Final Exam TA Review Medsurg PDF

Final Exam TA Review Hunter Lynch Prioritization/Delegation Delegation is prioritizing a task for someone else on the healthcare team to complete like CNAs or LPNs You can only delegate a task to someone that is within their scope of practice You CANNOT delegate tasks that r...

Final Exam TA Review Hunter Lynch Prioritization/Delegation Delegation is prioritizing a task for someone else on the healthcare team to complete like CNAs or LPNs You can only delegate a task to someone that is within their scope of practice You CANNOT delegate tasks that require patient education, evaluation of treatment, nursing diagnosis, passing most meds, and if they can pass meds it must be on a stable patient Prioritize patients who have a life threatening emergency first, then focus on things like pain, and then basic needs after that like hunger Signs of Dehydration Thirst Dry mucous membranes, lips, tongue Dark urine Decreased urine output Headache Weakness Poor skin turgor Signs of Fluid Overload Edema Shortness of breath High Blood Pressure Weight Gain Discomfort You may hear crackles in the lungs TPN (Total Parietal Nutrition) Provides nutrients directly to the bloodstream through an IV Often used as a last resort when a patient is unable to eat or they have intestinal failure Can cause hyperglycemia, fluid overload, infections, injury to the body/tissue due to tubing Hemolytic Transfusion Reactions Patient’s immune system destroys the red blood cells given to them during the transfusion S/S: ○ Back pain ○ Bloody urine ○ Chills ○ Fainting/dizziness ○ Fever ○ Flank pain ○ Flushing of the skin ○ Hypotension ○ Pain ○ N/V Hyponatremia Low levels of sodium in the bloodstream Normal Range 135-145 Severe S/S ○ Seizures ○ Coma ○ Death ○ Hallucinations ○ Altered mental status ○ N/V Hyperkalemia High levels of potassium in the bloodstream Normal levels 3.5-5 Treatments: ○ Loop diuretics (furosemide) ○ Insulin ○ Calcium ○ Dialysis ○ Kayexalate S/S ○ Shortness of breath ○ Chest pain ○ N/V Get an EKG, peaked T waves Hypocalcemia Low levels of calcium in the bloodstream Normal levels 8.6-10.2 S/S ○ Muscle cramps ○ Dry skin, brittle nails ○ Tetany ○ Seizures ○ Syncope ○ Numbness and tingling ○ Fatigue Mechanical Restraints Restrains should only be used as a last resort and when the patient is a danger to themselves or others Requires an order to be used 4 bed rails up is considered a restraint Tie with a quick tie release knot Make sure they aren’t too tight Perform circulation checks frequently Need order every 24 hours What is Delirium? Delirium is a state of temporary but acute mental confusion Life threatening Highest in hospitalized older adults Hyperactive delirium. Probably the most easily recognized type, this may include restlessness (for example, pacing), agitation, rapid mood changes or hallucinations, and refusal to cooperate with care. Hypoactive delirium. This may include inactivity or reduced motor activity, sluggishness, abnormal drowsiness, or seeming to be in a daze. Mixed delirium. This includes both hyperactive and hypoactive signs and symptoms. The person may quickly switch back and forth from hyperactive to hypoactive states. Drug Therapy Only used for patients with severe agitation Treated with low dose antipsychotics ○ Start low go slow Etiology of Dementia 60-80% of patients with dementia also have Alzheimer’s disease Caused by ○ Alzheimers ○ Dementia with Lewy bodies ○ Down syndrome ○ Parkinsons ○ Huntingtons ○ Amyotrophic lateral sclerosis ○ Frontotemporal degeneration Diagnostic Testing Focused on finding cause (reversible vs irreversible) Looking at medication history Labs for ○ Vitamin B12 ○ Neurosyphilis ○ Hypothyroidism Head CT Head MRI Neuropsych testing (mini cog/mini mental status exam) What is Parkinson’s Disease? Disease of the basal ganglia ○ Slow movement (bradykinesia) ○ Increased muscle tone ○ Tremors (pill rolling) ○ Shuffling gait Lack of the neurotransmitter dopamine ○ Degeneration of substantia nigra Know the Parkinson’s Triad!!! Tremor (pill rolling) Rigidity Bradykinesia Gradual onset Nursing Interventions Promote independence with ADL for as long as possible Give them adequate time to take meds and perform tasks ○ Be patient Promote safety when it comes to fall risks and aspiration risks ○ Make food easier to consume (thicken, cut it, etc) ○ Have smaller meals throughout the day Monitor diet ○ If taking levodopa, protein/vitamin B6 needs to be monitored Use elevated toilet seats ○ Prevent constipation by ambulating and taking fluids Types of Stroke Ischemic (87% of strokes) Hemorrhagic Transient Reversible Ischemic Neurological Deficit Hypertension is the leading causes of strokes! Transient Ischemic Attacks (TIAs) Blood flow is blocked/reduced to part of the brain, but after a short while it returns and symptoms subside ○ Temporary! Warning that a stroke may happen soon Medical Management of Ischemic Stroke Quick diagnosis and treatment Assess stroke using NIHSS assessment tool If needed use thrombolytic therapy (tPA) ○ May cause potential bleeding Elevate the HOB unless otherwise noted Maintain airway and ventilation Continuous hemodynamic monitoring and neuro assessment Diagnostic CT scans tPA criteria Used during ischemic strokes to break up the clot Needs to be used within 3 hours of the stroke ○ This is why timing is so important! Medical Management of Hemorrhagic Stroke Prevent it by controlling hypertension Diagnosed through CT scan or cerebral angiography ○ Lumbar puncture can be used if CT is negative and ICP is not high to confirm subarachnoid hemorrhage Bed rest Oxygen Treat vasospasms, increased ICP, hypertension, potential seizures, and further bleeding Common symptom is a severe headache and/or vomiting Within 24 hours after a stroke someone from speech therapy should do a swallow test. Otherwise the patient should be NPO Effects Based on the Side of the Stroke Left side is more likely to Right side is more likely to affect speech and language affect spatial awareness Observe area by using the Patients can sometimes be scanning technique by almost too careful and limit turning head from side to themselves with a left sided side stroke Patients are less likely to realize the limitations they have when having a right sided stroke What is a seizure? Uncontrolled electrical discharge of neurons in the brain that interrupt normal function ○ Can be caused by a variety of disorders Seizure disorder a cluster of abnormal neurons that fire without a clear cause (epilepsy) Status Epilepticus Occurs when a person is in a state of a constant seizure or seizures occur in rapid succession without a return to consciousness ○ Seizure activity is greater than 5 minutes Causes brain to use more energy than it is supplied ○ Neurons become exhausted and no longer function ○ Permanent brain damage can result Diagnostics and Emergency Management Electroencephalogram (EEG) can show abnormal findings ○ Only help when patient is wearing them during a seizure Ensure patient airway (turn head to the side) Do NOT restrain them Remove or loosen tight clothing Establish IV access Stay with patient until seizure has passed and time it if possible Have suction equipment available in the room beforehand NEVER put anything in the patient's mouth Acute Kidney Injury Caused by reduced blood flow to the kidneys, blockage, direct kidney damage through toxins, infection, or medications like NSAIDs S/S ○ Less urine output ○ Edema ○ Nausea ○ Pain ○ Confusion ○ Can lead to kidney failure ○ Leads to electrolyte imbalances ○ Elevated BUN and creatinine End Stage Renal Disease Kidneys can no longer filter waste and excess fluids Requires dialysis GFR