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Adult Health Nursing II > HESI Review > Flashcards

HESI Review Flashcards

1
Q

Pneumonia Nursing Assessment

A

Tachypnea, shallow respirations with accessory muscles

Productive cough with pleuritic pain

Rapid, bounding pulse

Pain and dullness to percussion

Increased fremitus

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2
Q

Nursing Interventions for Pneumonia

A

Assess sputum

TCDB q2h

Humidity, suctioning, physiotherapy

Fluids

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3
Q

Early Signs of Cerebral Hypoxia

A

Irritability and restlessness

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4
Q

COPD Hints

A

Compensation occurs over time, ABGs are altered

Hypoxemia and hypercapnia

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5
Q

Normal pH

A

7.35–7.45

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6
Q

Normal PCO2

A

35–45 mmHg

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7
Q

Normal PO2

A

80–100 mmHg

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8
Q

Normal HCO3

A

21–28 mEq/L

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9
Q

Pathophysiology of Chronic Bronchitis

A

Chronic sputum with cough production

Chronic hypoxemia, cor pulmonale

Increase in mucus, cilia production

Increase in bronchial wall thickness

Higher incidence in smokers

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10
Q

Assessment of Chronic Bronchitis

A

Generalized cyanosis

“Blue bloaters”

Right-sided heart failure

Distended neck veins

Crackles

Expiratory wheezes

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11
Q

Nursing Interventions for Chronic Bronchitis and Emphysema

A

Lowest FiO2 possible to prevent CO2 prevention

Monitor for S/S of fluid overload

Teach pursed lip breathing and diaphragmatic breathing

Teach tripod position

Bronchodilators and anti-inflammatory agents

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12
Q

Pathophysiology of Emphysema

A

Reduced gas exchange surface area

Increased air trapping

Cigarette smoking, exposure, genetic

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13
Q

Assessment of Emphysema

A

Barrel chest

Pursed lip breathers

Wheezes

Pulmonary blebs on radiograph

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14
Q

Precipitating Factors for Asthma

A

Mucosal edema

Increased work of breathing

Beta blockers

Respiratory infection

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15
Q

Assessment of Asthma

A

Dyspnea, wheezing, chest tightness

Assess precipitating factors

Medication history

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16
Q

Nursing Interventions for Asthma

A

Administer bronchodilators

Administer fluids and humidification

ABGs

Ventilatory patterns

C-PAP and Bi-PAP

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17
Q

Nursing Assessment of Pulmonary Tuberculosis

A 
Fever with night sweats
Anorexia, weight loss
Malaise, fatigue
Cough, hemoptysis
Repeated URIs
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18
Q

Drug Therapy for Tuberculosis

A

Drug therapy is usually long-term

DO NOT skip doses

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19
Q

Chest Tubes

A

If it becomes disconnected, immediately place end of tube in a container of sterile water

Cover client with a dry sterile dressing taped on three sides

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20
Q

Typical Daily Urine Output

A

1500–2000 mL

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21
Q

Nephrotoxic Drugs

A

Salicylates, antibiotics, NSAIDs, ACE inhibitors, angiotensin receptor blockers

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22
Q

Nursing Assessment for Acute Kidney Injury

A

Alterations in urinary output

Edema, weight gain

Change in mental status

Hematuria

Dry mucous membranes

Drowsiness, headache, muscle twitching, seizures

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23
Q

Primary Extracellular Ions

A

Sodium and chloride

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24
Q

Primary Intracellular Ions

A

Potassium and phosphate

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25
Risk Factors for Acute Kidney Inury
``` Chronic kidney disease Older age Massive trauma Major surgical procedures Extensive burns Cardiac failure Sepsis Obstetric complications ```
26
Nursing Interventions for Acute Kidney Injury
Monitor intake and output Weigh daily Report any change in fluid volume status Adequate protein intake Monitor electrolyte status Potassium and sodium restriction
27
Signs/Symptoms of Hyperkalemia
Dizziness Weakness Cardiac irregularities Muscle cramps Diarrhea Nausea
28
Nursing Assessment for Chronic Renal Failure
History of renal disease, hypertension, diabetes Edema, pulmonary edema Decreasing urinary function (hematuria, proteinuria, cloudy urine, oliguria, anuria)
29
Nursing Interventions for Chronic Renal Failure
Restrict protein Monitor serum electrolyte levels Weigh daily, strict I&O Check for JVD and edema Low-protein, low-sodium, low-potassium, low-phosphate diet
30
Nursing Assessment for Urinary Tract Obstructions
Pain Fever, chills, NVD, abdominal distention Changes in voiding pattern (dysuria, hematuria, urgency, frequency, hesitancy, incontinence)
31
Nursing Interventions for Urinary Tract Obstructions
Administer analgesics and alpha-adrenergic blockers Moist heat to painful area High oral fluid intake Strain all urine
32
Nursing Assessment for Benign Prostatic Hyperplasia
Increased frequency of voiding with a decrease in amount Nocturia Hesitancy Terminal dribbling Acute urinary retention Bladder distention Recurrent UTIs
33
Nursing Interventions for Benign Prostatic Hyperplasia
Observe color and content of urinary output Monitor for signs of hemorrhagic or hypovolemic shock Increase fluid intake to 3000 mL/day
34
Causes of Angina
Atherosclerotic heart disease Hypertension Coronary artery spasm Hypertrophic cardiomyopathy Physical exertion, cold temperatures
35
Nursing Assessment of Angina
Pain, dyspnea, tachycardia, palpitations, nausea, vomiting, fatigue, diaphoresis, pallor, weakness, syncope, dysrhythmias
36
Nursing Interventions for Angina
Provide immediate rest, take vital signs, record an ECG Administer no more than three nitroglycerin tablets 5 minutes apart
37
Antianginals
Nitrates (nitroglycerin, isosorbide) Beta Blockers (propranolol) Calcium Channel Blockers (verapamil, nifedipine)
38
Nursing Assessment of MI
Sudden onset of pain in the lower sternal region Rapid, irregular, and thready pulse Decreased LOC Cardiac dysrhythmias Cardiogenic shock or fluid retention Troponin
39
Nursing Interventions for MI
Obtain vital signs and ECG Administer oxygen Keep in semi-Fowler's position Bed rest for 12 hours MONA: morphine, oxygen, nitroglycerin, aspirin
40
Nursing Assessment of Arterial Insufficiency
Associated with Raynaud's, Buerger's, diabetes, acute occlusion Smooth, shiny, cool skin Loss of hair Thickened nails Pallor on elevation Decreased or absent pulses Sharp pain increases with walking and elevation
41
Nursing Assessment of Venous Insufficiency
Brown pigment around ankles Warm Pulses are normal Persistent aching, full feeling, dull sensation Relieved when horizontal
42
Antihypertensives
Alpha-Adrenergic Blockers (Prazosin, Terazosin) Beta Blockers (Metaprolol, Propranolol) Vasodilators (Hydralazine) Angiotensin II Receptor Antagonists (Losartan) ACE Inhibitors (Captopril) Calcium Channel Blockers (Nifedipine)
43
Anticoagulants
Heparin Warfarin Antiplatelet agents (Clopidogrel) LMWH (Enoxaparin)
44
Nursing Interventions for Peripheral Vascular Disease
Monitor extremities at designated intervals Encourage rest at first sign of pain Encourage elevation
45
Nursing Assessment of Abdominal Aortic Aneurysm
Bruit Abdominal or lower back pain May feel heartbeat in abdomen Symptoms of rupture: hypovolemic or cardiogenic shock with sudden, severe abdominal pain
46
Assessments Required within the First Few Hours of Abdominal Aortic Dissection
Vital sings every hour Neurologic vital signs Respiratory status Urinary output Peripheral pulses
47
Nursing Assessment for Thrombophlebitis
Calf tenderness, redness or pain Edema and warmth in extremity Functional impairment of the extremity
48
Heparin
Antagonist: protamine sulfate Laboratory: PTT or aPTT Keep 1.5 to 2.5 times normal control
49
Warfarin
Antagonist: vitamin K Laboratory: PT Keep 1.5 to 2.5 times normal control INR therapeutic level usually 2--3
50
Nursing Interventions for Thrombophlebitis
Observe client for bleeding Monitor laboratory data Antiembolic stockings Advise bedrest Monitor for pulmonary embolus
51
Nursing Assessment of Heart Failure
Left-sided: dyspnea, orthopnea, crackles, cough, fatigue, confusion, restlessness Right-sided: peripheral edema, weight gain, distended neck veings, hepatomegaly, ascites High BNP levels indicate heart failure
52
Digitalis
Side effects are increased when client is hypokalemic Negative chronotropic effect (slows heart rate); hold if pulse rate is less than 60 or greater than 120 Digitalis toxicity includes bradycardia, tachycardia, nausea, vomiting, headache
53
Nursing Interventions for Heart Failure
Monitor vital signs every 4 hours Assess for hypoxia Auscultate lungs Elevate HOB Observe for signs of edema Limit sodium intake
54
Nursing Assessment of Endocarditis
Fever, chills, malaise, night sweats, fatigue, murmurs, symptoms of heart failure, atrial embolization
55
Nursing Assessment of Pericarditis
Sudden, sharp, severe pain in substernal region Pericardial friction rub heart best at left lower sternal border Fever
56
Nursing Interventions for Endocarditis
Monitor hemodynamic status Encourage client to to maintain good hygiene Instruct client to inform dentist and other health providers of history
57
Nursing Interventions for Pericarditis
Provide rest and maintain position of comfort Administer analgesics and anti-inflammatory drugs
58
Nursing Assessment for Valvular Heart Disease
Pericardial effusion with possible tamponade that required pericardiocentesis Fatigue, dyspnea, orthopnea, hemoptysis and pulmonary edema, murmurs, angina
59
Nursing Interventions for Valvular Heart Disease
Teach the necessity for prophylactic antibiotic therapy before any invasive procedure Need for lifelong anticoagulant therapy with mechanical valve replacement
60
Nursing Assessment for Hiatal Hernia and GERD
Heartburn after eating that radiates to arms and shoulders Feeling of fullness and discomfort after eating Positive diagnosis determined by fluoroscopy, barium swallow, or gastroscopy
61
Nursing Interventions for Hiatal Hernia and GERD
Encourage small, frequent meals Sit up while eating Stop eating 3 hours before bedtime Elevate HOB
62
Antiulcer Drugs
Antacids (aluminum hydroxide) Histamine-2 Antagonists (cimetidine) PPIs (lansoprazole) Prokinetic drugs Antiemetics Cough suppressants Stool softeners
63
Nursing Assessment of Peptic Ulcer Disease
Determine presence of melena Potential complications include hemorrhage, perforation, obstruction) EGD, barium swallow, gastric analysis
64
Nursing Interventions for Peptic Ulcer Disease
Determine symptom onset and how symptoms are relieved Monitor stools Encourage small, frequent meals Teach that dumping syndrome may occur postoperatively Teach symptoms of GI bleedng
65
Clinical Manifestations of GI Bleeding
Pallor Dark, tarry stools Bright-red or coffee-ground emesis Abdominal mass or bruit Decreased BP, rapid pulse, cool extremities, increased respirations
66
Nursing Assessment of Crohn's Disease
Abdominal pain in right lower quadrant Diarrhea, steatorrhea, weight loss Constant fluid loss Low-grade fever Weight loss, anemia, malnutrition
67
Nursing Interventions for Crohn's Disease
Provide well-balanced, low-residue, low-fat, high-protein, high-calorie diet Provide complete bowel rest Administer aminosalicylates, antimicrobials, corticosteroids, immunosuppressants, biologic therapy Weigh at least twice a week
68
Nursing Assessment of Ulcerative Colitis
Diarrhea, abdominal pain and cramping Intermittent tenesmus and rectal bleeding Liquid stools containing blood, mucus, and pus Weakness and fatigue, anemia
69
Nursing Interventions for Ulcerative Colitis
Avoid caffeinated beverages, smoking, pepper, and alcohol Provide complete bowel rest Administer corticosteroids, antidiarrheals, biologic treatments Monitor I&O and serum electrolytes Weigh at least twice a week
70
Nursing Assessment of Diverticular Disease
Left lower quadrant pain Increased flatus Signs of intestinal obstruction (constipation/diarrhea, abdominal distention, anorexia, low-grade fever) Barium enema or colonoscopy positive for diverticular disease
71
Nursing Interventions for Diverticular Disease
Well-balanced, high-fiber diet unless inflammation is present, in which client will be NPO followed by low-residue foods Bulk-forming laxatives Increase fluids to 3 L/day Monitor I&O and bowel elimination
72
Mechanical Bowel Obstruction
Due to disorders outside the bowel (hernia, adhesions) by disorders within the bowel (tumors, diverticulitis) or by blockage of the lumen in the intestine
73
Nonmechanical Bowel Obstruction
Due to paralytic ileus
74
Nursing Assessment of Intestinal Obstruction
Sudden onset of abdominal pain, tenderness, or guarding Distention Increased peristalsis when obstruction first occurs, then paralytic ileus causes absent peristalsis Bowel sounds are high pitched early and diminished late
75
Nursing Interventions for Intestinal Obstruction
Maintain client NPO with IV fluids and electrolyte therayp Monitor I&O Implement NG intubation Assess abdomen regularly for distention, rigidity, change of status in bowel sounds
76
Diet to Prevent Bowel Cancer
Eat more cruciferous vegetables (cabbage family) Increase fiber intake Maintain average body weight Eat less animal fat
77
Recommendations for Early Detection of Colon Cancer
Digital rectal examination every year after 40 Stool blood test every year after 50 Colonoscopy or sigmoidoscopy every 10 years after the age of 50
78
Nursing Assessment of Colorectal Cancer
Rectal bleeding Change in bowel habits Sense of incomplete evacuation, tenesmus Abdominal pain, nausea, vomiting, weight loss, cachexia Abdominal distention or ascites History of polyps
79
Nursing Interventions for Colorectal Cancer
Bowel preparation (GoLYTELY) High-calorie, high-protein diet High-fiber
80
Nursing Assessment of Cirrhosis
Weakness, malaise Anorexia, weight loss Palpable liver early Jaundice Fruity breath Bruising, erythema Gyencomastia
81
Clinical Manifestations of Jaundice
Yellow skin, sclera, or mucous membranes Dark-colored urine Chalky or clay-colored stools
82
Laboratory Findings for Cirrhosis
Elevated bilirubin, AST, ALT, alkaline phosphatase, PT, and ammonia Decreased Hgb, Hct, electrolytes, potassium, sodium, and albumin
83
Nursing Interventions for Cirrhosis
Bleeding precautions Monitor fluid and electrolyte status daily Restrict protein, low sodium, low potassium, low fat, high carbohydrate
84
Nursing Assessment of Hepatitis
Fatigue, malaise, weakness, anorexia, nausea, vomiting Jaundice, dark urine, clay-colored stools Myalgia, joint pain Dull headaches, irritability, depression Abdominal tenderness in right upper quadrant Elevations of ALT, AST, alkaline phosphatase, bilirubin
85
Nursing Interventions for Hepatitis
High-calorie, high-carbohydrate diet with moderate fats and proteins Administer interferon, nucleoside and nucleotide analogs, protease inhibitors, and antiemetics as prescribed Adhere to personal hygiene Promote rest
86
Nursing Assessment for Acute Pancreatitis
Severe midepigastric pain radiating to back Abdominal guarding, boardlike abdomen Elevated temperature, tachycardia, decreased BP Bluish discoloration of flanks (Grey Turner) or umbilicus (Cullen) Elevated amylase, lipase, triglycerides, and glucose levels
87
Nursing Assessment for Chronic Pancreatitis
Continuous burning or gnawing abdominal pain Recurring attacks of severe upper abdominal and back pain Ascites Steatorrhea, diarrhea Weight loss Jaundice, dark urine S/S of DM
88
Nursing Interventions for Acute Pancreatitis
Maintain NPO status Hydromorphone or fentanyl as needed Antacids, H2 receptor blocking drugs, anticholinergics, PPIs Monitor for neuromuscular manifestations of hypocalcemia Place in semi-Fowler position Lean forward to reduce pain
89
Nursing Interventions for Chronic Pancreatitis
Administer hydromorphone, fentanyl, morphine as needed Monitor stools for number and consistency Bland, low-fat diet Monitor for S/S of DM
90
Nursing Assessment for Cholecystitis and Cholelithiasis
Pain, anorexia, vomiting, or flatulence following fried, spicy, or fatty foods Fever, elevated WBCs, and other signs of infection Abdominal tenderness Jaundice and clay-colored stools (blockage) Elevated liver enzymes, bilirubin, and WBCs
91
Nonsurgical Management of Cholecystitis
Low-fat diet Decompression of the stomach via NG tube Medications for pain and clotting if required
92
Nursing Assessment of Hyperthyroidism
Enlarged thyroid gland Weight loss, increased appetite, diarrhea, heat intolerance, tachycardia, increased systolic blood pressure, diaphoresis, nervousness Exophthalmos T3 and T4 elevated
93
Nursing Interventions for Hyperthyroidism
Observe for signs of thyroid storm High-calorie, high-protein, low-caffeine, low-fiber diet PTU and methimazole
94
Normal Serum Calcium
9.0--10.5
95
Chvostek Sign
Twitching of upper lip after a tap over the facial nerve
96
Trousseau Sign
Carpopedal spasm after BP cuff is inflated
97
Nursing Assessment for Hypothyroidism
Fatigue, weigh gain Thin, dry hair and thick, brittle nails Bradycardia, hypotension Cold intolerance, weight gain, dull emotions and mental processes Low T3, low T4
98
Nursing Interventions for Hypothyroidism
Bowel elimination plan to prevent constipation Avoid sedating the client
99
Corticosteroids
Hydrocortisone, prednisone, dexamethasone, methylprednisone
100
Nursing Assessment for Addison's Disease
Fatigue, weakness, weight loss, anorexia, postural hypotension Hypoglycemia, hyponatremia, hyperkalemia, hyperpigmentation
101
Nursing Interventions for Addison's Disease
Take vital signs frequently Monitor I&O and weigh daily Administer IV glucose with parenteral hydrocortisone during crisis Monitor serum electrolyte levels Reduce stress
102
Addisonian Crisis
Vascular collapse--administer IV fluids rapidly until stabilized Hypoglycemia--administer IV glucose Reverse crisis by administering parenteral hydrocortisone Aldosterone replacement--administer fludocortisone acetate with simultaneous administration of sodium chloride
103
Nursing Assessment of Cushing Syndrome
Moon face, truncal obesity, buffalo hump, abdominal striae, muscle atrophy Hyperglycemia, hypernatremia, hypokalemia
104
Nursing Interventions for Cushing Syndrome
Encourage to protect from exposure to infection Provide low-sodium diet, encourage consumption of foods that contain vitamin D and calcium Take steroids with meals to prevent gastric irritation
105
Clinical Characteristics of Type I DM
Results from progressive loss of autoimmune-based destruction of beta cells Can become hyperglycemic and ketosis-prone relatively easily
106
Clinical Characteristics of DKA
Serum glucose of 250 or above Ketonuria in large amounts Arterial pH of < 7.3 and HCO3 < 15 Nausea, vomiting, dehydration, abdominal pain, Kussmaul's respirations, acetone odor to breath
107
Treatment of DKA
Isotonic IV fluids 0.9% NaCl until BP is stabilized Slow infusion by IV pump of regular insulin Careful replacement of potassium
108
Pathophysiology of Type II DM
Results from either inadequate production of insulin by the body or lack of sensitivity to the insulin being produced Can develop HHNKS
109
Clinical Characteristics of Hyperosmolar Hyperglycemic Nonketotic Syndrome
Hyperglycemia greater than 600 Plasma hyperosmolality Dehydration Changed mental status Abent ketone bodies
110
Treatment of Hyperosmolar Hyperglycemic Nonketotic Syndrome
Usualy with isotonic IV fluid replacement and careful monitoring of potassium and glucose levels IV insulin until blood glucose stabilizes at 250
111
Nursing Assessment of Diabetes
Retinopathy Angina, dyspnea, HTN Hair loss, poor perfusion, pallor Edema, UTI, renal failure, diabetic nephropathy Nighttime diarrhea, gastroparesis Impotence, vaginal dryness, vaginal infections, menstrual irregularities
112
Rapid Acting Insulin
Human insulin lispro aspart Give within 15min of meal
113
Short Acting Insulin
Regular insulin May be given IV
114
Intermediate Acting Insulin
Isophane insulin Combines rapid acting regular insulin with intermediate acting NPH
115
Long Acting Insulin
Glargine Give once daily at bedtime
116
Hyperglycemia
Polydipsia, polyuria, polyphagia, blurred vision, weakness, weight loss, syncope Encourage water intake Check blood glucose frequently Assess for ketoacidosis
117
Hypoglycemia
Headache, nausea, sweating, tremors, lethargy, hunger, confusion, slurred speech, tingling around the mouth Treat immediately with a complex carbohydrate (glucose gel, fruit juice, jelly beans, gum drops) Check blood glucose (may seize if < 40)
118
Nursing Assessment of Rheumatoid Arthritis
Fatigue, generalized weakness, weight loss, anorexia, morning stuffiness, bilateral inflammation of the joints, joint deformity
119
Diagnosis of Rheumatoid Arthritis
Elevated ESR Positive rheumatoid factor Presence of antinuclear antibody Arthroscopic examination Abnormal synovial fluid C-reactive protein
120
Nursing Interventions for Rheumatoid Arthritis
Moist heat Provide periods of rest after periods of activity Avoid overexertion Encourage use of assistive devices
121
NSAIDS
Aspirin, ibuprofen, indomethacin, ketorolac, naproxen, celecoxib May cause GI symptoms Hepatotoxic Check liver/renal labs and CBC
122
Nursing Assessment of Lupus
Dry, scaly rash on upper face or upper body Joint pain, fever, nephritis, pleural effusion, pericarditis, abdominal pain, photosensitivity, HTN
123
Nursing Interventions for Lupus
Avoid exposure to sunlight Monitor and instruct client in administration of steroids
124
Nursing Assessment of Osteoarthritis
Joint pain that increases with activity and improves with rest Morning stiffness Asymmetry of affected joints Crepitus Limited movement Joint enlargement and bony nodules
125
Nursing Interventions for Osteoarthritis
Weight-reduction diet Use correct posture and body mechanics Encourage rest
126
Nursing Assessment of Osteoporosis
Kyphosis of the dorsal spine Loss of height Back pain Pathologic fractures Compression fracture of spine Postmenopausal white women are at highest risk
127
Nursing Interventions for Osteoporosis
Keep bed in low position Provide assistance with ambulation Diet high in protein, calcium, and vitamin D; discourage alcohol and caffeine Hormone replacement therapu
128
Fat Embolism
Greatest risk 36 hours after a fracture Initial symptom is confusion due to hypoxemia Petechial rash
129
5 Ps of Neurovascular Functioning
Pain Paresthesia Pulse Pallor Paralysis
130
Nursing Assessment of Joint Replacement
Joint pathology (OA, rheumatoid arthritis, fracture) Pain not relieved by medication Poor ROM in the affected joint
131
Nursing Interventions for Amputations
Change dressing as needed Monitor for signs of infection Position client to relieve edema and spasms at residual limb site Elevate residual limb for the first 24 hours postoperatively (only on one pillow) Keep residual limb in extended position, and turn client to prone position three times a day to prevent contracture
132
Nursing Assessment of Glaucoma
Early signs include increase in IOP > 22 mmHg and decreased accommodation; often painless and symptom free Late signs include loss of peripheral vision, seeing halos, decreased visual acuity, headache or eye pain Diagnostic tests include tonometer to measure IOP, gonioscopy
133
Nursing Interventions for Glaucoma
Administer eye drops as prescribed Orient client to surroundings Avoid activities that may increase IOP
134
Medications for Glaucoma
Parasympathomimetics (pilocarpine) Beta-Adrenergic Receptor-Blocking Agents (careolol, levobunolol) Carbonic Anhydrase Inhibitors (acetazolamide)
135
Nursing Assessment of Cataracts
Early signs: blurred vision, decreased color perception, photophobia Late signs: diplopia, reduced visual acuity, clouded pupil Diagnosis with ophthalmoscope, slit-lamp biomicroscope, keratometry
136
Nursing Interventions for Cataracts
Fall prevention is very important Warn not to put pressure or rub on the eye
137
Nursing Assessment for Altered State of Consciousness
Glasgow Coma Scale (Max 15, Min 3) Neurologic vital signs (pupil size, limb movement, BP, temperature, pulse, respirations) Assess skin integrity and corneal integrity Check bladder for fullness, auscultate lungs, and monitor cardiac status
138
Nursing Interventions for Altered State of Consciousness
Maintain adequate respirations, airway, and oxygenation Provide nutritional and fluid and electrolyte support--NPO until responsive Prevent complications of immobility and thrombus formation Monitor and evaluate the vital sign changes--if temperature elevates, take quick measures to decrease it because fever increases cerebral metabolism and can cause cerebral edema
139
Nursing Assessment of Head Injury
Unconsciousness or disturbances in consciousness Vertigo, seizures, ataxia, abnormal posturing Confusion, delirium, disorientation Symptoms of increased ICP (change in LOC is most important indicator) Changes in vital signs (slowed respirations, increase/decrease in pulse, rising BP, rising temperature) Headache, vomiting, pupillary changes
140
Nursing Interventions for Head Injury
Maintain adequate ventilation and airway HOB at 30-45 degrees Neurologic vital signs q2h Avoid activities that increase ICP
141
Medications for Head Injury
Hyperosmotic agents (Mannitol, Urea) Steroids (Dexamethasone, Methylprednisone) Barbiturates
142
Nursing Assessment of Spinal Cord Injury
Assess breathing pattern and auscultate lungs Check neurologic vital signs Assess abdomen for girth, bowel sounds, distention Assess temperature
143
Nursing Interventions for Spinal Cord Injury
Maintain a patent airway High-dose corticosteroids Assess for respiratory failure Evaluate for hypotension, bradycardia, paralysis, bowel and bladder distention Watch for paralytic ileus
144
Nursing Assessment of Brain Tumor
Headache that is more severe on awakening Vomiting not associated with nausea Papilledema with visual changes Behavioral and personality changes Seizures
145
Nursing Interventions for Brain Tumor
Elevate HOB 30-40 degrees Similar to increased intracranial pressure interventions
146
Craniotomy Preoperative Medications
Corticosteroids to reduce swelling Agents and osmotic diuretics to reduce secretions (atropine, glycopyrrolate) Agents to reduce seizures (phenytoin) Prophylactic antibiotics
147
Nursing Assessment of Multiple Sclerosis
Visual or swallowing defects Gait disturbances Unusual fatigue, weakness, or clumsiness Numbness, speech disturbances, impaired bowel/bladder control Usually begin in the upper extremities with weakness progressing to spastic paralysis
148
Nursing Interventions for Multiple Sclerosis
Encourage rest periods Voiding schedule Adequate fluid intake, high-fiber foods, and a bowel regimen ACTH, cortisone, cyclophosphamide, immunosuppressive drugs
149
Nursing Assessment for Myasthenia Gravis
Diplopia, ptosis, masklike affect Weakness of laryngeal and pharyngeal muscles (choking, food aspiration, difficulty speaking) Muscle weakness improved by rest Respiratory failure, bladder and bowel incontinence
150
Myasthenic Crisis
Attributed to disease worsening Associated with undermedication More difficulty swallowing, diplopia, ptosis, dyspnea
151
Cholingergic Crisis
Attributed to anticholinesterase overdosage Diaphoresis, diarrhea, fasciculations, cramps, marked worsening of symptoms
152
Treatment of Myasthenia Gravis
Diagnosis made by positive Tensilon test Pyridostigmine bromide Can cause cholingergic crisis
153
Nursing Interventions for Myasthenia Gravis
Conserve energy as much as possible Administer cholinergic drugs as prescribed TCDB every 4-6 hours
154
Nursing Assessment of Parkinson Disease
Rigidity of extremities Masklike facial expressions with associated difficulty in chewing, swallowing, and speaking Drooling Tremors at rest, "pill-rolling" movement Emotional lability
155
Nursing Interventions for Parkinson Disease
Schedule activities later in the day Encourage activities and exercise Eliminate environmental noise Serve a soft diet Antiparkinson drugs
156
Antiparkinson Drugs
Anticholinergics (atropine) Dopamine Replacements (levodpa) Monoamine Oxidase Type B Inhibitors (selegiline) COMT Inhibitors (entacapone)
157
Nursing Assessment of Guillain-Barre Syndrome
Paresthesia Muscle weakness of legs progressing to the upper extremities, trunk, and face Paralysis of the ocular, facial, and oropharyngeal muscles Increasing pulse rate and disturbances in rhythm Transient HTN Weakness or paralysis in intercostal and diaphragm muscles
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Nursing Interventions for Guillain-Barre Syndrome
Monitor for respiratory distress and initiate mechanical ventilation if necessary
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Hemorrhagic Stroke
Caused by a slow or fast hemorrhage into the brain tissue, often related to HTN
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Embolic Stroke
Caused by a clot that has broken away from a vessel Often related to atherosclerosis
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Behavior with Left Hemisphere Disruption
``` Slow Cautious Anxiety Depression Sense of guilt Feeling of worthlessness Worries over future Quick anger and frustration ```
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Behavior with Right Hemisphere Disruption
``` Impulsive Unaware of neurological deficits Confabulates Euphoric Constantly smiles Denies illness Poor judgment Impaired sense of humor ```
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Nursing Assessment of Stroke
``` Change in LOC Paresthesia, paralysis Aphasia, agraphia Memory loss Vision impairment Bowel/bladder dysfunction Behavioral changes ```
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Nursing Interventions for Stroke
Control HTN Maintain proper body alignment when in bed Perform full ROM four times a day Analyze bladder elimination pattern Steroids administered to decrease cerebral edema and retard permanent disability
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Apraxia
Inability to perform purposeful movements in the absence of motor problems
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Dysarthria
Difficulty articulating
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Nursing Assessment for Anemia
Pallor, fatigue, exercise intolerance, lethargy, orthostatic hypotension Tachycardia, heart murmurs, heart failure Signs of bleeding Cool skin, cold intolerance
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Diagnostic Tests for Anemia
Hgb < 10 Hct < 36% RBCs < 4 x 10^12 Bone marrow aspiration positive for anemia
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Nursing Interventions for Anemia
Alternate periods of activity with periods of rest Eat more iron, folic acid, and vitamin B12 rich foods Take iron on empty stomach, take with vitamin C Sickle cell crisis is precipitated by hypoxia Stools may turn black
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Administration of Iron
DO use z-track method, air bubble to avoid withdrawing medication into subcutaneous tissue DON'T use deltoid muscle, massage injection site
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Acute Myelogenous Leukemia
Involves inability of leukocytes to mature Can occur at any time in the life cycle Onset is insidious Poor prognosis; cause of death tends to be infection
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Chronic Myelogenous Leukemia
Results from abnormal production of granulocytic cells Occurs in young to middle-aged adults Poor prognosis Oral antineoplastic agents (hydroxyura, interferon, gleevec)
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Acute Lymphocytic Leukemia
Abnormal leukocytes are found in blood-forming tissue Occurs in children (most common childhood cancer) Prognosis is favorable
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Chronic Lymphocytic Leukemia
Increased production of leukocytes and lymphocytes Occurs after age 35 Favorable prognosis Most clients are asymptomatic and are never treated
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Nursing Assessment for Leukemia
Tendency to bleed Anemia Infection GI distress
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Nursing Interventions for Leukemia
Monitor WBC count daily Monitor vital signs frequently Teach importance of infection control
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Nursing Assessment for Hodgkin Disease
Enlarged lymph nodes Anemia, thrombocytopenia, elevated leukocytes, decreased platelets Fever, increased susceptibility to infections Anorexia, weight loss Malaise, bone pain Night sweats, pruritus, pain
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Nursing Interventions for Hodgkin Disease
Protect client from infection Observe for signs of anemia Provide adequate rest Encourage high-nutrient foods
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Nursing Assessment of Benign Tumors of the Uterus
Menorrhagia (most important factor related to benign uterine tumors) Dysmenorrhea Uterine enlargement Low back pain and pelvic pain
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Nursing Assessment of Uterine Prolapse, Cystocele, and Rectocele
Uterine Prolapse: dysmenorrhea, dyspareunia, pressure, protrusions, fatigue, low backache Cystocele: incontinence, urinary retention, cystitis Rectocele: constipation, hemorrhoids, sense of pressure/need to defecate
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Nursing Interventions for Hysterectomy
Administer enema and douche as ordered Avoid rectal thermometers or tube Encourage ambulation Monitor urinary output Maintain adequate fluid intake Notify physician of elevated temperature, swelling of suture line, or foul-smelling vaginal drainage
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Nursing Assessment of Ovarian Cancer
Asymptomatic in early stages Laparotomy is primary tool for diagnosis/staging Pelvic discomfort, low back pain, weight change, abdominal pain, nausea/vomiting, constipation, urinary frequency
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Nursing Interventions for Ovarian Cancer
Major emphasis on early detection
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Nursing Assessment of Breast Cancer
Hard lump (not freely movable and not painful) Dimpling of skin Retraction of nipple Discharge from nipple Pain and ulcerations
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Nursing Interventions for Breast Cancer
Assess lesion (size, location, shape, consistency, fixation, lymph node involvement) Monitor for bleeding Avoid BP, injections, venipuncture in arm of surgery
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Nursing Assessment of Testicular Cancer
Early signs are subtle and go unnoticed Lump or swelling (painless) on the testicle Low back pain, weight loss, fatigue
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Nursing Interventions for Testicular Cancer
Observe for hemorrhage Encourage genetic counseling Counsel that sexual functioning is usually not affected
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Nursing Assessment of Prostate Cancer
Asymptomatic if confined to gland Symptoms of urinary obstruction Elevated PSA Definitive diagnosis by biopsy
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Nursing Interventions for Prostate Cancer
Teach importance of early detection Prepare client for radiation therapy Provide preoperative bowel preparation

Adult Health Nursing II (22 decks)

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