiritual distress is when clients state: "I do not understand why this happened to me" This indicates that the client is not accepting of the consequences of their health problems  Neutropenic Precautions No fresh fruit or veggies (intestinal growth) No flowers Limit visitors Enforce strict handwashing Visitors must wear masks and gloves Watch for s/s infection Assess lab values, temperature No rectal temperatures, suppositories, or enemas Avoid urinary catheters Use soft toothbrush (mouth is most frequent site of infection Skin examinations (skin is major protective measure) Michele Lopez, MA, RN, CH ES,CDE, CNE  Bleeding Precautions Use of soft toothbrush and brush gently Foam swabs if platelet count is low Report bleeding gums Use only electric razors Minimize lab draws and IM’s, apply pressure to all needle sticks for 3-5 minutes Report bruising, rashes, bleeding Check urine, stool for hidden blood Avoid constipation Use with caution/avoid drugs containing ASA or anticoagulants Michele Lopez, MA, RN, CH ES,CDE, CNE Bleeding precautions Bleeding precautions are recommended for clients with a platelet count of less than 50,000/mm3. A few Key Concepts….. Pernicious Anemia Risk factors: Positive family history. For a client with pernicious anemia, the nurse emphasizes the importance of lifelong administration of vitamin B12. The nurse will teaches the client or a family member of the proper method to administer vitamin B12 injections. Aplastic Anemia: estrogen and progesterone used to stimulate bone growth hemolytic anemia: decreased RBC, increased bilirubin, decreased hemoglobin and hematocrit, increased reticulocytes Splenectomy: clients now at risk for increased infection DIC: Alteration in tissue perfusion related to bleeding and diminished blood flow, Heparin is used to prevent clot formation. Stem Cell: Induction therapy places the client at risk for infection, thus this is the priority nursing diagnosis. During the time of induction therapy, the client is very ill, with bacterial, fungal, and occasional viral infections. Multiple Myeloma Decreased bone density Clients with multiple myeloma are at risk for pathologic bone fractures secondary to diffuse osteoporosis and osteolytic lesions. Hypercalcemia may result when bone destruction occurs due to the disease process. Orders will include Calcium replacement therapy. Medical Math 1.Order: Units/hour and the nurse must calculate ml/hour to infuse 2.Range questions Xmg/kg/day. Convert weight to KG, determine the amount of dosage (note the time frame) 3.CBI calculations (Amount in drainage bag – amount of CBI irrigant = urine output).  Leukemia: Summary Malignancy of blood forming tissues Bone marrow produces increased numbers of immature wbc’s (can’t protect the body) The increased numbers of WBC’s crowd the other cells in bone marrow…. decreased rbc and platelets Michele Lopez, MA, RN, CH ES,CDE, CNE  Leukemia: Summary ↓ RBC = anemia : fatigue, pallor, malaise, tachycardia and tachypnea ↓ Platelets= HR bleeding: petechaie, ecchymosis, epistaxis, melena, gingival bleeding, menstrual flow heavy Leukemia: s/s all of the above and weight loss, night sweats, swollen lymph nodes Dr. Lopez 10  Leukemia: Signs and Symptoms Fever or chills Persistent fatigue, weakness Frequent or severe infections Losing weight without trying Swollen lymph nodes, enlarged liver or spleen Easy bleeding or bruising Recurrent nosebleeds Tiny red spots in your skin (petechiae) Excessive sweating, especially at night Bone pain or tenderness Dr. Lopez 11  Nursing Assessment: Leukemia Cardiovascular changes Respiratory changes Skin changes Intestinal changes Central Nervous system changes Musculoskeletal changes Extreme Fatigue Dr. Lopez  Leukemia need education and support, no ASA (when platelets are low) Bleeding: delayed clotting you’ll need to apply prolonged pressure to needle sites or other sources of bleeding Low neutrophils: monitor for infection Dr. Lopez 13 Leukemia Assess educational needs Assess WBC, RBC, platelets, (if not within normal ranges, prepare for bleeding precautions, infection control precautions, stool softners to avoid straining, etc) (refer to class notes) Bleeding precautions – nurse to prepare to apply prolonged pressure to needle sites or other external sources of bleeding. Delayed clotting means client is more prone to bleeding (to decreased platelets with leukemia).  Nursing Assessment: Leukemia Psychosocial Assessment: anxious, fearful Boredom, loneliness, isolation, financial distress Dr. Lopez  Leukemia: Classification Leukemia is classified based on its speed of progression and the type of cells involved. The first type of classification is by how fast the leukemia progresses: Acute leukemia. In acute leukemia, the abnormal blood cells are immature blood cells (blasts). They can't carry out their normal functions, and they multiply rapidly, so the disease worsens quickly. Acute leukemia requires aggressive, timely treatment. Chronic leukemia. There are many types of chronic leukemias. Some produce too many cells and some cause too few cells to be produced. Chronic leukemia involves more-mature blood cells. These blood cells replicate or accumulate more slowly and can function normally for a period of time. Some forms of chronic leukemia initially produce no early symptoms and can go unnoticed or undiagnosed for years. The second type of classification is by type of white blood cell affected: Lymphocytic leukemia. This type of leukemia affects the lymphoid cells (lymphocytes), which form lymphoid or lymphatic tissue. Lymphatic tissue makes up your immune system. Myelogenous leukemia. This type of leukemia affects the myeloid cells. Myeloid cells give rise to red blood cells, white blood cells and platelet-producing cells. Dr. Lopez 16  Leukemia: More About Acute Rapid onset Must be treated quickly for good prognosis DX: (usually decreased H &H, low platelets, abnormal WBC, CBC, Bone marrow biopsy/aspiration, lumbar puncture-to determine if malignant cells are in the CNS (Bone Marrow Biospy: place patient side lying with the knees flexed (iliac crest usually site for bone marrow aspiration) Management includes: Diet: bland, ↑ protein, ↑ carb Radiation and chemo to destroy bone marrow Addressing the HR for infection and death as healthy cells in bone marrow are destroyed Dr. Lopez 17  Nursing Management of Patient diagnosed with Leukemia Pain management Bleeding: Monitor platelet counts, bleeding precautions Infection: Neutropenic Precautions Good handwashing, teach visitors about handwashing Oral care: (oral mucosa gets irritated) ***Chemo ↓ wbc … may stop formation of pus so infection can manifest with edema, erythema, pain Safety: Psychosocial: Dr. Lopez  Interventions for Patients with Leukemia Drug therapy: Induction, consolidation, maintenance therapy. Hematopoietic stem cell transplantation aka bone marrow transplantation Chemo and radiation Blood transfusions, nutrition therapy (supportive) Michele Lopez, MA, RN, CH ES,CDE, CNE  Lymphoma: Hodgkin’s and non- Hodgkin’s Both Hodgkin's lymphoma and non-Hodgkin's lymphoma are lymphomas — a type of cancer that begins in a subset of white blood cells called lymphocytes. Lymphocytes are an integral part of your immune system, which offer protection from microorganisms. The main difference between Hodgkin's and non- Hodgkin's lymphoma is in the specific lymphocyte each involves. The presence of a specific type of abnormal cell called a Reed-Sternberg cell, the lymphoma is classified as Hodgkin's. If the Reed-Sternberg cell is not present, the lymphoma is classified as non-Hodgkin's. Dr. Lopez  Multiple Myeloma Risk of injury: decreased bone density Clients have Hypercalcemia. Calcium replacement therapy is needed as calcium is being released from the bone (pathologic fractures). 24 Hour urine, Bence Jones Protein Dr. Lopez 21 Multiple Myeloma: complications Frequent infections. Myeloma cells inhibit the body's ability to fight infections. Bone problems. Multiple myeloma can also affect the bones, leading to bone pain, thinning bones and broken bones (pathological fractures). Administer bone-building drugs to help prevent bone loss. Bone pain. Pain medications, radiation therapy and surgery may help control bone pain. Reduced kidney function. Multiple myeloma may cause problems with kidney function, including kidney failure. dialysis Low red blood cell count (anemia). As myeloma cells crowd out normal blood cells, multiple myeloma can also cause anemia and other blood problems. Administer medications to increase the red blood cell count.  Multiple Myeloma Hypercalcemia: Bone Marrow Biospy Urine tests. Analysis of the urine may show M proteins, which are referred to as Bence Jones proteins when they're detected in urine (24 hour urine specimen). X-rays: Multiple myeloma presents as the classic “punched out” lytic lesions on radiographs Dr. Lopez 23  MDS: Complications Anemia. Reduced numbers of red blood cells can cause anemia, which can make you feel tired. Recurrent infections. Having too few white blood cells increases your risk of serious infections. Bleeding that won't stop. Lacking platelets in your blood to stop bleeding can lead to excessive bleeding. Increased risk of cancer. Some people with myelodysplastic syndromes might eventually develop a cancer of the bone marrow and blood cells (leukemia) Dr. Lopez 24  Bone Marrow Aspiration Review the procedure for bone marrow aspiration in the text Consider the nurses role: How to prepare the client for the procedure Pre and post care Purpose of bone marrow aspiration (client education). M. Lopez - NUR215 25  Bleeding Precautions More prone to bleeding: apply prolonged pressure to needle sites or other external sources of bleeding (leukemia). M. Lopez - NUR215 26  Tumor Lysis Syndrome https://jamanetwork.com/journals/ja maoncology/fullarticle/2680750 M. Lopez - NUR215 27  Tumor Lysis Syndrome M. Lopez - NUR215 28  Blood disorders in general: Monitor for: Bleeding, fatigue, fainting, infection Increase in BANDS: s/s of infection Bleeding precautions: platelet count is less than 50,000/mm3 Thrombocytopenia can result from a decreased platelet production, increased platelet destruction, or increased consumption of platelets Sulfa-containing medications and aspirin- based or other NSAIDs alter platelet function. Dr. Lopez 29  Anemia: The nurse should assist the client when ambulating to prevent a fall because the client who has anemia can experience dizziness. The nurse should monitor oxygen saturation when the client has anemia due to the decreased carrying capacity of the blood. The nurse should weigh the patient daily rather than weekly, as there could be fluid retention due to cardiac complication, and an inability to take in food due to weakness associated with low oxygen levels can result in weight loss. The patient will require rest periods because of reduced oxygen levels and it is important to test30 Dr. Lopez stool to identify any GI bleeding.  Iron Deficiency Anemia Iron will cause the stools to become dark in color. Iron should be taken on an empty stomach, as its absorption is affected by food, especially dairy products. Clients should be instructed to increase their intake of vitamin C to enhance iron absorption. Foods high in fiber should be consumed to minimize problems with constipation, a common side effect associated with iron therapy. Dr. Lopez 31 Iron Deficiency Anemia S/S: bleeding, fatigue, fainting Iron replacement: if liquid sip the medication through a straw, constipation, dark tarry stool, stool for occult, administer with vit c rich foods to increase absorption, if parenteral iron administration use the Z-track technique to administer the medication. Dairy reduces absorption. Vit B12 deficiency Clinical manifestation is a red, beefy tongue of Vit B12 deficiency. The vitamin B12–intrinsic factor complex is absorbed in the distal ileum. Clients who have had a partial or total gastrectomy may have limited amounts of intrinsic factor, and therefore the absorption of vitamin B12 may be diminished  Sickle Cell Sickle cell disease is a common genetic disorder found primarily in African Americans but also in people from Mediterranean and Middle Eastern countries Sickle-shaped red blood cells clump together in a blood vessel, which causes occlusion, ischemia, and extreme pain. Management: O2 for the ischemia. Management of extreme pain, fluids for hydration, psychosocial support. Dr. Lopez 34 Sickle Cell Administer oxygen is priority during crisis. Prevention of crisis: Ensure adequate hydration Complications include: Cerebral vascular accidents, MI, priapism, hemarthrosis Sickle cell A&P: sickled cells have 15 day lifespan In sickle cell crisis, sickle-shaped red blood cells clump together in a blood vessel, which causes occlusion, ischemia, and extreme pain (Acute pain) Sickle cell disease is a common genetic disorder found primarily in African Americans but also in people from Mediterranean and Middle Eastern countries.  Pernicious Anemia Risk: familial predisposition Pernicious anemia: lifelong administration of vitamin B12 Red, beefy tongue. The vitamin B12–intrinsic factor complex is absorbed in the distal ileum. Lack of intrinsic factor by the parietal cells of gastric mucosa. Absorption of Vit B12 is affected. Clients who have had a partial or total gastrectomy may have limited amounts of intrinsic factor, and therefore the absorption of vitamin B12 may be diminished Dr. Lopez 36  Aplastic Anemia Bone marrow elements are suppressed (RBC, Leukocytes, Platelets). Estrogen and Progesterone can be used as part of a treatment plan to stimulate bone growth. Dr. Lopez 37  Hemolytic Anemia Decreased RBC as a result of the excessive destruction of RBC’s Decrease in H&H The destruction causes elevated bilirubin levels. M. Lopez - NUR215 38 Hemophilia Management of hemarthrosis: ice to the affected area, elevate the extremity, immobilize the extremity  Hemophilia Two X-linked inherited bleeding disorders (males > females) – Hemophilia A Genetic defect resulting in deficient or defective factor VIII 1 of 5000-7000 births 5X more common than Hemophilia B Tendency for bleeding based on severity – Severe - plasma factor activity level < 1 IU/dL for deficient, or < 1% for normal factor VIII levels – Moderate - 1–5 IU/dL or factor VIII level between 1% and 5% of normal – Mild - above 5 IU/dL or factor VIII level above 5% – Hemophilia B (Christmas Disease) Genetic defect that causes deficient or defective factor IX  Hemophilia Clinical Manifestations – Hemorrhage into various body parts with severe to minimal trauma – Usually bleed into joints – Bruising, hematomas, hematuria or GIB Medical Management (active bleeding or pre- procedures) – Recombinant forms of factor VIII and X concentrates – 13% to 33% with hemophilia A, and 3% with hemophilia B, develop antibodies (inhibitors) to factors Immunosuppression therapy (e.g., cyclophosphamide, IVIG, prednisone) – Recombinant factor VIIa- (K-Centra) – Aminocaproic acid or desmopressin  Hemophili Nursing Management a – Coping skills, especially for children – Education Activity restrictions and self-care measures to reduce hemorrhage and bleeding complications Administration of factor concentrate at home at first sign of bleeding – Avoid agents that interfere with platelet aggregation aspirin, NSAIDs some herbal/nutritional supplements (e.g., chamomile, nettle, alfalfa) alcohol – Oral hygiene, applying pressure to small wounds, avoid injections – Wear a medical ID – Pain management with joint bleeds – Genetic testing and counseling  Blood Transfusion: Acute hemolytic transfusion reaction: The donor blood was incompatible with that of the client. Chronic Transfusions: Clients can quickly acquire more iron than they can use, leading to iron overload. Dr. Lopez 43  Blood Donation Autologous blood donation is useful for many elective surgeries where the potential need for transfusion is high. Review: universal donor, universal recipient, Dr. Lopez 44  Blood Transfusions: setting up Prime tubing of blood administration set with 0.9% NS solution, completely filling the filter. M. Lopez - NUR215 45 Blood Transfusions Safety: Identifying the patient! Stop the transfusion – if fever develops, any issues with breathing, chills, shortness of breath, nausea, excessive perspiration, vague sense of uneasiness (apprehension), chest tightness. Know Universal donor and universal recipient Setting up for transfusion: Prime tubing of blood administration set with 0.9% NS solution, completely filling the filter. Clients with chronic transfusion requirements can quickly acquire more iron than they can use, leading to iron overload. An acute hemolytic reaction occurs when the donor blood is incompatible with that of the recipient. febrile nonhemolytic reaction, antibodies to donor leukocytes remain in the unit of blood or blood component. An allergic reaction is a sensitivity reaction to a plasma protein within the blood component. Autologous blood donation is useful for many elective surgeries where the potential need for transfusion is high.  Blood Transfusions: Stop the Transfusion Difficulty Breathing, chest tightness, Vascular collapse, bronchospasm, laryngeal edema, shock, fever, chills, and jugular vein distension are severe reactions. The nurse should discontinue the transfusion immediately, monitor the client's vital signs, and notify the health care provider. The blood container and tubing should be sent to the blood bank. A blood and urine specimen may be needed if a transfusion reaction or a bacterial infection is suspected. The client's IV access should not be removed. Dr. Lopez 47  DIC Heparin is used to prevent clotting that is simultaneously occurring with bleeding. Client is at risk for altered tissue perfusion as clots cause obstruction of blood flow. D-Dimer Dr. Lopez 48 Disseminated Intravascular Coagulation (DIC) An underlying condition triggered by sepsis, trauma, cancer, shock, abruptio placentae, toxins, allergic reactions, and other conditions – Majority (2/3) initiated by infection or malignancy – Life threatening depending on severity Normal hemostatic mechanisms are altered Pathophysiology: – Response caused by underlying condition initiating inflammatory process and coagulation within the vasculature – Anticoagulant pathways (intrinsic and extrinsic) are simultaneously impaired – Fibrinolytic system is initially suppressed causing massive amounts of tiny clots form in microcirculation throughout body causing hypoperfusion Disseminate d Intravascula r Coagulation (DIC)  Clinical Manifestations – Bleeding mucous membranes, venipuncture and arterial lines, GI and urinary tracts, minimal to profuse Disseminat – Multi-Organ Dysfunction Syndrome- ed kidneys, lungs, CNS secondary to Intravascul thrombosis Diagnosis ar – Reduced platelet count Coagulation – Elevated D-dimer, – Increased PT and aPTT, (DIC) – Decreased fibrinogen level  Disseminated Intravascular Coagulation (DIC)  – Correct secondary effect of tissue ischemia: Improve oxygenation Replace fluids Correct electrolyte Dissemin imbalances Administer ated vasopressors – If hemorrhage, replace Intravasc depleted coagulation ular factors and platelets to reestablish potential for Coagulati normal hemostasis and on (DIC) reduce bleeding – Cryoprecipitate to replace fibrinogen and factors V and VII – Controversial, IV heparin may inhibit the formation of microthrombi and thus  Disseminated Intravascular Coagulation (DIC) Nursing Management – Assess for risk of DIC – Assess signs and symptoms of DIC – Follow lab values closely  Polycythemia Vera: Complications Blood clots. Increased blood thickness and decreased blood flow, as well as abnormalities in the platelets, raise the risk of blood clots. Blood clots can cause a stroke, a heart attack, or a blockage in an artery in your lungs or a vein deep within a leg muscle or in the abdomen. Enlarged spleen. The spleen helps your body fight infection and filter unwanted material, such as old or damaged blood cells. The increased number of blood cells caused by polycythemia vera makes your spleen work harder than normal, which causes it to enlarge. Problems due to high levels of red blood cells. Too many red blood cells can lead to a number of other complications, including open sores on the inside lining of your stomach, upper small intestine or esophagus (peptic ulcers) and inflammation in the joints (gout). Other blood disorders. In rare cases, polycythemia vera can lead to other blood diseases, including a progressive disorder in which bone marrow is replaced with scar tissue, a condition in which stem cells don't mature or function properly, or cancer of the blood and bone marrow (acute leukemia) Dr. Lopez 55  Splenectomy High Risk for infection Dr. Lopez 56 Head and Neck Tumors Frequently assess the client’s breath sounds (airway)  Oral Cancer Review text and notes: Risk factors Management of care Dr. Lopez 58  Esophageal Cancer Review text and notes: Risk factors Management of care *With surgical resection, the nurse must monitor breath sounds frequently – airway is priority (high risk for respiratory complications). Dr. Lopez 59 NCLEX Style Questions: Answer 1. A patient suffering incurable cancer is prescribed chemotherapy to relieve pain. This approach to therapy is: A. Palliative B. Heroic C. Optimistic D. Humane (Palliative means non curative, but to moderate the intensity of pain, to keep comfortable) NCLEX Style Questions 2. What does the patient undergoing radiation therapy need to know about the markings on the skin? A. Markings are permanent effects of radiation B. Markings should be protected as they are landmarks for treatment C. Markings are warning signs of serious side- effects D. Markings indicate that treatments are not successful NCLEX Style Questions: Answer 2. What does the patient undergoing radiation therapy need to know about the markings on the skin? A. Markings are permanent effects of radiation B. Markings should be protected as they are landmarks for treatment C. Markings are warning signs of serious side-effects D. Markings indicate that treatments are not successful NCLEX Style Questions 3. Two days after undergoing a modified radical mastectomy, a patient tells the nurse, “Now I won’t be sexually attractive to my husband.” Based on this statement which nursing diagnosis is most appropriate? A. Anxiety B. Body image disturbance C. Altered sexual pattern D. Ineffective individual coping NCLEX Style Questions: Answer 3. Two days after undergoing a modified radical mastectomy, a patient tells the nurse, “Now I won’t be sexually attractive to my husband.” Based on this statement which nursing diagnosis is most appropriate? A. Anxiety B. Body image disturbance C. Altered sexual pattern D. Ineffective individual coping NCLEX Style Questions 4. A patient is being discharged after undergoing abdominal surgery and colostomy formation to treat colon cancer. When planning for this patients discharge, which nursing action is most likely to promote continuity of care? A. Notifying the American Cancer Society of the patient’s diagnosis. B. Request Meals on Wheels to provide adequate nutrition intake C. Refer the patient to a home health nurse for follow-up visits to provide colostomy care D. Ask an occupational therapist to evaluate the patient at home NCLEX Style Questions: Answer 4. A patient is being discharged after undergoing abdominal surgery and colostomy formation to treat colon cancer. When planning for this patients discharge, which nursing action is most likely to promote continuity of care? A. Notifying the American Cancer Society of the patient’s diagnosis. B. Request Meals on Wheels to provide adequate nutrition intake C. Refer the patient to a home health nurse for follow-up visits to provide colostomy care D. Ask an occupational therapist to evaluate the patient at home NCLEX Style Questions 5. For a patient with newly diagnosed radiation-induced thrombocytopenia, the nurse should include which intervention in the plan of care? A. Administer aspirin if the temperature exceeds 102 B. Inspect the skin for petechiae once every shift C. Provide for frequent periods of rest D. Place the patient in strict isolation NCLEX Style Questions: Answer 5. For a patient with newly diagnosed radiation-induced thrombocytopenia, the nurse should include which intervention in the plan of care? A. Administer aspirin if the temperature exceeds 102 B. Inspect the skin for petechiae once every shift C. Provide for frequent periods of rest D. Place the patient in strict isolation (thrombocytopenia impairs blood clotting so we should look for signs of bleeding like petechiae, purpura, epistaxis, bleeding gums. Frequent rests are associated with anemia. Strict isolation for people with virulent infections, highly contagious via air or physical contact. NCLEX Style Questions 6. After cancer chemotherapy, a patient develops nausea and vomiting. For this patient, the nurse should give the highest priority to which action in the plan of care? A. Serve small portions of bland food B. Encourage rhythmic breathing exercises C. Administer metoclompramide (Reglan) and dexamethasone (Decadron) as prescribed D. Withhold foods and fluids for the first 4-6 hours after chemotherapy administration NCLEX Style Questions: Answer 6. After cancer chemotherapy, a patient develops nausea and vomiting. For this patient, the nurse should give the highest priority to which action in the plan of care? A. Serve small portions of bland food B. Encourage rhythmic breathing exercises C. Administer metoclompramide (Reglan) and dexamethasone (Decadron) as prescribed D. Withhold foods and fluids for the first 4-6 hours after chemotherapy administration (give antiemetic like raglan and anit-inflammatory like decadron. Prevents dehydration NCLEX Style Questions 7. A patient in the terminal stage of cancer is receiving a continuous infusion of morphine for pain management. Which assessment finding suggests an adverse effect of this drug? A. Voiding of 350ml of concentrated urine in 8 hours. B. Respiratory rate of 8 breaths/minute C. Irregular pulse rate of 82 beats/minute D. Constricted and equal pupils NCLEX Style Questions: Answer 7. A patient in the terminal stage of cancer is receiving a continuous infusion of morphine for pain management. Which assessment finding suggests an adverse effect of this drug? A. Voiding of 350ml of concentrated urine in 8 hours. B. Respiratory rate of 8 breaths/minute C. Irregular pulse rate of 82 beats/minute D. Constricted and equal pupils (respiratory depression with morphine. 350ml in 8 hours is dehydration, irregular pulse is cardiac problem. Pupils are noted to be normal. NCLEX Style Questions 8. The nursing diagnosis for a patient receiving external radiation to the left thorax for lung cancer is high risk for impaired skin integrity. Which intervention should be part of this patient’s plan of care? A. Avoid the use of soap on the irradiated areas B. Apply talcum powder to the areas after bathing C. Wear a lead apron when in direct contact with the patient D. Remove thoracic skin markings after each radiation treatment NCLEX Style Questions: Answer 8. The nursing diagnosis for a patient receiving external radiation to the left thorax for lung cancer is high risk for impaired skin integrity. Which intervention should be part of this patient’s plan of care? A. Avoid the use of soap on the irradiated areas B. Apply talcum powder to the areas after bathing C. Wear a lead apron when in direct contact with the patient D. Remove thoracic skin markings after each radiation treatment (radiation causes skin irritation. Clean with water only and leave open to air. Nothing applied. No apron necessary as no radiation source is present. Do not remove the markings. NCLEX Style Questions 9. Which of these findings is an early sign of bladder cancer? A. painless hematuria B. occasional polyuria C. nocturia D. dysuria NCLEX Style Questions: Answer 9. Which of these findings is an early sign of bladder cancer? A. painless hematuria B. occasional polyuria C. nocturia D. dysuria (cancer cells destroy normal bladder tissue. Bleeding occurs. Pain is a late symptom. Others not associated with bladder CA. NCLEX Style Questions 10. After cancer chemotherapy, a patient develops nausea and vomiting. For this patient, the nurse should give the highest priority to which action in the plan of care? A. Serve small portions of bland food B. Encourage rhythmic breathing exercises C. Administer metoclompramide (Reglan) and dexamethasone (Decadron) as prescribed D. Withhold foods and fluids for the first 4-6 hours after chemotherapy administration (give antiemetic like raglan and anit-inflammatory like decadron. Prevents dehydration NCLEX Style Questions: Answer 10. After cancer chemotherapy, a patient develops nausea and vomiting. For this patient, the nurse should give the highest priority to which action in the plan of care? A. Serve small portions of bland food B. Encourage rhythmic breathing exercises C. Administer metoclompramide (Reglan) and dexamethasone (Decadron) as prescribed D. Withhold foods and fluids for the first 4-6 hours after chemotherapy administration (give antiemetic like raglan and anit-inflammatory like decadron. Prevents dehydration NCLEX Style Questions 1. The nurse is evaluating the outcome of a pt with a nursing diagnosis of grieving r/t loss of right breast. Which of the following indicates that pt goal-“the pt will adjust to her altered breast appearance”- has been reached? A. The pt talks repeatedly about her surgical experience when the nurse enters the room B. The pt states the correct wound care procedure to use when she is d/c C. The pt looks at her incision and demonstrates proper wound care D. The pt states that she does not want to see her husband NCLEX Style Questions 1. The nurse is evaluating the outcome of a pt with a nursing diagnosis of grieving r/t loss of right breast. Which of the following indicates that pt goal-“the pt will adjust to her altered breast appearance”- has been reached? A. The pt talks repeatedly about her surgical experience when the nurse enters the room B. The pt states the correct wound care procedure to use when she is d/c C. The pt looks at her incision and demonstrates proper wound care D. The pt states that she does not want to see her husband NCLEX Style Questions 2. A pt with advanced cancer has been receiving chemotherapy and is now experiencing stomatitis. To promote comfort and nutrition while the pt’s mouth is sore, the nurse should plan to speak with the pt’s family about: A. Providing hot fluids, such as tea, and broth between meals. B. Brushing the pt’s teeth with a firm toothbrush C. Encouraging the pt to eat favorite Mexican foods D. Rinsing the pt’s mouth with diluted H2O2 every 2 hours. NCLEX Style Questions 2. A pt with advanced cancer has been receiving chemotherapy and is now experiencing stomatitis. To promote comfort and nutrition while the pt’s mouth is sore, the nurse should plan to speak with the pt’s family about: A. Providing hot fluids, such as tea, and broth between meals. B. Brushing the pt’s teeth with a firm toothbrush C. Encouraging the pt to eat favorite Mexican foods D. Rinsing the pt’s mouth with diluted H2O2 every 2 hours. NCLEX Style Questions 3. An 80-year-old male pt with lung cancer is scheduled for surgery. According to hospital policy, the pt’s dentures, hearing aid, rings, and other protheses must be removed. However, the pts insists on keeping his hearing aid. What should the nurse do? A. insist that the hearing aid be removed B. report this to the charge nurse C. leave the hearing aid in, but tell the operating room nurse that the aid is in place D. remove the hearing aid after performing preoperative care  NCLEX Style 3. An 80-year-old male pt with lung cancer is Questions scheduled for surgery. According to hospital policy, the pt’s dentures, hearing aid, rings, and other protheses must be removed. However, the pts insists on keeping his hearing aid. What should the nurse do? A. insist that the hearing aid be removed B. report this to the charge nurse C. leave the hearing aid in, but tell the operating room nurse that the aid is in place D. remove the hearing aid after performing preoperative care NCLEX Style Questions 4. When gathering data from a pt who is receiving external beam radiation for lung cancer, the nurse should focus on which finding? A. Dysphagia B. Fatigue C. Diarrhea D. Bruising NCLEX Style Questions 4. When gathering data from a pt who is receiving external beam radiation for lung cancer, the nurse should focus on which finding? A. Dysphagia B. Fatigue C. Diarrhea D. Bruising NCLEX Style Questions 5. The nursing is planning to teach a postmastectomy pt exercises to increase her shoulder mobility on the affected side. Which activity of daily living would best help to increase shoulder mobility? A. Tying a shoe B. Fastening a button C. Typing D. Brushing the hair NCLEX Style Questions 5. The nursing is planning to teach a postmastectomy pt exercises to increase her sholder mobility on the affected side. Which activity of daily living would best help to increase shoulder mobility? A. Tying a shoe B. Fastening a button C. Typing D. Brushing the hair  6. Which position is contraindicated when caring for a pt who has had a pneumonectomy for lung CA? A. Semi-Fowler’s B. Lying on nonoperative side C. Fowler’s D. Supine NCLEX Style Questions 6. Which position is contraindicated when caring for a pt who has had a pneumonectomy for lung CA? A. Semi-Fowler’s B. Lying on nonoperative side C. Fowler’s D. Supine NCLEX Style Questions 7. The nurse can evaluate the effectiveness of morphine sulfate when the pt demonstrates A. Restful sleep pattern B. Decreased pulse rate C. Decreased respiratory rate D. Change in cardiac rhythm NCLEX Style Questions 7. The nurse can evaluate the effectiveness of morphine sulfate when the pt demonstrates A. Restful sleep pattern B. Decreased pulse rate C. Decreased respiratory rate D. Change in cardiac rhythm Endocrine and Neuro Key Concepts Risk Factors for Neuro Injuries Age Gender (male higher risk) Risky behaviors (alcohol, drug use, motor cycle use, driving at night and in bad weather, and driving without seatbelts and driving without obeying laws of the road, young men driving, contact sports and sports without using proper safety equipment, diving, etc. Babinski Reflex Babinski Reflex (abnormal in adults) Left Plantar reflexes of the adult This is an abnormal finding and must be communicated to other health care professionals. In adults or children over 2 years old, a positive Babinski sign happens when the big toe bends up and back to the top of the foot and the other toes fan out. This can mean that the client has an underlying nervous system or brain condition that's causing your reflexes to react abnormally.  *Nurse to Know S/S Meningeal Irritation: Photophobia, nuchal rigidity, focal Kernig’s Sign deficits, and neurological Brudzinski’s Sign https://youtu.be/rJ-5AFuP3Y A https://youtu.be/jO9PAPi-yus With the patient supine, the physician places + Pt reports Back pain one hand behind the patient’s head and places the other hand on the patient’s chest. patient supine with hips The physician then raises the patient’s head (with the hand behind the head) while the hand and knees in flexion. on the chest restrains the patient and prevents the patient from rising. Extension of the knees is Flexion of the patient’s lower extremities (hips and knees) constitutes a positive sign. attempted: the inability to Brudzinski’s neck sign has more sensitive than Kernig’s extend the patient’s knees Reference: beyond 135 degrees Saberi, A., Syed, S. A. (1999). Meningeal signs: Kernig’s sign and Brudzinski’s Sign. Retrieved from without causing pain http://www.turner-white.com/pdf/hp_jul99_signs.pdf constitutes a positive test for Kernig’s sign (meningeal irritation) MLOPEZ MA RN CHES CDE CNE NIH Stroke Scale The patient may score 0-40 on this scale. 0 having no neurological deficits, and 40 being the most deficits Monroe-Kellie Exam States that because of limited space for expansion within the skull, an increase in any one of these components causes a decrease in volume of the other. (If one volume increase, another one will decrease to keep the pressure constant. For example if brain tissue becomes edematous, cerebral blood flow will decrease or CSF will be absorbed) Lumbar puncture Lumbar puncture is contraindicated in Increased ICP as there is increased risk for brain herniation The client is placed in a side-lying fetal position for the procedure Lumbar punctures allow for injection of select medications Complications associated with lumbar punctures: Infection Herniation of intracranial contents Neck stiffness headache EEG Nursing education for preparation of exam will include: Client may consume decaffeinated coffee the morning of the procedure Client is guided to avoid sleeping night before the exam Client is guided to avoid caffeine morning of exam Wash hair prior to exam and avoid using hair products (gels, hairsprays, etc). Glasgow Coma Scale (GCS) Glasgow Coma Scale (GCS) is used to gauge level of consciousness Assessing eye, motor, verbal Score of 15 is normal Lowest score possible is a 3 and the client is totally unresponsive Increased Intracranial Pressure (ICP) S/S: Alterations in LOC Restless and irritability Changes in pupils Glasgow Coma Scale (GCS) is used to gauge level of consciousness Lumbar puncture is contraindicated in Increased ICP as there is increased risk for brain herniation Mannitol (Osmitrol)- used to treat increased intracranial pressure. The nurse must carefully monitor for the development of heart failure and pulmonary edema (auscultate the client’s lungs). Traumatic Brain Injury Management of agitation- (guiding principle is least restrictive first) Tone of voice should be soft Consistency within the health care team is necessary Use simple 1-2 step commands/statements Nurses must be prepared to educate and support families of TBI clients that the client may experience changes in personality and cognitive abilities after head injuries Autonomic Dysreflexia (AD) Multiple noxious stimuli can trigger AD Constipation Spinal cord injury (SCI) above T6 Urinary catheter is occluded (patient is sitting on the catheter, tube gets stuck in the rails of the bed, etc.  Autonomic Dysreflexia (AD) - Usually found only in patient with SCI above T6 - Occurs after spinal shock has passed - Results in normal loss of compensatory mechanisms when sympathetic nervous system is stimulated - Cause: Irritation, pain or stimulus below level of injury Examples: full bladder*, constipation (fecal impaction)**, pressure ulcers, etc - Life-threatening reflex activity- BP rises and can result in cerebral hemorrhage and death (BP can go as high as 300/160) Professor Michele L. Lopez, DHED, MA, RN, CHES, CDE  Pathophysiology AD The stimulus sends nerve impulses to the spinal cord- travels up until it reaches the lesion and but they are blocked This initiates reflex activity of the SC- sympathetic portion of ANS is stimulated Narrowing of blood vessels – constriction- elevated BP Nerve receptors in heart and blood vessels detect rise in BP, and send a message to the brain Brain sends message to heart- bradycardia and only blood vessels above level of injury dilate Brain cannot send messages below level of SCI- BP remains elevated Symptoms: (vasodilation) :sudden, severe headache, hypertension, bradycardia, sweating & flushing above level of lesion (vasoconstriction): pale, cool, clammy skin of extremities below lesion Professor Michele L. Lopez, DHED, MA, RN, CHES, CDE  Nursing Interventions AD Elevate HOB to 90 degrees (causes orthostatic hypotension thus lowering BP) Lower legs Remove tight clothing: (abd binder, support hose/venodynes) Monitor BP Assess patient to find the stimuli/irritation Remove the stimulus once identified Medications only if unable to find stimulus or it persists: nitropaste or *Nitroglycerine (Not if patient took Viagra or Cialis), Hyperstat (diazoxide), Procardia (nifedipine), Catapres (clonidine), Apresoline (hydralazine) Professor Michele L. Lopez, DHED, MA, RN, CHES, CDE  Nursing Interventions AD (con’t) Assess Bladder * (retention, bladder distention, urinary tract infection, blocked catheter or kinked catheter) Assess Bowel – rectal exam for impaction (distended bowel, constipation , hemorrhoids or anal infections) Assess skin condition , pressure sores , ingrown toenails, burns (including sunburn) Remove tight or restrictive clothing Assess BP q 2-3 minutes (or check after stimulus removed) Professor Michele L. Lopez, DHED, MA, RN, CHES, CDE  Teaching for sexual expression after SCI Maintain an open discussion and provide access to education Introduce topic in a straightforward and nonjudgmental manner Ask direct, open-ended questions to facilitate a discussion of sexual matters Educate the individual about the effects of alcohol, tobacco, and other drugs Discuss the broad range of options for sexual expression Consider bladder/bowel care prior to sexual activity STDs counseling Explain that reflex erections may occur with either sexual stimulation or nonsexual stimuli Professor Michele L. Lopez, DHED, MA, RN, CHES, CDE Multiple Sclerosis (MS) MS is a progressive demyelinating neurologic disease S/S: visual disturbances, blurred vision, Fatigue Tremors, intention tremors (tremor when performing an activity). Urinary hesitancy (nerve damage can cause urinary hesitancy) paresthesia coordination problems Deep tendon reflexes are increased or hyperactive Positive Babinski’s Nursing Care plan to address: fall prevention and safety monitoring for bowel and bladder function assessing coordination, ambulation needs Assessing mental health needs (grief, loss) Coma Severe alteration in level of consciousness Complications associated with coma include: Pneumonia constipation DVT Decubiti Meningitis Irritation and inflammation of the meninges. S/S Meningitis: Headache Photosensitivity Nausea, vomiting Nuchal rigidity Kernig’s sign- client with positive Kernig’s will c/o pain when the knees are extended and resistance with extending the leg (sign of meningeal irritation). Seizures Pertinent information to assess and communicate Seizure activity start time and end time Presence of aura Any precipitating factors Tonic-clonic – alternating with rigidity and muscle contraction and relaxation. Seizures Keeping the patient safe and maintaining a patent airway is the most important implementation for a patient experiencing a seizure. Loosen clothing and ensure a safe environment The use of restraints during seizures is contraindicated as restraints can induce a reaction, and possible injury. Tongue depressors are not recommended for seizure patient Post-ictal state (after the seizure)- clients are often very confused, tired, lethargic, and high risk for safety issues (falls). Assess vital signs immediately s/p seizure (make sure they are breathing). After v/s assessed, nurses will check client for injuries s/p seizure, and reorient to environment. Cerebral Vascular Accident (CVA) Ischemic stroke risk factors: afib Priority for care of the client with CVA is to recognize that time is brain. *Prior to administration of TPA , the time of onset of stroke must be determined. Cerebral Vascular Accident (CVA) Anticonvulsants may be prescribed s/p CVA due to increased risk of developing increased ICP Assess for alterations in visual perceptions and teach for ways to adapt to visual disability: Approach the client on the side where the visual perception is intact As a primary safety precaution for clients with alterations in visual perceptions, nurses must teach the client to scan (turn head from side to side) the surroundings. Nurses must also teach client with alterations in visual perceptions to pay attention to their affected side (to avoid neglecting the affecting side)  Communication issues and Stroke: Broca’s Area, Wernicke’s Area Damage to a language center located on the dominant side of the brain, known as Broca's area, causes expressive aphasia. People with this type of aphasia have difficulty conveying their thoughts through words or writing. *Use Picture Board for communication They lose the ability to speak the words they are thinking and to put words together in coherent, grammatically correct sentences. In contrast, damage to a language center located in a rear portion of the brain, called Wernicke's area, results in receptive aphasia. People with this condition have difficulty understanding spoken or written language and often have incoherent speech. Although they can form grammatically correct sentences, their utterances are often devoid of meaning. The most severe form of aphasia, global aphasia, is caused by extensive damage to several areas of the brain involved in language function. People with global aphasia lose nearly all their linguistic abilities; they cannot understand language or use it to convey thought. Reference National Institutes of Health National Institute of Neurological Disorders and Stroke. (2014, Sept). Post-stroke rehabilitation. Retrieved from http://stroke.nih.gov/materials/rehabilitation.htm MLOPEZ MA RN CHES CDE CNE Terms Decorticate posturing: flexion of the elbows Troussoue’s sign Chvotesk’s sign Wernicke’s area: damage to this area will result in the inability to comprehend the spoken word. Aphasia: loss of ability to understand or express speech, caused by damage to the brain. NIHSS Stroke scale Meningitis Plan of care Droplet precautions Neuro checks at least every 2 hours Client is at risk for increased ICP- seizure precautions, prevent coughing as coughing increases ICP, Prepare to administer prescribed broad spectrum antibiotics after blood cultures obtained Maintain in quiet, dark room Pain management – headache, Parkinson’s Disease S/S: Tremor is present while the patient is at rest; it increases when the patient is walking, concentrating, or feeling anxious. Resting tremor characteristically disappears with purposeful movement, but is evident when the extremities are motionless. The nurse should assess for the presence of a tremor when the patient is not performing deliberate actions. Goal of the current drug regimen that includes levodopa/carbidopa (Sinemet) is to improve the client’s ability to carry out ADL’s. Migraines Clinical manifestations: Photophobia Nausea and vomiting Phonophobia Aura Horrific pain from headache Chvostek’s Sign Trousseau’s Sign Hypothyroidism S/S: Fatigue, c/o of always being tired despite sleeping adequate amounts Cold intolerance Weight gain Increase in infections Management: Administer Levothyroxine(Synthroid). Nurse to monitor heart rate and rhythm upon first dose. Nursing education to include instructions to call provider immediately if experiencing chest pains and palpitations when taking the med. Hyperthyroidism PTU administration- frequent blood work should be done as client is now at risk for development of hypothyroidism. Thyroid Surgery Nurse to monitor for alterations in calcium levels (muscle twitching and spasms due to High Risk for inadvertent removal of parathyroid glands development of Parathyroid hormone deficiency (PTH) as parathyroid regulates calcium and phosphorus. Nurse to monitor for s/s of respiratory distress and be prepared to place client in High Fowler’s and apply O2, contact provider, and prepare for intubation. Diabetes Insipidus S/S during assessment: Polyuria – the urine for clients with DI is pale (clear) and dilute, and increase in output Polydipsia Low urine specific gravity Treatment Desmopressin acetate (DDAVP) SIADH Treatment is effective when the body weight decreases there is an increase in urine output SIADH can become a collaborative problem in the presence of other neuro health issues such as meningitis and can be identified in the serum sodium levels (when abnormally low) Adrenal Hypofunction Cravings for salty foods like potatoe chips, pretzels, peanuts, etc. Cushing’s Syndrome Dietary plan for client with Cushing’s: low carbs and low sodium Gullian-Barre Syndrome (GBS) Nurse to continue to monitor pulse ox, resp rate, lung sounds and Keep intubation tray at the bedside Recovery can be slow for several months, client is advised to go slow and gradual and not to overexert. Fluid deprivation test for DI Fluids are withheld for 8-10 hours Patients are weighted frequently during the test Plasma and urine osmolarity studies are performed at the beginning of the test The inability to increase urine specific gravity and osmolarity of the urine is characteristic of diabetes insipidus Musculoskeletal Orthopedic Key Concepts: Many Complications for Orthopedic patients, and orthopedic patients having surgery are many Nursing Assessment: Impaired neurovascular function is an acute threat. NURSES must monitor neurovascular status continually for ortho clients. Orthopedic surgery places client at risk for osteomyelitis: nursing to assess for s/s of infection. Hematomas are complications which may cause an interruption of tissue perfusion (nursing diagnosis is Risk of Peripheral Neurovascular Dysfunction). Traction Buck's extension is used for fractures of the proximal femur. Russell's traction is used for lower leg fractures. Dunlop's traction is applied to the upper extremity for supracondylar fractures of the elbow and humerus. Cervical head halters are used to stabilize the neck. To reposition a client balanced suspension traction, the nurse must maintain consistent traction tension. Orthopedic Surgery: Hip Fracture and Hip Replacement Nursing Education: Client to keep several pillows between legs while in bed (Abductor Pillow) Client must not cross legs Use of assisted devices to assist with ADL’s Will need a high rise toilet seat (to prevent hip dislocation) To prevent hip dislocation in the client who has had hip fracture/hip replacement: The hips should be kept in abduction by an abductor pillow. Hips should not be flexed more than 90 degrees, and the head of bed should not be elevated more than 60 degrees. The patient's hips should be higher than the knees; as such, high seat chairs should be used. Muscle Strain Nursing Management: Ice packs for pain Hip Fracture Nursing Assessment Priority: continually assess neurovascular status of the affected extremity as impaired circulation can cause permanent damage, neurovascular assessment of the affected leg is always a priority assessment. Leg shortening and internal or external rotation are common findings with a fractured hip. Pain, especially on movement, is common after a hip fracture. Knee Injury Nursing Education Provide guidance for knee brace (i.e., orthoses). Used to: support, control movement, and prevent additional injury. FYI: They are not used to immobilize body parts or to facilitate bone remodeling. Fractured Jaw The nature of jaw fractures and the surgery to treat (rigid fixation) threatens the patient's nutritional status The patient who has had rigid fixation should be instructed not to chew food in the first 1 to 4 weeks after surgery. A liquid diet is recommended, and dietary counseling should be obtained to ensure optimal caloric and protein intake.  Thoughts, Questions, Analysis? Dr. Lopez 140