Med Surg Rem Flashcards
IBS Diet
No dairy, eggs, wheat
Increase fiber to 30-40 g/day
Seizure steps
Turn patient on side
Loosen restrictive clothing
Blood transfusion: circulatory overload s/s
Dyspnea Chest tightness Tachycardia Tachypnea Headache HTN jugular vein distention Edema Crackles
Blood transfusion: circulatory overload interventions
O2 Vitals Slow infusion Admin diuretics Notify provider
TPN Tubing
Change every 24 hrs
Glycosylated hemoglobin
HbA1c
Best indicator for past 120 days
Expected is 4-6%
Diabetics 6.5-8%
Chronic lymphatic leukemia s/s
Chills Fever Night sweats Swollen lymph nodes Feeling full in belly
Glossectomy teaching
Frequent mouth cleanse
Glossectomy
Removal of part or all of tongue
Thickened liquids
Alternate communication
Elevating head to reduce edema
Chemo treatment teaching
Temp daily
No crowds
Avoid foods containing bacteria
Avoid drink at room temp longer than 1 hr
No gardening, changing litter box
Toothbrush in dishwasher or bleach solution
Thrombolytic therapy contraindications
Hemorrhagic stroke
Increase bleeding with anticoagulant
Lupus erythematosus s/s
Fatigue/malaise Slope is Blurred vision Pleuritic pain Anorexia Depression Joint pain, swelling, tenderness
Lupus erythematosus physical findings
Fever Anemia Lymphadenopathy Pericarditis (pleural friction rub) Raynauds Butterfly rash
Thyroid storm s/s
Nervousness Irritability Hyperactivity Heat intolerance Decreased weight Increased appetite Insomnia Amenorrhea Increased stools and diarrhea Warm, sweaty, flushed skin Tremor
Nephrotic syndrome
Fluid overload Dysrhythmia Crackles SOB Increased urine output Hematuria (RBCs in urine) Lethargy, twitching, seizure Dry skin and mucous membranes
Acute respiratory failure
Pulmonary embolism
Edema
Pneumonia
Pathophysiology: Parkinson’s
Overstimulation of basal ganglia by acetylcholine
Increase dopamine
Increase in acetylcholine
Loss of fluids with burn
Elevated Hct and Hgb
Low sodium
High potassium
Elevated BG
hypoxemia and metabolic acidosis
Low protein and albumin
Polycystic kidney disease nutrition
Restrict potassium , phosphate, magnesium
High protein
Possible TPN
ACE inhibitors education
Can increase potassium levels
Dry cough
Notify- rash, decreased taste, swelling face or extremities
BP monitored for 2 hrs after initial dose
Blood transfusion steps
Assess labs Hgb (less than 8) and Hct
Verify prescription
Obtain blood samples
Initiate large bore 20-g
Assess for history of reactions
Obtain product from blood bank
Confirm identity etc with 2nd nurse
Prime with .9% Na chloride
Acute hemolytic reaction
Chills Fever Low back pain Tachycardia Flushing Hypotension Chest tightening Tachypnea Nausea Anxiety Hemoglbonuria
Febrile reaction blood transfusion
Chills Fever Flushing Headache Anxiety
Use WBC Filter
Admin antipyretics
Mild allergic reaction blood transfusion
Itching
Urticaria
Flushing
Admin diphenhydramine
Anaphylactic reaction blood transfusion
Wheezing Dyspnea Chest tightness Cyanosis Hypotension
Maintain airway O2 IV fluids Antihistamines Corticosteroids Vasopressors
Septic shock blood transfusion
Fever Nausea Vomiting Abdominal pain Chills Hypotension
Admin O2
Dopamine- vasopressor
Elevate feet!!!
MI meds
Aspirin
Beta blockers
MI labs
Myoglobin (0-85)
Creatinine kinase (25-200)
Troponin (0-0.4)
Musculoskeletal trauma
Crepitus Deformity Muscle spasms Edema Ecchymosis (bleeding to tissues)
Hypovolemic shock s/s
Hypotension
Decreased urine output
Tachycardia
Slow cap refill
Paralytic ileus
Monitor bowel sounds Encourage ambulatory Advance diet as tolerated NG- empty stomach contents Med- metoclopramide
Wound dehiscence or evisceration intervention
Call for help Stay w client Cover with sterile dressing Place supine with hips and knees bent Monitor for shock Notify provider
Arterial venous fistula s/s
Hypotension Clotting Headache Muscle cramps Bleeding Disequilibrium syndrome HYPOVOLEMIA Tachycardia
Urine specific gravity
1.002-1.030
Mannitol
Osmotic diuretic
Treat cerebral edema
- insert indwelling catheter to monitor I & O
- monitor electrolytes and osmolality e/6 hr
Pentobarbital
Decrease ICP
want ICP below 20 (10-15 norm)
Phenytoin
Treat or prevent seizure
Open head injury greatest risk
Infection
Skull fracture greatest risk
Damage to brain tissue
Decreased O2
Alteration in neurological synaptic ability
Head injuries with hemorrhage greatest risk
Cerebral spinal fluid leakage
Epidural
Subdues
Intracerebral
Collection of fluid or foreign objects
Risk for cerebral edema
Cerebral hypoxia
Brain herniation
Pertussis
Droplet precautions
Gown
Mask
Nursing intervention for hearing loss
Tympanogram
Otoscope
Electronystagmography
Caloric testing
Continuous bladder irrigation complications
Catheter obstruction = bladder spasms and reduced outflow
Turn off and flush with 50 mL irrigation solution
Ambulate ASAP
PUD: GI bleed
Avoid foods that cause distress
Monitor BP
Monitor tachycardia
Decrease environment stress
Encourage periods of rest
Smoking cessation and no alcohol
Promoting wound healing
High calorie
High protein
High Vit C
Appropriate glycemic control
