Med-Surg 2 Exam 3 Notes PDF
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Summary
This document contains notes on medical-surgical nursing topics, including manifestations and diagnostics for conditions like endometrial and cervical cancer, post-mastectomy care, and patient education on breast self-exams. The notes cover various diseases, treatments, and nursing interventions, including details on electrolyte imbalances, acid-base disturbances, and the management of conditions such as pancreatitis and portal hypertension. There are questions throughout the document.
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1. Manifestations of endometrial cancer (uterus) - Irregular bleeding - Post menopause bleeding - Nulliparity = no live births Risk factor: unopposed estrogen therapy (estrogen w/o progesterone) 2. Diagnostic test for cervical cancer - A bnormal Pap→ biopsy...
1. Manifestations of endometrial cancer (uterus) - Irregular bleeding - Post menopause bleeding - Nulliparity = no live births Risk factor: unopposed estrogen therapy (estrogen w/o progesterone) 2. Diagnostic test for cervical cancer - A bnormal Pap→ biopsy CIN III or carcinoma insitu,invasive cancer - Dilatation and Curettage (D&C)to further state 3. Actions for the patient with drains post-mastectomy - D rains are usually removed when less than 30 mL of drainage in 24 hours; usually 7 to 10 days - Education: Incision care - Observe for drainage color Pus = infection Should be: sanguineous → serosanguineous → serous fluid - Avoid lifting weights Nursing Teachings: ★ If drain becomes occluded, it causes hematoma; pt needs to be seen ASAP ★ Teach drainage “squeeze when opening & closing to avoid air getting in” ★ Complications lymphedema - Avoid BP, injections, and blood draws on the affected side - Avoid lifting weights heavier than 5-10 lbs - DO ARM EXERCISES - PREVENTS SHOULDER DROP - 4. Teaching about breast self-exam - 5-7 days after 1st day of period or 1x/month formenopausal women - D one in shower with soapy hands - Include breast & underarm - Orange-peel& skin dimple look on the breast is suspicious/RUBBERY SUS - Important areas are between the breast and underarm 5. A patient who is having an abdominal hysterectomy - D oris Bowman - All questions below are on Bowman's case ysterectomy:removal of the uterus to treat cancer,dysfunctional uterine H bleeding, endometriosis, nonmalignant growths, persistent pain, pelvic relaxation and prolapse, and previous injury to the uterus Total Hysterectomy:takes out uterus & cervix Radical Hysterectomy: theuterus and surrounding tissue Salpingo-Oophorectomy:ovaries, fallopian tubes Goals/Planning: Relief Anxiety Acceptance of uterus loss Absence of pain or discomfort Increase knowledge of self-care Absence of complications Assessment: History Physical & pelvic exam Psychosocial & emotional responses Patient knowledge he nurse monitors the patient for which of the following major T postoperativecomplicationsafter an abdominal hysterectomy? - Infection - Hemorrhage - Deep vein thrombosis - Bladder dysfunction - Atelectasis - Paralytic ileus rs. Bowman underwent an abdominal hysterectomy with a M salpingo-oophorectomy. In addition to the removalof the uterus, this procedure involves theremoval of which of the following? - O varies - Fallopian tubes hat are specific assessments the nursemonitors todetect the W complicationof hemorrhage following a hysterectomy? - A bdominal dressing - Perineal pad count - Vital sign trends 6. Workings of a chest tube → What is supposed to happen / not - Used post-op to re-expand the lung and remove excess air, fluid, and lood b - Used in the removal of air and fluid from the pleural space Teachings: - Deep breathing/coughing every 2 hours - Keep drainage below the patient's chest level, plus ambulation - Report excessive drainage (more than 70 ml/hour) Water Seal System: ormal: intermittent bubbling in the water seal chamber N NOT normal: Continuous bubbling can indicate a water leak Dry Suction Water Seal system ormal: filled with water at the 2 cm mark N NOT NORMAL: bubbling can indicate an air leak Dry Suction System ormal: you can't tell, but there's an air leak indicator present that can be N checked - Can be used for transportation - If suspected, inject 30 mL of water so fluid enters the air leak detection chamber NOT NORMAL: ★ bubbles = leak - If drainage goes from 100 to 20, there may be a blockage - Drainage is more than 70 ml/hr - Cloudy and red drainage is ABNORMAL! 7. How do you know if the lungs have re-expanded? - N O BUBBLING - Drainage will decrease !!! - The consistency of the drainage color 8. 2 questions on ABGs - Lab findings !!! Acidosis Normal Alkalosis pH ↓ 7.35 7.35 - 7.45 ↑ 7.45 CO2 ↑ 45 35- 45 ↓ 35 HCO3 ↓ 22 22 - 26 ↑ 26 **Alkalosis = HypoK CO2 ↑ pH ↓ = Respiratory Acidosis - Hypoventilation,↑HR,↓ LOC, weakness (tremors) CO2 ↓ pH ↑ = Respiratory Alkalosis - A nxiety!!, → use brown bag to breathe - hyperventilation, hypotension, HypoK,muscle cramps,extremities numb HCO3 ↓ pH ↓ = Metabolic Acidosis - HyperK →DKA, renal failure, Kussmaul's, abdominalpain,cardiac arrest HCO3 ↑ pH ↑ = Metabolic Alkalosis - oss of acids→ vomiting L - SUCTION, HypoK,kidney dx,lethargy, hyperreflexia 9. Care for a patient who is neutropenic, what advice would you give - P revent infection → wear a mask, no fresh flowers, no raw foods (veggies) - Avoid crowds - Good hygiene: oral, hand, skin Precaution: - Private room - Avoid invasive procedures - Keep dedicated equipment in the patient's room - Avoid indwelling catheters tomatitis:inflammation of the mouth and lips thatcan cause painful sores, swelling, S and redness Xerostomia:dry mouth → use lube 0. Patient who has had cancer and is now having surgery, why are 1 patients complaining of fatigue, What’s the main reason they are having fatigue during cancer treatment - A nemia = fatigue - Low blood count - What CBCs Low hemoglobin and hematocrit Not enough O2 11. Radiation treatment, education to the patient ★ Bone Marrow Suppression ○ Suppression of RBC & WBC Pt tired & anemic Fatigue Mucositis Gastroenteritis N/V - Do NOT wash off markers - Wear loose-fitting clothes - Unscented soaps ★ Protection from others ○ Shielding equipment ○ No pregnant staff/visitors ○ Maintaining a 6-foot distance 12. Stages of cancer - size of primary tumor & if it has invaded surrounding tissue T N- how far the cancer has spread to lymph nodes M – whether cancer has metastasized into other organs or distant lymph nodes - E x. Stage 1 = amazing chance of survival - Stage 3 = cancer has spread - Stage 4 = met. To diff organs, poor chance of survival 13. What is the BRCA1 gene have to do with - Breast & ovarian cancer 14. Acute pancreatitis nursing care cute pancreatitis: A The pancreatic duct becomes obstructed and enzymes back up into the pancreatic duct; causing autodigestion and inflammation - (organs are eating it on healthy tissue) ★ DIC is the main complication Relieving Pain and Discomfort: - U se of analgesics - Nasogastric suctionto relieve nausea and distention - requency oral care F - Best rest - Promote comfort and relieve anxiety - Patient education: Low-fat diet No alcohol WATCH OUT FOR - Infection - Hypocalcemia - Respiratory distress 15. Normal platelet count - Normal Platelet Count: 150,000 - 400,000 16. What do you DO when the platelet count is very low - M onitor for petechiae, ecchymosis, gum bleeding, nose bleeds, and occult or frank blood in stools, urine, or vomit - Administer thrombopoietic meds (Oprelvekin) - PREVENT BLEEDING(use an electric razor or soft toothbrush,avoid blowing your nose vigorously) 17. What do you NOT do when the platelet count is low - A void IVs and injections(use the smallest gauge whennecessary) - AVOID NSAIDs QUESTION nurse is planning the care of a client who has a diagnosis of hemophilia A. When A addressing the nursing diagnosis of Acute Pain Related to Joint Hemorrhage, what principle should guide the nurse's choice of interventions? . Gabapentin (Neurontin) is effective because of the neuropathic nature of the client's A pain. B. Opioids partially inhibit the client's synthesis of clotting factors. C. Opioids may cause vasodilation and exacerbate bleeding. D. NSAIDs are contraindicated due to the risk of bleeding. ANS: D ationale: NSAIDs may be contraindicated in clients with hemophilia due to the R associated risk of bleeding. Opioids do not have a similar effect and they do not inhibit platelet synthesis. The pain associated with hemophilia is not neuropathic. 18. Early signs of laryngeal cancer - H oarseness of more than 2 weeks duration - Persistent cough, sore throat & pain/burning in throat - A lump may be felt in the neck Late Symptoms = Metastasized - Dysphagia, dyspnea, pain radiating to ear - Weight loss - Foul breath - Unilateral nasal discharge - Cervical lymphadenopathy 19. Early signs of lung cancer - N ormally asymptomatic - Dyspnea (early) Symptoms once it has developed - Cough or change in cough - Hemoptysis “bloody nose” - pleural effusion 0. Treatment for the patient getting chemotherapy, what do we do to 2 reduce fatigue, nausea, poor appetite Premedicate !! - Antiemetics - Antihistamines if pt is hypersensitive Ex. Zofran/Ondansetron 21. Normal blood counts for - WBC: 5,000 - 10,000 - RBC: 4.5 - 5.5 million - Platelets: 150,00 - 400,000 - Hgb 12 - 18 - Hct 37 - 50% - Serum Amylase: 60 - 120 - Lipase: 0 - 160 2. Patients who getplatinum-based chemo, what'sthe biggest 2 complaint Drug: Oxaliplatin, Cisplatin - Peripheral neuropathy - Drops things because they can't feel their feet - GI upset: N/V - Bone Marrow Suppression - Alopecia - Hemorrhagic cystitis(inflammation + bleeding bladder) 3. If the patient is getting radiation to a specific organ, what is going 2 to happen, what will it result to that organ Ex. Stomach - Hard to keep food down - Stomatitis - Decreased salivation & xerostomia - Change or loss of taste - Difficulty swallowing 24. Hepatitis A, where do you get it from Viral infection that causes necrosis and inflammation of liver cells - Spread via fecal/oral route - Ingestion of contaminated food or water - Not washing hands - Sex Last 4-8 weeks 25. Teaching a patient about hepatitis B, more chronic ★ Spread via body fluids, IV drug abuse - ast 1-6 months L - Preventing transmission - Active immunization - Adequate rest and nutrition - Avoid drinking alcohol - Use condoms! - Consider moving elsewhere if possible 26. Lab values in pancreatitis Normal Lipase: 0 - 160 ★ High levels = pancreatitis Normal Serum Amylase: 60 - 120 ★ High levels = pancreatitis ★ Amylase is elevated 3x the normal limit ★ Electrolyte imbalances → hypokalemia & hypomagnesemia 27. Post Op care for a patient with a laryngectomy ★ MAINTAIN PATENT AIRWAY - D O NOT EAT FOR 7 DAYS → IV FOOD - Cant eat until swallow test - Semi Fowler position - void sweets A - Oral care every 2 hours - Observe for restlessness, labored breathing - Pulse ox - Suction to remove secretions - CAREFUL when coughing, suture lines must be avoided - Encourage early ambulation to prevent atelectasis, pneumonia, and venous thromboembolism formation 28 In the article about Cholelithiasis Post op care (week 11) (Gallstones:hardened pieces of bile that form inyour gallbladder or bile duct) Post-Op Nursing Priorities: - Monitor for signs of infection - Watch for bile leakage or peritonitis - Monitor liver function and bile flow - Respiratory function - Pain management - Educate patients on long-term diets 9. For a patient who has chemo and is getting stomatitis mouth 2 sores, what recommendation would you give them for comfort - ating becomes difficult → topical anesthetic before meals E - Soft bristle toothbrush - No alcohol-based mouthwash - Rinse mouth before and after meals - Nystatin !! Antihistamine tx fungal infections in the mouth 0. Multiple Myeloma, physical finding while doing an assessment 3 CRAB hyperCalcemia Renal dysfunction Anemia Bone destruction - B one pain: back and ribs - Osteoporosis - Fractures 31. Bleeding esophageal varices, the treatment we do - X for shock →multiple IVs T - Oxygen - IV fluids electrolytes and volume expanders - Vasopressin, Somatostatin, and Octreotide to decrease bleeding - Nitroglycerin + Vasopressin to reduce coronary vasoconstriction Nitroglycerin dilates blood vessels Vasopressin brings up BP and does not dilate blood vessels as much - Beta Blockers (-olol) Decrease portal pressure If the patient has a cardioselective beta blocker give Carvedilol Medical Management: - Indwelling catheter:monitor output - IV Electrolytes:restore fluid volume and replaceelectrolytes - Balloon Tamponade: aballoon to put pressure to stopbleeding - Endoscopic Sclerotherapy:burns them off - Esophageal Banding - Portal Systemic Shunt 32. Education about Lactulose ★ reduces/excretes serum ammonia levels ★ T reat constipation. Broken down in the colon intoproducts thatpull water out from the bodyand into the colon - 2 -3 soft stools per day; this indicates it is working as intended - Dilute it with fruit juice to mask the taste - M onitor for hypokalemia anddehydration - DO NOT TAKE OTHER LAXATIVES Disturbs dosage regulation - May be given NGT or enema - Ammonia levels increase when cirrhosis of the liver is present (Complication of Hep. B) Possible side effects: - Bloating - Cramping(disappears in a week) - Dehydration 33. Post-thoracotomy care incision in the chest wall to access and treat conditions within the chest cavity, such as thelungs, heart, or esophagus ★ MAINTAIN PATENT AIRWAY - echanical ventilation M - Promote mobility and shoulder exercises - Coughing to promote clearance - Careful positioning 30 - 40 degrees - Chest drainage - VS checked frequently - AVOID heavy lifting 34. Finding in DIC(Disseminated Intravascular Coagulation) serious condition where blood clotting process is disrupted,leading to both a excessive clotting and potential bleeding SIGNS AND SYMPTOMS:BLEEDING - Ischemia and bleeding - Clotting and bleeding - Unusual spontaneous bleeding from gums/nose - oozing, trickling, or flow of blood from incisions or lacerations - etechiae and ecchymoses P - Hematuria - Tachycardia, hypotension, and diaphoresis - Respiratory distress - Platelets DECREASE Question: n intensive care nurse is aware of the need to identify clients who may be at risk of A developing disseminated intravascular coagulation (DIC). Which ICU client most likely faces the highest risk of DIC? A. A client with extensive burns B. A client who has a diagnosis of acute respiratory distress syndrome C. A client who suffered multiple trauma in a workplace accident D. A client who is being treated for septic shock ANS: D ationale: Sepsis is a common cause of DIC. A wide variety of acute illnesses can R precipitate DIC, but sepsis is specifically identified as a cause. 35. Assessing the patient with portal hypertension Abnormally high blood pressure in the portal vein - Due to obstruction, which carries blood from the digestive organs (stomach, intestines, and spleen) to the liver You have to assess for Ascites and Esophageal Varices Assessment for Ascites: Fluid in the peritoneal cavity - P ortal hypertension results in increased capillary pressure and obstruction of venous blood flow - Percussion of the abdomen Shifting dullness or fluid wave - Flank bulges when the patient is in the supine position - Abdomen girth Assessment for Esophageal Varices: → varicose veins → enlarged, swollen veins in the esophagus - atients are at risk for bleeding: monitor Hgb & Hct!! P - Endoscopy: identify the bleeding site - Balloon Tamponade: aballoon to put pressure to stopbleeding - Endoscopic Sclerotherapy:burns them off - Esophageal Banding - Portal Systemic Shunt 36. What can portal hypertension result in - E sophageal varices - Ascites 1 delegation question (what can nurses do CNAs cant) Don't Delegate What You Can EAT (educate, assess, teach) Administer medications(oral, IV, IM, etc.) Start and manage IV lines Insert and care for catheters(e.g., Foley catheters) Perform wound careand sterile dressing changes Interpret patient assessmentsand clinical data Develop nursing care plans Perform head-to-toe physical assessments Monitor and titrate oxygen therapy Provide patient education ***37. How would you position your patient post-pneumonectomy - R emoval of an entire lung - Turned every hour from the back to the operative side This allows the fluid left in the space to consolidate and prevents the remaining lung and heart from shifting toward the operative side WANT THEM ON THE AFFECTED SIDE***** 38. What is the nadir? - Lowest point WBC get after chemo 39. When do we see nadir? - 7-10 days after chemo 40. The patient has end-stage liver cancer; review the grief process - Recognize what stage the patient is in . Denial 1 2. Anger 3. Bargaining 4. Depression 5. Acceptance ★ Pt and family mostly go throughacceptanceat theend-stage 41. Lab findings with a patient with multiple myeloma - levated BUN & creatinine= renal dysfunction E - Elevated Albumin (total protein)because of the productionof M protein - Increased risk for bleeding - Hypocalcemia Severe thirst/dehydration Constipation ltered mental status A - LDH and beta-2 microglobulin= measure the degreeof tumor burden - Serum electrolytes - Radiographic evaluation (CT, MRI, PET scan) Determine lytic bone lesions 2. If a patient has an injury to the chest, they have a pneumothorax. 4 What kind of treatment would you expect to happen, what would be contraindicated NOT to do Chest Drainage: - U sed to treat pneumothorax ★ Used post-op to reexpand lungs and remove excess air, fluid and blood - Types of drainage systems DO NOT CLAMP THE CHEST TUBE !! xpectations: red, purulent blood 24 - 48 hours postop and then should start E producing clearer/light pink drainage Chest Tube Draining System Have: - Suction source - Collection chamber for pleural drainage - Mechanism to prevent air from reentering the chest with inhalation 43. Bowtie questions ALL ABOUT CHEST TUBES Actions to take Tube is not kinked or clamped Monitor drainage (movement of fluid w breathing) & bubbling → this can indicate an air leak Document drainage output → amt, color, consistency of drainage Condition pt is most likely experiencing Pneumothorax ○ a collapsed lung due to air accumulating in the pleural space Pleural effusion ○ fluid backup in the pleural space, due to bleeding, infection or heart failure Parameters to monitor: RR & breathing effort (use of accessory muscles) O2 saturation Lung sounds Drainage output Air leaks → bubbling in the water seal chamber Insertion site for signs of infection or bleeding Vitals → temp, HR, & BP QUESTION nurse is educating a client in anticipation of a procedure that will require a A water-sealed chest drainage system. What should the nurse tell the client and the family that this drainage system is used for? A. Maintaining positive chest-wall pressure B. Monitoring pleural fluid osmolarity C. Providing positive intrathoracic pressure D. Removing excess air and fluid ANS: D 44. Know electrolyte levels - erum amylase: 60 - 120 S - Lipase: 0 - 160 - Calcium: 9 - 10.5 - Mg: 1.3 - 2.1 - K: 3.5 - 5 - Sodium: 135-145 45. Pancreatitis !!! Acute Chronic ause: Obstruction of the pancreatic C Cause: long-term alc. abuse duct → Enzymes back up → - leads topermanent damage uto-digestionandinflammationof A - increases pressure in the pancreas the pancreas - obstruction of pancreatic and bile ducts ★ Sudden onset,REVERSIBLE - The destruction of enzyme-secreting cells rgans become “tense” anddigest O healthy tissue ★ Repeated eps,IRREVERSIBLE Manifestations Manifestations - SEVERE ABD PAIN !! - recurrent upper abd & back pain (may radiate to back) - weight loss -steatorrhea - abd guarding - malnutrition due to enzyme - N/V - fever insufficiency - jaundice - confusion/agitation ★ Cullens Sign (umbilical bruising) ★ G rey Turners (flank bruising) Nursing Assessment Acute Pancreatitis: - A bdominal pain/discomfort - Fluid and electrolyte imbalance - Alcohol hx - M edications - GI and nutrition assessment - Respiratory status COMPLICATIONS: - ancreatic necrosis P - Shock - Multiple Organ Dysfunction Syndrome (MODS) - Disseminated Intravascular Coagulation (DIC) Pain and Comfort Measures: - nalgesics A - NG suction - Frequent oral care - Bed rest - Anxiety and emotional support 46. Review Calcium levels Hypocalcemia Positive Trousseau’s + Chvosteks Trousseau’s Signs Apply BP cuff to patient's upper arm - Inflate to 20mmHg above SBP Takes 1-4 minutes for a positive response Chvostek’s Signs C for Cheek Tap the patient's face adjacent to the ear Cheek twitches ❖ MENSTRUAL DISORDERS: Premenstrual Syndrome (PMS) ○ Emotional& physical symptoms before menstruation Dysmenorrhea ○ Painful periods Amenorrhea ○ No period onset ○ Primary (important for conception) Young women with no signs = genetic disorder It does NOT show til puberty Turners syndrome (female) Klenfelters Syndrome (male) ○ Secondary Menstrual cycle & now stopped Due to birth control, weight loss, hormone imbalances, thyroid stress, trauma, athlete, anorexia Menorrhagia ○ Excessive bleeding Metrorrhagia ○ Comes and goes (irregularly) Postmenopausal Bleeding ○ Big red glass ○ 1-year period free ○ #1 sign of endometrial cancer
