Med Surg Flashcards
1
Q
To reduce the risk of HIV health care workers should…
A
- Hand hygiene
- wear PPE (gown, glove, mask)
- DO NOT recap needles, if necessary usr scoop technique ONLY
- put sharps in puncture proof container
2
Q
What is the CDC criteria for AIDS diagnosis?
A
- Lab confirmation
- CD4 t-lymphocytes less than 200 mcL or CD4 less than 4%
3
Q
What are the early HIV symptoms?
A
- 1st stage may be asymptomatic
- may show S&S of skin rash and fatigue
4
Q
New diagnosed AIDS home care consist of…
A
Educating self-care
- avoiding transmission
- personal hygiene
- avoiding smoking, alcohol, OTC and other street drugs
- caregiver taught hot to administer drugs
5
Q
HIV continuing care consist of…
A
- Home health nurse maybe needed
- complex wound care and respiratory care may be needed
- home care and hospice nurse may be needed
6
Q
Nursing intervention for Advanced AIDS- altered thought processes?
A
- Assess mental status and neurological function
- asses for medical interaction, infection, electrolyte imbalance, and depression
- frequently orient patient to time place person reality and environment
- use simple explanations
- instruct the patient to perform task in incremental steps
- give memory aids (clocks and calendars)
- memory aids for medications
- post activity schedule
- give positive feedback
- educate caretakers on time place person etc
- encourage patient to choose a power of attorney
7
Q
What does CD4 count less than 400 mean?
A
CD4 count serves as major lab indicator of immune function and deciding whether to initiate ART therapy and prophylaxis for opportunistic infections
-CD4
8
Q
ART considerations…
A
- ART targets stages of HIV life cycle
- patient MUST take more than 1 med which causes non-comp
- side effects cause non-comp as well
- regular labs required to evaluate effectiveness of ART for patient
- Adverse effects include
- hepatotoxicity
- nephrotoxicity
- osteopenia
- risk of CV disease and MI
- Can cause dyslipedemia and insulin resistance (risk for heart disease and diabetes)
9
Q
How do you prevent contracting HIV?
A
- Preventive education (use condoms and avoid risky sexual behaviors)
- Reproduction education (prevent transmission to infants in utero)
- Dont share needles
10
Q
Radical Mastectomy nursing interventions…
A
Pre-op
- Educate and prep
- Reduce fear and anxiety
- promote autonomy and decision making
Post-op
- Relieve pain and discomfort
- manage post-op sensations
- promote positive body image, adjustment, and coping
- improve sexual function
- NO BP, VENIPUNCTURE, OR IV on side of mastectomy
11
Q
What is the breast cancer psychological impact?
A
- difficulty making treatment decisions
- fear of pain, mutilation, loss of attractiveness, fear caring for self and family, concern about missing work, coping with uncertain future
12
Q
What to do for post op hysterectomy?
A
- Relieve anxiety
- improve body image; reassure patient that she can still have sex after temporary abstinence allowing tissue to heal.
- relieving pain
- monitor complications (Hemorrhage, VTE, and bladder dysfunction) may need catheter if having difficulty voiding
13
Q
What are the BPH assessment findings if they have urine retention? (irritative)
A
BPH is slow enlargement of prostate gland, enlarging causes hypertrophy that causes prostate to obstruct bladder and urethra causing urinary retention and cause UTIs
- Nocturia (waking up to pee)
- urgency and urinary frequency
- dysuria
- bladder pain
- incontinence
14
Q
What are the BPH assessment findings if they have urine retention? (obstructive)
A
- decrease in force of urinary symptoms
- difficulty to initiating voiding
- intermittency- starting and stopping several times
- dribbling at the end of urination
- all symptoms are due to urinary
chronic urinary retention
large residual volumes lead to azotemia (accumulation of waste products) and kidney failures
15
Q
What is the Post-Op care for TURP (Trans Urethral Resection of the Prostate)?
A
- maintain fluid balance
- relieving pain
- Monitor for complications (hemorrhage, infection, VTE, potential cath problems, urinary incontinence, sexual dysfunction
16
Q
BPH patient will have….
A
- a catheter (single of triple lumen)
- bladder irrigation
- nurse should note color of drainage (should be light pink with no clots)
17
Q
When are health care workers most at risk to contract HIV?
HIV is spread through….
A
HIV is transmitted through body fluids
- blood
- seminal fluid
- amniotic fluid
- breast milk
- vaginal secretions
18
Q
Nursing management of BPH…
A
- good peri care to prevent infection
- blood clots expected first 24-36 hrs
- large amount of blood could hemorrhage
- no activities that increase abdominal pressure (sitting, walking prolonged periods, and straining during BM)
- if bladder spasms happen, check cath for clots
- cath removed 2-4 days after surgery
19
Q
When catheter removed for BPH, patient should….
A
- void on their own within 6 hours
- poor sphincter tone, do kegal exercises (start and stop stream)
- may take several weeks to achieve urinary continence
- condom cath
20
Q
What medications should be avoided when a patient has a history of BPH?
A
-AVOID anticholergenics, antihistamines, decongestants, and antidepressants (causes urine retention)
21
Q
What are the symptoms of anemia?
A
- Tachycardia on exertion
- Fatigue
- dyspnea
- chest pain
- muscle pain
- cramping
22
Q
What is iron deficiency?
A
decreased iron stores in the bone marrow, hemoglobin synthesis depressed, and erythrocytes are small and low in hemoglobin
23
Q
What labs should be monitored for patient with anemia and/or iron deficiency?
A
Hemoglobin, hematocrit, and iron
24
Q
What are nursing interventions for post-op thyroidectomy?
A
- monitor for respiratory distress
- have tracheostomy set, oxygen, and suction at bedside
- limit patient talking, and assess hoarseness
- monitor for laryngeal nerve damage
- monitor for HYPOCALCEMIA and tetany which can be caused by trauma to the parathyroid
- prepare to administer calcium gluconate for tetany
- check for thyroid storm
25
What is a Thyroid storm?
Very high levels of thyroid hormone (severe hyperthyroidism), seen in patients with GRAVES DISEASE.
- drastically increased temperature
- sweating
- irregular heartbeat
- delirium
- weakness
- jaundice
- severely low BP
- coma
26
What are the signs of TETANY?
- cardiac dysrhythmias
- carpopedal spasms (trousseau sign)
- dysphagia
- muscle and abdominal cramps
- positive chvostek's (cheek) and trousseau signs (hand)
- wheezing
- seizures
27
When would you use calcium gluconate?
When patient becomes HYPOcalcemic and there are signs of TETANY.
28
What are the S&S for Hyperthyroidism?
- irritability, agitation, and mood swings
- tremors and nervousness
- heat intolerance
- weight loss
- smooth soft skin and hair
- tachycardia and A-Fib
- diarrhea
- EYEBALLS popping out (exophthalmos)
- sweating
- HYPERTENSION
- enlarged thyroid gland (GOITER)
29
What are the S&S for HYPOthyroidism?
- lethargy and fatigue
- intolerance to cold
- weak, muscle ache, paresthesia
- WEIGHT GAIN
- dry skin, loss of body hair
- bradycardia
- constipation
- puffiness and swelling around eyes
- loss of memory
- may or may not have goiter
30
Nursing management of HYPOTHYROIDISM...
-Activity intolerance>>> promote independence
-risk for temp imbalance>>> provide extra clothing, discourage use of external heat source
-Constipation related to decreased GI function>>>encourage fluids intake within limits
-ineffective breathing>>> monitor RR, depth, pattern, O2 sat, and ABGs
Acute confusion>>> reorient to time, place, person, etc. monitor for further changes
Myxedema and Myxedema coma>>> severe HYPOthyroidism, difficulty arousing patient
31
What is Myxedema?
Severe HYPOthyroidism that can be found in patients with Graves disease.
32
What are the complications of Crohns disease?
- intestinal obstruction
- fluid and electrolyte imbalance
- malnutrition and malabsorption
- fistula and abscess formation
33
What is C-Diff?
The most commonly identified agent in antibiotic diarrhea
- loss of appetite
- diarrhea
- weight loss
- severe abdominal pain
- WASH with SOAP AND WATER EVERYTIME!!!
34
How do you manage diarrhea?
- monitor characteristics and pattern of diarrhea
- get health history
- stool samples
- oral and IV rehydration
- monitor electrolytes
35
What are the findings of left-sided heart failure?
- Crackles in the lungs (check sounds for congestion)
- dyspnea
- orthopnea
- dry nonproductive cough
- oliguria
36
What are the findings for a patient with right-sided heart failure?
- Edema (legs and sacrum)
- jugular vein distention (JVD)
- abdominal distention
- hepatomegaly
- splenomegaly
- weight gain
- swelling in fingertips and hands
37
What labs should be monitored for CHF?
- Serum electrolytes
- BUN
- Creatinine
- liver function
- TSH
- CBC
- BNP
38
CHF medication teachings....
```
ACE inhibitors
ARBs (angiotensin receptor blockers)
hydralazine and isosorbide
beta blockers
diuretics>>>remove fluid from body
digitalis>>> digoxin and can cause toxicity
```
39
What pre-op labs should be watched?
CBC and electrolytes
40
What medications need to be avoided prior to surgery?
- Aspirin
- corticosteroids (prednisone)
- diuretics
- phenthyazines (diazepam)
- insulins
- antibiotics
- anticoagulants
- thyroid hormone
- opiods
41
What are the post-op interventions?
- assess the patient
- maintain a patent airway
- maintain CV stability (shock, hemorrhage, hypertension)
- relieve pain and anxiety
- determine readiness for PACU discharge
42
What labs do you monitor for a patient with hypertension on diuretics?
Potassium
43
If a patient starts a new antihypertensive, what do you need to assess?
Assess BP prior to giving med and check for orthostatic hypotension (systolic greater than 20 mmhg from original reading)
44
What do you teach a patient with Hep B?
- prevent transmission
- recommend vaccination
- avoid high risk behaviors
45
What is jaundice?
condition where skin and eye sclera become yellow tinged or greenish yellow due to high billirubin levels.
46
How do you assess for jaundice? what lab do you look at?
Check skin color and eye sclerae.
| Monitor serum billirubin levels.
47
What are the signs of severe Pancreatitis?
- hypocalcemia (tetany)
- severe abdominal and back pain
- occurs 24 to 48 hours after heavy meal or alcohol ingestion
- rigid boardlike abdomen
- fever, jaundice, confusion
48
What are the assessment findings for Fluid Volume Deficit?
-acute weight loss
-poor skin turgor
-concentrated urine
-prolonged cap refill
-decreased bp
thirst
muscle cramps
increased temp
cool, clammy, skin
increased osmolality, BUN, creatinine, and gravity
49
What are the assessment findings for fluid volume overload?
- acute weight gain
- peripheral edema
- distended jugular veins
- crackles
- SOB
- increased BP
- increased RR
- increased urine output
- decreased osmolality and gravity
