Med Surg 1 HESI Final Exam Blueprint Answers PDF

lOMoARcPSD|47091348 Med Surg 1 HESI Final Exam Blueprint Answers Medical-Surgical Nursing I (Herzing University) Scan to open on Studocu Studocu is not sponsored or endorsed by any college or university Downloaded by Cedric Barnes (c...

lOMoARcPSD|47091348 Med Surg 1 HESI Final Exam Blueprint Answers Medical-Surgical Nursing I (Herzing University) Scan to open on Studocu Studocu is not sponsored or endorsed by any college or university Downloaded by Cedric Barnes ([email protected])  lOMoARcPSD|47091348 Preop assess- checklist Consent is obtained- how do you know they understand. If they do not understand it is the surgeons job to go over surgery. Go over patient history Allergies and effects of any previous surgery medications. Testing, labs, medications and confirmed Go over expectation of pre and post-op Post op vital sign- drug use Any regional anesthesia will be weaning off, pain meds may be administered Frequent monitoring and safety Baseline vitals documented in order to assess if patient is declining after surgery. Post op priority Pain control Assessment of the surgical site and drainage tubes Monitoring the rate and patency of IV fluids and IV access Assessing the patient's level of sensation, circulation. Safety Signs of infection or decline in bassline vitals Post op vital signs- reason Ensure patient is not decline Monitor for post-op infection or complications Signs of bleeding or aspiration Pain scale- med selection Preventive approach, rather than an "as needed" (PRN) approach, is more effective in relieving pain Opioid analgesic agents are commonly prescribed for pain and immediate postoperative restlessness. PCA permits patients to administer their own pain medication when needed Epidural Infusions and Intrapleural Anesthesia: allows more effective coughing and deep breathing in conditions such as cholecystectomy, renal surgery, and rib fractures, in which pain in the thoracic region would interfere with these exercises Catheter is attached to a pump that delivers a continuous amount of local anesthetic at a specific amount determined and prescribed by the primary provider Malignant hyperthermia- postop The patient is still at risk in the postoperative period Severe muscle rigidity or spasms. Rapid, shallow breathing and problems with low oxygen and high carbon dioxide Pain outcomes- POC The nurse assesses the patient's pain level using a verbal or visual analog scale and assesses the characteristics of the pain. The goal is pain prevention rather than sporadic pain control. Patients recover more quickly when adequate pain relief measures are used PCA permits patients to administer their own pain medication when needed. 1 Downloaded by Cedric Barnes ([email protected])  lOMoARcPSD|47091348 Shock- hypovolemic Monitor fluid and electrolyte imbalance Patient is NPO after surgery which will decrease fluid volume Pneumonia- CAP In older people that live in close quarters. Prevention is through vaccination 23. Occurs in patients who have not been hospitalized or resided in a long-term care facility within 14 days of the onset of symptoms. Can be treated at home or in hospital Pneumonia- airway Pneumonia arises from normal flora present in patients whose resistance has been altered or from aspiration of flora present in the oropharynx Atelectasis - alveoli unable to expand due to fluid COPD- oxygen level Patient will have a low level for baseline 88% Pulse oximetry values to assess the patient's need for oxygen and administers supplemental oxygen as prescribed HF & COPD Pulmonary vascular changes result in pulmonary and HTN Over time, pulmonary hypertension may occur as a result of chronic hypoxemia COPD & infections - 1st sign Infection may be accompanied by subtle changes Report any signs of infection!!!! Fever Change in sputum color, character, consistency, or amount. Any worsening of symptoms (increased tightness of the chest, increased dyspnea, fatigue) Crohn's disease Chronic inflammation of the GI tract wall that extends through all layers Bowel wall thickens and becomes fibrotic, and the intestinal lumen narrows (cobblestone) Diarrhea Crampy abdominal pain (especially after meals) Malnourishment Secondary anemia Crohn's disease- menu Avoid consumption of nuts, corn, chocolate, diary, nuts, seeds, spicy foods, onions, and citrus fruits Bariatric Surgery- Post op checklist Watch for dumping syndrome and vitamin/mineral imbalances Ulcers can be possible Bleeding Nutritional education and portion size 2 Downloaded by Cedric Barnes ([email protected])  lOMoARcPSD|47091348 Medical management, including the use of dietary supplements Follow-up appointments Constipation- action Defined as less than 3 bowel movements per week High fiber/residue diet Establishing healthy bowel habits Digital dislodgement and enema administration Avoiding holding in stool when urge is present May consider bulk-forming OTC's Fissures likely require stool softener like Docusate Bowel obstruction- action Decompression of the bowel through an NG tube is necessary for all patients with small bowel obstruction. Bowel is completely obstructed then Appendicitis- pre-op preparation To correct or prevent fluid and electrolyte imbalance, dehydration, and sepsis, antibiotics and IV fluids are given until surgery Analgesic agents for pain NPO If pain stops entirely then emergency situation Septic shock- peritonitis Fever (100-101) increased pulse rate With progression patients may become hypotensive Hardening of the abdomen Absent bowel sounds Caused by leakage of contents from abdominal organs into the abdominal cavity Diverticulosis- S&S Diverticulum becomes inflamed, causing perforation and potential complications, such as obstruction, abscess, fistula (abnormal tract) formation, peritonitis, and hemorrhage Diverticula form when the mucosal and submucosal layers of the colon herniate through the muscular wall Bowel irregularity with intervals of alternating constipation and diarrhea, with nausea, anorexia, and bloating or abdominal distention Colitis Typically starts in the rectum and moves inward Bloody diarrhea Mucus or pus may also be present in stool Left lower quadrant abdominal pain HTN- blurred vision Hemorrhages, exudates (fluid accumulation), arteriolar narrowing, and cotton-wool spots (small 3 Downloaded by Cedric Barnes ([email protected])  lOMoARcPSD|47091348 infarctions) occur. Examined and laboratory studies are performed to assess possible target organ damage Retinopathy HTN- Diabetes- blurred vision Diabetic retinopathy Microvascular damage Antihypertensive- POC Hyperkalemia Nausea Constipation Palpitation Swollen feet or legs, cold hands or feet, cramps Persistent dry cough Skin rash Frequent urination Decreased sexual desires HTN meds- actions Reduce blood pressure. Angiotensin-Converting Enzyme Inhibitors Angiotensin II Receptor Blockers Calcium Channel Blockers Direct Renin Inhibitors Antiadrenergics Diuretics HCTZ- valsartan combo Valsartan (ARB) works by relaxing blood vessels so that blood can flow easier Hydrochlorothiazide is a water pill (diuretic) that causes patient to pee more which helps body get rid of extra salt and water. HF- fluid retention Right side failure Increased venous pressure leads to jugular venous distention JVD Increased capillary hydrostatic pressure throughout the venous system Edema of the lower extremities Hepatomegaly Ascites Weight gain due to retention of fluid. HF- fluid volume Pulmonary congestion when left ventricle cannot effectively pump blood out of the ventricle into the aorta and the systemic circulation Causing high blood pressure Fluid that accumulates in the dependent extremities during the day may be reabsorbed into the circulating blood volume when the patient lies down. 4 Downloaded by Cedric Barnes ([email protected])  lOMoARcPSD|47091348 Heart disease- diuretic Patients receiving potassium-sparing must be carefully monitored for hyperkalemia Using the smallest dose of diuretic necessary to control fluid volume Can also lead to orthostatic hypotension and kidney injury Loop diuretics, such as furosemide (Lasix) Loop, thiazide, and aldosterone blocking Aldosterone antagonists such as spironolactone (K sparing) Fe Supplement administration Oral iron that is poorly absorbed or poorly tolerated, or iron supplementation is needed in large amounts. alternative will be giving through IV administration several doses are required to replenish the patient's iron stores Can stain teeth Diverticulitis- WBC The inflammation of the weakened colonic wall of the diverticulum can cause it to perforate, giving rise to irritability and spasticity of the colon Acute onset of mild to severe pain in the left lower quadrant Abscess develops, the associated findings are tenderness, a palpable mass, fever, and leukocytosis Will need a CBC Pernicious anemia Deficiency of vitamin B12 absence of intrinsic factor Run in families Higher incidence of gastric cancer Develop a smooth, sore, red tongue and mild diarrhea Replacement is by monthly intramuscular injections of vitamin B12 done when defect in absorption or the absence of intrinsic factor Blood admin- negative response Febrile- Chills, Fever, Headache, flushing, Tachycardia Allergic-hives, pruritus, SOB, bronchospasm Hemolytic- low back pain, Hypotension, tachycardia, fever & chills, chest pain, quick onset, blood in urine High number of pregnancy, blood transfusions, incorrect blood typing SBAR- initiate process Confirm order and signed documents Confirm blood type match Take primary vitals Inform patient of signs of reaction Use proper needle and blood tubing Which for signs of fluid volume overload Monitor for the first 15 mins then every 30 mins after Notation of how patient handles transfusion Urine retention- incontinence-male 5 Downloaded by Cedric Barnes ([email protected])  lOMoARcPSD|47091348 Benign Prostatic Hyperplasia(BPH) obstruct the bladder neck or urethra, causing incomplete emptying of the bladder and urinary retention untreated obstruction can cause UTI S&S ○ Urinary frequency ○ Urgency ○ Nocturia ○ Hesitancy BPH- pathology Testicular androgens Dihydrotestosterone = metabolite of testosterone critical mediator of prostatic growth BPH generally occurs when men have elevated estrogen levels and when prostate tissue becomes more sensitive to estrogens and less responsive to DHT. TURP- discharge plan Catheter is removed usually when the urine appears clear Monitored for major complications such as hemorrhage, infection, VTE, catheter problems, and sexual dysfunction. Drink plenty of water to help flush fluids through the bladder Tamsulosin- BPH Relax the smooth muscle of the bladder neck and prostate. Improves urine flow and relieves symptoms of BPH Side effects ○ Dizziness ○ Headache ○ Asthenia/fatigue ○ Postural hypotension ○ Rhinitis ○ Sexual dysfunction Sildenafil- adverse effects Headache Facial flushing Dyspepsia Nasal congestion Dizziness Severe ○ Nonarteritic ischemic optic neuropathy (obstruction of blood flow to the optic nerve) ○ Sudden permanent hearing loss accompanied by dizziness and tinnitus ○ Priapism (prolonged erection of the penis) Stress Incontinence Involuntary loss of urine through an intact urethra as a result of sneezing, coughing, or changing position Women ○ Affects women who have had vaginal deliveries (decreasing ligament and pelvic floor support of 6 Downloaded by Cedric Barnes ([email protected])  lOMoARcPSD|47091348 the urethra and decreasing or absent estrogen levels within the urethral walls and bladder base) Men ○ After a radical prostatectomy for prostate cancer because of the loss of urethral compression that the prostate had supplied before the surgery, and possibly bladder wall irritability Urolithiasis (Kidney stones) Relieve pain Decrease swelling to allow stone to pass Eradicate the stone Determine the stone type Prevent nephron destruction Control infection Increase fluid Diet change Relieve any obstruction that may be present. Alzheimer's- ADL Goals ○ Physical safety ○ Promoting independence in self-care activities (instruct rather than do it for them) ○ Reducing anxiety and agitation ○ Improving communication ○ Providing for socialization and intimacy ○ Promoting adequate nutrition ○ Promoting balanced activity and res ○ Supporting and educating family caregivers Dementia- AD nighttime Nightlights are helpful, particularly if the patient has increased confusion Driving is prohibited Doors leading from the house must be secured Watch for increased risk for falls Donepezil Aricept- effects Centrally acting reversible cholinesterase inhibitor Increases acetylcholine in the brain by inhibiting its metabolism elevated acetylcholine levels in the cortex Lows the neuronal degradation that occurs in Alzheimer's disease. Rivastigmine Exelon- early Alzheimer's Enhance acetylcholine uptake in the brain, thus maintaining memory skills for a period of time Cognitive ability may improve within 6 to 12 months of therapy Indicated for severe AD; it is recommended that treatment continue as long as possible Parkinson's disease- freezing Transient inability to perform active movement and is thought to be an extreme form of bradykinesia Parkinson- ambulation 7 Downloaded by Cedric Barnes ([email protected])  lOMoARcPSD|47091348 Patient tends to shuffle and exhibits a decreased arm swing as well Loss of postural reflexes, the patient stands with the head bent forward and walks with a propulsive gait Shuffling gait Increased risk for falls Parkinson's Neuro-degenerative disease that is characterized by low dopamine levels in the brain More excitatory neurotransmitters than inhibitory neurotransmitters, leading to an imbalance that affects voluntary movement Parkinson's flat affect Hypomimia-affects the facial muscle movement given the patient a permanent unemotionless facial appearance loss of facial expression Parkinson's swallowing Drooling (accumulation of saliva) Poor head control Coughing risk for aspiration Swallowing difficulties due to muscle weakness dysphagia throat clearing during or after eating/drinking Feeling as food is stuck in the throat Seizure- home care Patient who has an aura may have time to seek a safe, private place Look at your watch at the start of the seizure, to time its length Don't put anything in their mouth Place them on their side, to help keep their airway clear Depakote D/C Do not stop the medication abruptly Consult doctor before you discontinue If you stop abruptly seizures will return Dilantin- pregnancy Risk of birth defects is a significant adverse effect Category D Gingival hyperplasia- dilantin An overgrowth of gum tissue, is also common, especially in children Can be associated with long-term use of phenytoin Periodic physical and dental examinations and laboratory tests are performed for patients Hypothyroid- labs Free T4 levels decreased High levels of TSH 8 Downloaded by Cedric Barnes ([email protected])  lOMoARcPSD|47091348 Hypothyroid- drug treatment Synthetic levothyroxine Dosage is based on the patient's serum TSH concentration Hypothyroid- weight loss Levothyroxine is not for treatment of obesity or for weight loss Adverse effects of levothyroxine is weight loss Myxedema, the nurse assesses for decreased edema and loss of weight Exophthalmos- patho Abnormal protrusion of one or both eyeballs Increase in orbital volume from the extraocular muscles and fat Graves = hyperthyroidism Thyroidectomy- postop Watch for bleeding, breathing, pain, oxygen, positioning watch for signs of hypothyroidism Thyroid carcinoma treatment is surgical removal Goiter- TSH Low levels of TSH trigger an increase in the pituitary gland this over production causing the thyroid to hypertrophy Do not palpate the goiter as it can further the production of thyroid Treatment of goiter with Potassium Iodide to protect the thyroid Thyroidectomy- hypocalcemia Major post-operative complication of total thyroidectomy Will need to take calcium supplements due to low levels of calcium Foot care Cardiac; peripheral vascular; foot complications Foot examination (lesions, signs of infection, pulses) Type I DM- teach Self-monitoring of blood glucose How to use monitoring equipment DM- Insulin Nausea, Vomiting Never eliminate insulin doses when nausea and vomiting occur Patient should take the usual insulin dose (or previously prescribed special sick day doses) and then attempt to consume frequent small portions of carbohydrates Blood glucose and urine ketones must be assessed every 3 to 4 hours Ketosis and acidosis of DKA lead to gastrointestinal DM- upper respiratory infection More likely to have lung conditions such as COPD and pulmonary fibrosis High risk for pneumonia and constant issues with congestion 9 Downloaded by Cedric Barnes ([email protected])  lOMoARcPSD|47091348 Insulin- meal time Rapid : 10 to 15 before meals Short: 3-60 mins before meals DM- safety Always double check insulin with the order given Monitor blood sugar before administration DM- illness Insulin temporarily during illness if was only taking oral medications Due to illness insulin may be required or dosage may even increase Rheumatoid arthritis- elevated RF Nodules occur only in people who have rheumatoid factor Rheumatoid arthritis Systemic, autoimmune inflammation Symmetric swelling in the small joints (hand, feet, wrist) NSAIDs Steroids DMARDs SLE- exacerbation Sun and ultraviolet light exposure can increase disease activity SLE- hematuria Lupus nephritis Kidney damage will have blood in urine Bariatric Surgery- Osteoporosis Increased risk for osteoporosis as the duodenum is bypassed, which is the primary site for absorption of calcium Malabsorption disorders Ulcerative Colitis chronic ulcerative and inflammatory disease of the mucosal and submucosal layers of the colon and rectum that is characterized by unpredictable periods of remission and exacerbation with bouts of abdominal cramps and bloody or purulent diarrhea. The inflammatory changes typically begin in the rectum and progress proximally through the colon Crohn's Disease characterized by periods of remission and exacerbation. It is a subacute and chronic inflammation of the GI tract wall that extends through all layers (i.e., transmural lesion). Although its characteristic histopathologic changes can occur anywhere in the GI tract, it most commonly occurs in the distal ileum and the ascending colon. The onset of symptoms is usually insidious in Crohn's disease, with prominent right lower quadrant abdominal pain and diarrhea unrelieved by defecation 10 Downloaded by Cedric Barnes ([email protected])  lOMoARcPSD|47091348 Crohn's Disease Diet Oral fluids and a low-residue, high-protein, high-calorie diet with supplemental vitamin therapy and iron replacement are prescribed to meet nutritional needs, reduce inflammation, and control pain and diarrhea. Fluid and electrolyte imbalances from dehydration caused by diarrhea are corrected by IV therapy as necessary if the patient is hospitalized or by oral fluids if the patient is managed at home. Any foods that exacerbate diarrhea are avoided. Milk may contribute to diarrhea in those with lactose intolerance. Cold foods and smoking are avoided because both increase intestinal motility. Parenteral nutrition may be indicated. Ulcerative Colitis-Goal major goals for the patient include attainment of normal bowel elimination patterns, relief of abdominal pain and cramping, prevention of fluid volume deficit, maintenance of optimal nutrition and weight, avoidance of fatigue, reduction of anxiety, promotion of effective coping, absence of skin breakdown, increased knowledge about the disease process and self-health management, and avoidance of complications. Bariatric Surgery Post Op After surgery, the nurse assesses the patient for complications from the bariatric surgery, such as hemorrhage, venous thromboembolism, bile reflux, dumping syndrome, dysphagia, and bowel or gastric outlet obstruction. Eat smaller but more frequent meals that contain protein and fiber; each meal size should not exceed 1 cup. Eat only foods high in nutrients (e.g., peanut butter, cheese, chicken, fish, beans). Eat slowly and chew thoroughly Assume a low Fowler position during mealtime and then remain in that position for 20-30 minutes after mealtime—this delays stomach emptying and decreases the likelihood of dumping syndrome. Do not drink fluid with meals; instead, consume fluids up to 30 minutes before a meal and 30-60 minutes after mealtime. Cholelithiasis- Jaundice Jaundice occurs in a few patients with gallbladder disease, usually with obstruction of the common bile duct. The bile, which is no longer carried to the duodenum, is absorbed by the blood and gives the skin and mucous membranes a yellow color. This is frequently accompanied by marked pruritus (itching) of the skin. Gallbladder Risk Factors The risk of developing such stones is increased in patients with cirrhosis, hemolysis, and infections of the biliary tract. Cholesterol stones account for most of the remaining 75% of cases of gallbladder disease in the United States Two to three times more women than men develop cholesterol stones and gallbladder disease Stone formation is more frequent in people who use oral contraceptives, estrogens, or clofibrate (Atromid-S); these medications are known to increase biliary cholesterol saturation. The incidence of stone formation increases with age as a result of increased hepatic secretion of cholesterol and decreased bile acid synthesis. Peptic Ulcer Disease Complication Although vomiting is rare in an uncomplicated peptic ulcer, it may be a symptom of a complication of an 11 Downloaded by Cedric Barnes ([email protected])  lOMoARcPSD|47091348 ulcer. It results from gastric outlet obstruction, caused by either muscular spasm of the pylorus or mechanical obstruction from scarring or acute swelling of the inflamed mucous membrane adjacent to the ulcer. Seizure Precautions maintained, including having available functioning suction equipment with a suction catheter and oral airway. The bed is placed in a low position with two to three side rails up and padded, if necessary, to prevent injury to the patient. The patient may be drowsy and may wish to sleep after the seizure; they may not remember events leading up to the seizure and for a short time thereafter. Rheumatoid Arthritis S/S The initial clinical manifestations of RA include symmetric joint pain and morning joint stiffness lasting longer than 1 hour. Over the course of the disease, clinical manifestations of RA vary, usually reflecting the stage and severity of the disease. Symmetric joint pain, swelling, warmth, erythema, and lack of function are classic symptoms. Palpation of the joints reveals spongy or boggy tissue. Often, fluid can be aspirated from the inflamed joint. Characteristically, the pattern of joint involvement begins in the small joints of the hands, wrists, and feet. In the early stages of disease, even before the presentation of bony changes, limitation in function can occur when there is active inflammation in the joints. Joints that are hot, swollen, and painful are not easily moved. SLE Exacerbation The lesions often worsen during exacerbations (flares) of the systemic disease and possibly are provoked by sunlight or artificial ultraviolet light. Oral ulcers, which may accompany skin lesions, may involve the buccal mucosa or the hard palate, occur in crops, and are often associated with exacerbations. Other cutaneous manifestations include splinter hemorrhages, alopecia, and Raynaud's phenomenon ○ should be instructed to avoid exposure or to protect themselves with sunscreen and clothing Pre-Op Lab Routine laboratory tests used to detect infection include the white blood count (WBC) and the urinalysis. Surgery may be postponed in the presence of infection. Ambulation Post-Op The patient should be taught that early and frequent ambulation postoperatively, as tolerated, will help prevent complications. Malignant Hyperthermia rare inherited muscle disorder that is chemically induced by anesthetic agents The initial symptoms of malignant hyperthermia are often cardiovascular, respiratory, and abnormal musculoskeletal activity. Tachycardia (heart rate greater than 150 bpm) may be an early sign. Sympathetic nervous stimulation also leads to ventricular dysrhythmia, hypotension, decreased cardiac output, oliguria, and, later, cardiac arrest. Hypercapnia, an increase in carbon dioxide (CO2), may be an early respiratory sign. With the abnormal transport of calcium, rigidity or tetanus-like movements occur, often in the jaw. Generalized muscle rigidity is one of the earliest signs. The rise in temperature is actually a late sign that develops rapidly; body temperature can increase 1°C to 2°C (2°F to 4°F) every 5 minutes, and core body temperature can exceed 42°C (107°F) 12 Downloaded by Cedric Barnes ([email protected])  lOMoARcPSD|47091348 Post-Op Bowel Sounds Assessment The nurse detects bowel sounds by listening to the abdomen with a stethoscope. Bowel sounds are documented so that diet progression can occur. The nurse should assess the abdomen for distention and the presence and frequency of bowel sounds. If the patient does not have a bowel movement by the second or third postoperative day, the primary provider should be notified and a laxative or other test or intervention may be needed. Wound Dehiscence & Evisceration Wound dehiscence (disruption of surgical incision or wound) and evisceration (protrusion of wound contents) are serious surgical complications. Dehiscence and evisceration are especially serious when they involve abdominal incisions or wounds. They may also occur because of increasing age, anemia, poor nutritional status, obesity, malignancy, diabetes, the use of steroids, and other factors in patients undergoing abdominal surgery. An abdominal binder can provide support and guard against dehiscence and may be used along with the primary dressing, especially in patients with weak or pendulous abdominal walls or when rupture of a wound has occurred. Galantamine hydrobromide (Razadyne, Razadyne ER): Contraindications & Common Adverse Effects Contraindications include severe hepatic or renal impairment. The most common adverse effects are insomnia, tremor, dizziness, somnolence, headache, bradycardia, and syncope. Galantamine hydrobromide (Razadyne, Razadyne ER): Indications & Similar to what drug? Galantamine hydrobromide (Razadyne, Razadyne ER) is similar to donepezil in its action. Indications include mild to moderate dementia. Teaching Galantamine hydrobromide (Razadyne, Razadyne ER) Patients and families should receive instructions about reporting any changes in mental status. To decrease gastric upset, it is necessary to take the medication with food. Sinemet: What two medications combined? What disease? What diet to avoid? Levodopa and carbidopa are usually given together in a fixed-dose formulation called Sinemet Levodopa-carbidopa is not administered with a high-protein diet. Adequate hydration is also necessary. Given to patients with Parkinson's Sinemet Teaching Take the medication as prescribed. Do not crush the sustained-release preparation. Do not take multivitamin preparations containing pyridoxine. Understand that there are adverse effects of medication, such as drowsiness, dizziness, and orthostatic hypotension. Change positions slowly to prevent drop in blood pressure. Avoid alcohol. Take the medication with food to prevent nausea and vomiting. 13 Downloaded by Cedric Barnes ([email protected])  lOMoARcPSD|47091348 Do not take the medication with a high-protein meal. Report fainting, light-headedness, irregular heart rate, uncontrolled facial movements, urinary retention, nausea, and vomiting to the prescriber. Notify the prescriber of any increase in symptoms such as static gait, altered mobility, and "pill rolling." Parkinson's Diet Patients may have difficulty maintaining their weight. Eating becomes a very slow process, requiring concentration due to a dry mouth from medications and difficulty chewing and swallowing. These patients are at risk for aspiration because of impaired swallowing and the accumulation of saliv. Monitoring weight on a weekly basis indicates whether caloric intake is adequate. Supplemental feedings increase caloric intake. As the disease progresses, a nasogastric or percutaneous endoscopic gastrostomy (PEG) tube may be necessary to maintain adequate nutrition. A dietitian can be consulted regarding nutritional needs. Pre-Op Teaching: Incentive Spirometry The patient is educated about breathing exercises and the use of an incentive spirometer, if indicated, to achieve optimal respiratory function prior to surgery. The potential compromise of ventilation during all phases of surgical treatment necessitates a proactive response to respiratory infections Pneumonia Breath Sounds Crackles Pursed-Lip Breathing Deep inspiration followed by prolonged expiration through pursed lips. Pursed-lip breathing helps slow expiration, prevents collapse of small airways, and helps the patient control the rate and depth of respiration. It also promotes relaxation, enabling the patient to gain control of dyspnea and reduce feelings of panic. COPD S/S Although the natural history of COPD is variable, it is generally a progressive disease characterized by three primary symptoms: chronic cough, sputum production, and dyspnea Prolonged expiratory phase, wheezes, decreased breath sounds, ↑ Anterior-posterior diameter (barrel chest), tripod position, pursed lip breathing Distinguishing symptoms can be difficult with comorbidities Asthma Trigger Allergic asthma usually develops in childhood and is triggered by allergens such as pollen, dust mites, and certain foods. Non-allergic asthma usually develops in patients over the age of forty and can have various triggers, such as cold air, medication (e.g., aspirin), exercise, and viral infection Exercise induced/cold air exposure May be seasonal or year-round Cockroaches, furry animals, fungi, mold Underlying respiratory infection Steroids in Asthma Glucocorticoids — Glucocorticoids are a class of medication that has anti-inflammatory properties. Glucocorticoids can be taken in different forms, including with an inhaler, as a pill, or through an IV. 14 Downloaded by Cedric Barnes ([email protected])  lOMoARcPSD|47091348 A spacer should be used with inhaled corticosteroids, and patients should rinse their mouth after administration to prevent thrush, a common complication associated with the use of inhaled corticosteroids. A systemic preparation may be used to gain rapid control of the disease; to manage severe, persistent asthma; to treat moderate to severe exacerbations; to accelerate recovery; and to prevent recurrence. GERD Meal Recommendations Small, frequent feedings (6 to 8 per day) are recommended because large quantities of food overload the stomach and promote gastric reflux. The patient is advised to avoid any activities that increase pain and to remain upright for 1 to 4 hours after each meal to prevent reflux. The head of the bed should be placed on 4- to 8-inch (10- to 20-cm) blocks. Eating before bedtime is discouraged. The patient is encouraged to eat slowly and to chew all food thoroughly so that it can pass easily into the stomach. Small, frequent feedings of nonirritating foods are recommended to promote digestion and to prevent tissue irritation. Sometimes liquid swallowed with food helps the food pass through the esophagus, but usually liquids should be consumed between meals. Food should be prepared in an appealing manner to help stimulate the appetite. GERD Aspiration The patient who has difficulty swallowing or difficulty handling secretions should be kept in at least a semi-Fowler position to decrease the risk of aspiration GERD Avoid Over using antacids Irritants such as tobacco and alcohol should be avoided Avoid eating before bed GERD Assess A baseline weight is obtained, and daily weights are recorded. The patient's intake of nutrients is assessed. S/S Peptic Ulcer Disease Many patients with peptic ulcers have no signs or symptoms. These silent peptic ulcers most commonly occur in older adults and those taking aspirin and other NSAIDs As a rule, the patient with an ulcer complains of dull, gnawing pain or a burning sensation in the midepigastrium or the back. Other nonspecific symptoms of either gastric ulcers or duodenal ulcers may include pyrosis vomiting, constipation or diarrhea, and bleeding. These symptoms are often accompanied by sour eructation (burping), which is common when the patient's stomach is empty. Gastric vs. Duodenal Ulcers: Main way to determine which it is There are few clinical manifestations that differentiate gastric ulcers from duodenal ulcers; however, classically, the pain associated with gastric ulcers most commonly occurs immediately after eating, whereas the pain associated with duodenal ulcers most commonly occurs 2 to 3 hours after meals. DASH Diet Dietary Approaches to Stop Hypertension includes consumption of a diet rich in fruits, vegetables, and low-fat dairy. Grains 7-8 servings a day 15 Downloaded by Cedric Barnes ([email protected])  lOMoARcPSD|47091348 Vegetables 4-5 servings per day Fruits 4-5 servings per day Low-fat or Fat-free dairy 2-3 per day Lean meat, fish, and poultry less than 2 per day Nuts, seeds, and dry beans 4 or 5 weekly Oxalate Foods Prevention of Kidney Stones: Avoid intake of oxalate-containing foods (e.g., spinach, strawberries, rhubarb, tea, peanuts, chocolate, wheat bran). Incontinence Bladder Training Pelvic floor muscle exercises (sometimes referred to as Kegel exercises) represent the cornerstone of behavioral intervention for addressing symptoms of stress, urge, and mixed incontinence Symptoms of BPH Obstructive and irritative symptoms may include urinary frequency, urgency, nocturia, hesitancy in starting urination, decreased and intermittent force of stream and the sensation of incomplete bladder emptying, abdominal straining with urination, a decrease in the volume and force of the urinary stream, dribbling (urine dribbles out after urination), and complications of acute urinary retention and recurrent UTIs. Symptoms of Hypothyroidism Extreme Fatigue Reports of hair loss, brittle nails, and dry skin are common, and numbness and tingling of the fingers may occur Weight gain without increase in food intake Hair Falls out and Thins Constipation Decreased libido Irregular Period Complaints of being cold in warm environment Myxedema Coma: Hypo or Hyperthyroidism? Myxedema coma is a rare life-threatening condition. It is the decompensated state of severe hypothyroidism in which the patient is hypothermic and unconscious. This condition may develop with undiagnosed hypothyroidism and may be precipitated by infection or other systemic disease or by use of sedatives or opioid analgesic agents. Patients may also experience myxedema coma if they forget to take their thyroid replacement medication. The condition occurs most often among older women in the winter months and appears to be precipitated by cold. However, the disorder can affect any age group. What happens in Myxedema Coma? In myxedema coma, the patient may initially show signs of depression, diminished cognitive status, lethargy, and somnolence. Increasing lethargy may progress to stupor. The patient's respiratory drive is depressed, resulting in alveolar hypoventilation, progressive carbon dioxide retention, narcosis, and coma. In addition, patients with myxedema coma can also exhibit hyponatremia, hypoglycemia, hypoventilation, hypotension, bradycardia, and hypothermia. 16 Downloaded by Cedric Barnes ([email protected])  lOMoARcPSD|47091348 Characteristics of Thyrotoxicosis (Thyroid Storm) High fever (hyperpyrexia), >38.5°C (>101.3°F) Extreme tachycardia (>130 bpm) Exaggerated symptoms of hyperthyroidism with disturbances of a major system—for example, gastrointestinal (weight loss, diarrhea, abdominal pain) or cardiovascular (edema, chest pain, dyspnea, palpitations) Altered neurologic or mental state, which frequently appears as delirium psychosis, somnolence, or coma What is Thyroid Storm precipitated by? Life-threatening thyroid storm is usually precipitated by stress, such as injury, infection, thyroid and nonthyroid surgery, tooth extraction, insulin reaction, diabetic ketoacidosis, pregnancy, digitalis intoxication, abrupt withdrawal of antithyroid medications, extreme emotional stress, or vigorous palpation of the thyroid Management of Thyroid Storm A hypothermia mattress or blanket, ice packs, a cool environment, hydrocortisone, and acetaminophen (Tylenol) Humidified oxygen is given to improve tissue oxygenation and meet the high metabolic demands. IV fluids containing dextrose are given to replace liver glycogen stores that have been decreased in the patient who is hyperthyroid. Propylthiouracil (PTU) or methimazole is given to impede formation of thyroid hormone and block conversion of T4 to T3, the more active form of thyroid hormone. Hydrocortisone is prescribed to treat shock or adrenal insufficiency. Iodine is given to decrease output of T4 from the thyroid gland. For cardiac problems such as atrial fibrillation, dysrhythmias, and heart failure, sympatholytic agents may be given. Propranolol, combined with digitalis, has been effective in reducing severe cardiac symptoms. Graves Disease most common cause of hyperthyroidism, is an autoimmune disorder that results from an excessive output of thyroid hormones caused by abnormal stimulation of the thyroid gland by circulating immunoglobulins Treatment of Graves Disease The use of radioactive iodine is the most common form of treatment for Graves disease in North America. Polyuria & Diabetes Clinical manifestations depend on the patient's level of hyperglycemia. Classic clinical manifestations of diabetes include the "three Ps": polyuria, polydipsia, and polyphagia. Polyuria (increased urination) and polydipsia (increased thirst) occur as a result of the excess loss of fluid associated with osmotic diuresis A1C Level for diabetes Over 6.5% Hypovolemia Deficient fluid volume Decreased cardiac output 17 Downloaded by Cedric Barnes ([email protected])  lOMoARcPSD|47091348 Risk for impaired oral mucous membranes Hypervolemia: Potential Complication Potential complications: Pulmonary edema or crackles, ascites Watch HCT and BUN, decreased urine output Hypovolemia Potential Complication Hypovolemic shock Watch NA+ and increased urine output Hypervolemia Excess fluid volume Impaired gas exchange Risk for impaired skin integrity Activity intolerance S/S Metabolic Acidosis Decreased BP Hyperkalemia Muscle Twitching Warm, Flush Skin Nausea, Vomiting, Diarrhea Changes in LOC Insulin Pens use small (150- to 300-unit) prefilled insulin cartridges that are loaded into a penlike holder. A disposable needle is attached to the device for insulin injection. Insulin is delivered by dialing in a dose or pushing a button for every 1- or 2-unit increment given. These devices are most useful for patients who need to inject only one type of insulin at a time (e.g., premeal rapid-acting insulin three times a day and bedtime NPH insulin) or who can use the premixed insulins. These pens are convenient for those who administer insulin before dinner if eating out or traveling. They are also useful for patients with impaired manual dexterity, vision, or cognitive function, which makes the use of traditional syringes difficult. Emergent Treatment DKA & HHS Emergent treatment for both DKA and HHS is IV insulin Thyroid Storm Definition Physiologic effects/clinical syndrome of hyper-metabolism Results from increased circulating levels of T3, T4, or both Life threatening emergency Myxedema Coma Things to Know Extreme, untreated hypothyroidism Will administer thyroid hormone IV- monitor for acute cardiac changes May worsen with infection, drugs, cold, trauma Patient will need to have temperature increased slowly! 18 Downloaded by Cedric Barnes ([email protected])  lOMoARcPSD|47091348 Safety while Seizing Keep away from danger Do not hold patient down Turn on side Often administer Ativan IV/IM Migraine Treatment Acetaminophen- works well for intermittent issues with most populations Aspirin, Ibuprofen, or Naproxen- watch with blood thinners, pregnancy, or cardiac issues Caffeine- can worsen symptoms in some populations Serotonin receptor agonist- Sumatriptan (Imitrex)- Can be IM, SQ or nasal routes. Focuses on vasoconstriction of cerebral blood vessels.Abortive therapy only, take early in migraine Organic Causes of Erectile Dysfunction HTN, DMI/DMII, CKD, MS, acute spinal injury, endocrine disorders Psychogenic Causes of Erectile Dysfunction Low energy, anxiety, depression, pressure to perform, trust or relationship issues Erectile Dysfunction Assessment Determine if there is a secondary cause prior to treatment Phosphodiesterase type 5 (PDE-5) inhibitors (Sildenafil- Viagra, Tadalafil- Cialis) is often first line medication class. Watch cardiac history and do not take more than daily For more severe forms surgical intervention may be necessary Balloon pumps Patients can use self injections or suppositories Peripheral Arterial Occlusive hallmark symptom is intermittent claudication described as aching, cramping, or inducing fatigue or weakness that occurs with some degree of exercise or activity, which is relieved with rest. Statins improve endothelial function in patients with PAD. Studies suggest that statins improve symptoms of intermittent claudication and also increase walking distance to the onset of claudication HF Lab Value BNP Left Heart Failure Symptoms Paroxysmal Nocturnal Dyspnea Cough Crackles Wheezes Blood Tinged Tachypnea Restlessness Confusion Orthopnea Tachycardia 19 Downloaded by Cedric Barnes ([email protected])  lOMoARcPSD|47091348 Exertional Dyspnea Fatigue Cyanosis Ways to Change Lifestyle for Hypertension Weight Reduction Adapt DASH eating Dietary Sodium Reduction Physical Activity Moderation of alcohol Powerpoint Gallbladder Risk Factors Female gender >40 years old Hx of children Obesity Post Op Bariatric Watch for dumping syndrome and vitamin/mineral imbalances Ulcers can be possible Bleeding Three Top Symptoms of GERD Heartburn- most common clinical manifestation Dyspepsia (pain or discomfort centered in upper abdomen) Regurgitation (Described as hot, bitter, or sour liquid coming into throat or mouth) Common Symptoms of Crohn's Diarrhea Crampy abdominal pain (especially after meals) Malnourishment (think- small intestine) Secondary anemia Things to know about Crohn's from Powerpoint Inflammation involving all layers of the bowel wall Occurring anywhere in the GI tract "skip" lesions- areas of disease alternating with healthy GI tract Ulcerations are deep, have a cobblestone appearance Strictures at areas of inflammation may cause bowel obstruction Oral fluids and a low-residue, high-protein, high-calorie diet with supplemental vitamin therapy and iron replacement Because inflammation goes through the entire wall, microscopic leaks can allow bowel contents to enter the peritoneal cavity Peritonitis or abscesses possible Common Symptoms of Ulcerative Colitis Bloody diarrhea Mucus or pus may also be present Left lower quadrant abdominal pain 20 Downloaded by Cedric Barnes ([email protected])  lOMoARcPSD|47091348 What to know about Ulcerative Colitis from Powerpoint Decrease inflammation and watch for changes Disease of the mucosal layer of the colon and rectum Typically starts in the rectum and moves inward Best viewed in colonoscopy Diarrhea with marked fluid loss Damage to mucosa, breakdown of cells, possible formation of pseudopolyps Treatment of Asthma Inhaled steroids for maintenance and long term control Short acting Beta-2 agonist or bronchodilator for short term/immediate Pneumonia Treatment Supportive care Oxygen for hypoxemia Analgesics for chest pain Antipyretics Individualize rest and activity PPSV 23 (Pneumovax) Antibiotic therapy Symptoms should improve in 3-5 days, if not IV abx may be needed Malignant Hyperthermia Treatment Cooling blanket IV fluids 100% oxygen Dantrolene (muscle relaxant) Hyponatremia Fluid Volume Loss, Hyponatremia occurs with increased thirst and ADH release. Hyponatremia occurs with diuresis owing to increased release of ADH secondary to reduction in circulating volume Dilutional Hyponatremia Definition FROM GOOGLE (on study guide but not in realizeit): ○ Dilutional hyponatremia, also known as water intoxication, is a potentially life-threatening condition which occurs when a person consumes too much water without an adequate intake of electrolytes Hypokalemia - Diuretics Hypokalemia can occur with all diuretics except those that work in the last distal tubule of the nephrons. potassium-sparing diuretics (e.g., spironolactone, triamterene, amiloride) Potassium supplements can be prescribed to avoid this complication. SLE- Skin Care Wear Sunscreen 21 Downloaded by Cedric Barnes ([email protected])  lOMoARcPSD|47091348 Regular Insulin Onset, Peak, & Duration Onset 30-60min Peak 2-3 hours Duration 4-6 hours Usually give 20-30 minutes before meal. May be taken along or in combination with longer acting insulin Rheumatoid Arthritis Plan of Care Meds: Methotrexate NSAIDS Short term steroid tapers PT and exercise used Energy conservation Avoid long term immobilization Type One Diabetes Autoimmune- body destroys beta cells in islets of Langerhans Only treatment is close monitoring and insulin 3 P's DKA is extreme hyperglycemia Type Two Diabetes Most common Body makes some insulin, but not enough to meet bodies needs Obesity is the most common risk factor HHS is extreme hyperglycemia Renal Calculi Make pain meds a priority! Straining urine to collect stone Test stone to determine type Prevent with diet ○ Oxalate- Spinach, beets, rhubarb, nuts/ seeds, black tea ○ Calcium Phosphate- dairy, rice, many green veggies, tofu ○ Uric Acid- high purine foods- organ meat, salmon, beer, wine, aged cheeses Treat with lithotripsy Hyperkalemia occurs with Hyperkalemia occurs with adrenal insufficiency. Hypernatremia Results From Hypernatremia results from increased insensible losses and diabetes insipidus. ABGs Bowel Obstruction FROM GOOGLE (Nothing in Realizit) ○ Patients with an SBO are at risk for metabolic acidosis and alkalosis due to vomiting and malabsorption of gastric contents related to the obstruction. Metabolic acidosis and alkalosis 22 Downloaded by Cedric Barnes ([email protected])  lOMoARcPSD|47091348 typically resolve when the SBO resolves. ○ Proximal small bowel obstructions cause early and abundant vomiting with fluid, Cl, Na, and K loss, and consequently dehydration, hypokalemia, hyponatremia, hypochloremia, and metabolic alkalosis. Methotrexate (Rheumatrex) DMARD Used in Rheumatoid Arthritis Immunosuppressant Liver function tests help guide methotrexate dosage Administration of methotrexate is weekly for rheumatoid arthritis or psoriasis, and patients should keep an accurate record of the date and time of each dose. To reduce gastric upset, they may take the drug with food. However, daily dosing for cytotoxic immunosuppressants should be consistent with regard to time and food (i.e., at the same time of day, with the same meal). PAD Signs & Symptoms Intermittent claudication Dependent edema, but elevation increases discomfort Pain while exercising- will improve with rest Cyanosis common Unequal or absent pulses Heart Failure Assessment Respiratory crackles, SOB. Excess sputum (pulmonary edema- pink, frothy sputum) Lower extremity swelling, reports of tight socks/shoes Weight gain (3lbs in a day, 5lbs in a week) BPH (Powerpoint) Significant amount of men > 60yrs will be affected- common complaint Prostate enlarges over time and can impede urine flow Often diagnosed by patient report of symptoms Not cancerous or painful Chronic retention issues can lead to a lower urinary tract infection (UTI) Right Sided Heart Failure Fatigue Distended Neck Veins Anorexia & complaints of GI distress Weight Gain Dependent Edema Enlarged liver and spleen Increased venous pressure Ascites 23 Downloaded by Cedric Barnes ([email protected])