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Hesi Final NR142

Nursing Assessment for GERD Heartburn after eating that radiates to shoulders/arms, feeling of fullness/discomfort after eating, positive diagnosis (several episodes) determined by fluroscopy or barium swallow, gastroscopy
Nursing interventions for GERD/Hernias small, frequent meals; eliminate irritating foods; sit up while eating & 1 hr after; stop eating 3 hrs before bed; elevate HOB on blocks; teach meds
What position should patient be in? Fowlers/Semi fowlers reduces amt of regurgitation and preventing stomach tissue upward thru diaphragm opening
Teaching for GERD difference btw hernia & MI Symptoms, be alert for aspiration possibility; teach meds
Peptic Ulcer ulceration that pentetrates mucosal wall of GI tract
Causes of PUD H pylori, stress, drugs (NSAIDS, corticosteroids), alcohol, smoking
Symptoms of PUD Belching, bloating, epigastric pain radiating to back & relieved by antacids, melena
Potential Complications of PUD Hemorrhage, obstruction, perforation
Interventions for PUD symptom onset/relief; monitor COCA of stools, test for occult blood;small freq meals, no bedtime snacks, no caffeine,
When do you give sulcrafate, a mucosal healing agent? 1-2 hrs after meals and one hour before bedtime
Dumping syndrome postop of stomach surgery secondary to rapid entry of hypertonic food into jejunum pulls water out of bloodstream, occurs 5-30 mins post eating; symptom: vertigo, syncope, swewating, pallor, tachycardia;
interventions for dumping syndrome minimized by small freq meals high protein/low fat/low carb diet; do not consume liquids with meals, do not lie down after eating
Avoid what medicines to prevent PUD? salicylates, NSAIDS, corticosteroids in high doses, reserpine, anticoags
Teach symptoms of GI Bleed such as? dark tarry stools, coffee ground emesis, bright red rectal bleeding, fatigue, pallor, severe abd pain (indicates perforation), Decreased BP, rapid pulse, cool extremities, abd mass/bruit,
Stress & PUD Stress can cause or exacerbate ulcers. teach stress reduction & those with family hx must obtain medical follow up
Patho of Crohns disease chronic inflammation thru entire intestinal mucosa w/periods of remission & exacerbation. occurs teenage/childhood. no cure just tx. with meds
Assessment of Crohns Disease abdominal pain unrelieved by defecation, diarrhea, steatorrhea, weight loss, constant fluid loss, low grade fever, perforation of intestine d/t inflammation
interventions for Crohns bowel elimination pattern, control diarrhea. low residue/low fat /high protein/high calorie diet. vitamin suppl. provide bowel rests, I/O, serum electrolytes, weight 2x week,
Teaching for clients w/crohns avoid diarrhea causing foods ie dairy & spicy foods, avoid smoking, caffeine, pepper, alcohol,
patho Ulcerative colitis superficial mucosa of colon causing bowel to narrow, shorten, and thicken. sigmoidoscopy/colonoscopy tests,
Water loss in GI tract 100-200ml/day but filters 8L
Assessment for UC diarrhea, abd pain, intermittent tenesmus/rectal bleeding, liquid stools w/blood, mucus & pus, anemia
NI for UC bowel pattern/Control diarrhea, low residue/low fat/high protein/high cal diet, no dairy, avoid spicy or diarrhea causing foods, I&O, electrolytes, emotional support
Opiate drugs and GI motility depresses so must be given with care & monitored
Diverticulitis Inflammed pouches in intestinal wall. can lead to bowel perforation
Assessment for Diverticulitis left lower quadrant pain, increased flatus, rectal bleeding, signs of intestinal obstruction,
Signs of intestinal obstruction constipation altering with diarrhea, abd distention, anorexia, low grade fever
NI for Diverticulitis well balanced high fiber diet unless inflammation is present, include bulk forming laxatives, increase fluid to 3L, monitor I/O, weight, bowel elimination, avoid constipation, observe for complications -obstruction, peritonitis, hemorrhage, infection
Intestinal Obstruction -causes adhesions (most common), hernia, intusseception Neurogenic - paralytic ileus, spinal cord lesion; vascular causes
Nutritional needs of client w/Diverticulitis (hesi hint) Acute phase-NPO graduating to liquids; recovery phase- no fiber or bowel irritating foods; maintenance-high fiber w/bulk laxatives to prevent pooling of foods & avoid small poorly digested foods such as popcorn, nuts, seeds
Bowel Obstruction mechanical vs non mechanical (hesi Hint) mech- due to disorders outside bowel caused by disorder inside bowel or blockage; non mech- d/t paralytic ileus which isnt an actual physical blockage
NA for Bowel Obstruction sudden onset of ab pain, tenderness or guarding, hx of abd surgeries, hx of obstruction, distention, increased peristalsis then becoming absent when paralytic ileus occurs, high pitched sounds diminishing to absent with late mech obstruction
Blood gas analysis with bowel obstruction (hesi hint) alkalotic state if obstruction is high blocking gastric acid secretion; acidotic state if obstruction is low blocking base secretion
NI for bowel obstruction maintain NPO w/iV fluids & electrolytes; monitor I/O, catheter, NG intubation, food./fluids restricted 8-10hrs if surgery, prophylactic antibiotics, NG intub done before surgery unless complete obstruction
Patho for Cirrhosis degeneration of liver tissue causing enlargement d/t alcoholism, viral hepatitis, hepatoxins, infections, congenital abnormalities. Initially hepatomegaly then liver hardens and becomes nodular
NA for Cirrhosis hx alcohol or drug use, work hx of exposure to chemicals medication hx of hepatoxic drugs, family hx.
NA for cirrhosis - physical weakness, malaise, anorexia, weight loss, palpable liver. abd girth increases, jaundice, fetor hepaticus, asterixis, mental changes, spider angiomas, ascites, neuropathy, hematemesis,
Clinical manifestations of jaundice (hesi hint) yellow skin, sclera or mucous membranes; dark color urine (bilirubin in urine); clay or chalky colored stools (absence of bilirubin)
Fetor Hepaticus distinctive breath odor of chronic liver disease with a fruity or musty odor
treatment of ascites (hesi hint) paracentesis or peritoneovenous shunts
Tx of esophageal varices caused by portal hypertension in liver (hesi hint) may rupture and cause hemorrhage. insertion of balloon tamponade, vasopressors, vitamin K, coagulation factors and blood transfusions
Lab findings in Cirrhosis elevated bilirubin, AST, ALT, alkaline phosphate; decreased Hct, Hgb, albumin
Encephalopathy (hesi hint) ammonia is not broken down so serum level rises causing confusion/mental changes; also metabolism of drugs is slowed so they remain in system longer
Complications of Cirrhosis ascites, portal hypertension, esophageal varices, encephalopathy, resp distress, coag defects
NI for Cirrhosis adm vit supplements (ABCK) observe mental status, avoid initiating bleeding (no uncessary sticks, electric razor, soft tooth brush, maintain venipressure 5 mins, check stools for blood, prevent straining w/defecation. restrict protein, skin care
NI for cirrhosis (continued) low sodium/low fat/high carb diet. restrict/monitor protein
What drug is used for encephalopathy lactulose
Hepatitis patho inflammation of liver cells
NA for hepatitis known exp (sex, blood, parenteral, oral-fecal) recent transfusions,
Individuals at risk for hepatitis homosexual males, iv drug users, piercings/tattoos, living in crowded conditions, health care workers
Physical assessment for hepatitis fatigue, malaise, weakness, anorexia, n/v, jaundice, myalgia, dull headaches, irritability, abd tenderness RUQ, elevation of liver enzymes
NI for Hep A (hesi hint) provide environment conducive to eating d/t n/v- remove odors, encourage pt to sit up while eating, small frequent meals, antiemetic b4 eating
Hepatitis NI (hesi hint) rest & adequate nutrition, monitor drug therapy d/t drugs being metabolized in liver, do not resume drugs or use OTC during tx for hepatitis w/out dr approval
patho for pancreatitis non bacterial inflammation of pancreas. acute- digestions of the pancreas by its own enzymes d/t alcohol ingestion & biliary tract disease. chronic-progressive destructive w/permanent dysfunction
NA acute pancreatitis severe mid epigastric pain radiating to back w/alcohol consumption or fatty meal; abd guarding, rigid boardlike abd, n/v, temp, tachycardia, dcreased bp, bluish flank discoloration or periumbilical area, elevated amylase, lipase or glucose levels
NA chronic pancreatitis continuous burning or gnawing abd pain, ascites, steatorrhea, diarrhea, weight loss, jaundice, dark urine, s/s of DM
NI acute pancreatitis NPO, NG suction, TPN, pain med, antacids PPI, H2; side laying w/knees to chest, avoid alcohol, fatty & spicy foods, monitor blood sugar (insulin if needed),monitor for hypocalcemia
NI Chronic Pancreatitis administer analgesics, pancreatic enzymes (mix w/fruit juice or applesauce, monitor coca of stool to determine enzyme tx effectiveness, low fat bland diet, monitor for s/s of DM
Acute pancreatic pain (hesi hint) acute pain located retroperitoneally. any enlargement of pancreas causes the peritoneum to stretch tightly. sitting up or leaning forward reduces pain
Hyperthyroidism (graves disease) excessive thyroid activity
Common tx for hyperthyroidism thyroid ablation by medication, radiation, thyoidectomy, adenectomy (removing anterior portion of pituitary (tsh)
NA for hyperthyroidism enlarged thyroid (goiter), weight loss, diarrhea, heat intolerance, tachycardia, Inc BP, diaphoresis, exopthalmos
Labs for Hyperthyroidism T3 >220, T4 >12, low level TSH indicates primary disease, high level =pituitary prob, thyroid scan
NI for hyperthyroidism calm restful atmosphere, observe for s/s thyroid storm,
Thyroid storm (hesi hint) life threatening uncontrolled hyperthyroidism d/t graves. s/s fever, tachycardia, agitation, anxiety, htn. maintain adequate airway. PTU/tapazole antithyroid drugs to tx thyroid storm with propanolol
teach for hyperthyroidism daily HRT, medic alert bracelet, s/s of hormone replacement overdose or underdose; diet- high cal high protein low caffeine low fiber (if diarrhea), eye care.
tx for hyperthyroidism medications-take as prescribed; radiation -GI irritant, vomitus is radioactive; thyroidectomy
Post op thyroidectomy (hesi hint) be prepared for laryngeal edema. trach kit with O2 and suction machine. calcium gluconate accessible; check for bleeding, support neck,
calcium implications w/thyroidectomy d/t removal of parathyroid glands (hesi hint) normal serum calcium 9-10.5. best indicator of prob is decrease in calcium level post op
If parathyroid glands removed change of tetany increases so...(hesi hint) monitor calcium level, check for tingling of toes, fingers and circumoral; check for chovsteks & trousseaus sign
Hypothyroid - myxedema coma (hesi hint) can be precipitated by acute illness, withdrawal of meds, anesthesia, sedatives or hypoventilation. airway must be kept patent and ventilator support if needed
NA hypothyroidism weight gain, constipation, bradycardia, fatigue, cold intolerance, thin brittle hair, think brittle nails, goiter, periorbital edema.
Teachings for hypothyroidism medication regimen, effects, s/s of myxedema coma, 3L fluid intake, increase activity, high fiber diet. avoid sedation (leads to resp distress)
Addison's disease - andrenocortical deficiency autoimmune disorder - lack of cortisol, aldosterone & androgens. diagnosis made by ACTH stimulation test.
Teaching in Addisons' disease (hesi hint) that pts must follow prescribed regimen precisely. no stopping suddenly and must taper off dosage.
NA for Addisons fatigue, weakness, weight loss, anorexia, postural hypotension, hypOglycemia, hypOnatremia, HypErkalemia, hyperpigmentation, alopecia (loss of body hair), hypovolemia
NI for Addisons disease VS q15 mins if crisis, monitor I/O & weight, rise slowly d/t ortho hypotn, monitor electrolytes
Addison Crisis (Hesi hint) sudden withdrawal of steroids or stress. vascular collapse - fast IV of fluids; IV glucose for hypOglycemia, essential to administer Hydrocortisone and aldosterone replacement
Cushing syndrome excess adrenocorticoid caused by chronic corticosteroid administration, adrenal, pituitary or hypothalamus tumors
Physical assessment of Cushing's moon face, buffalo hump, truncal obesity, abd stiae, muscle atrophy, hirsuitism, hyperpigmentation, amenorrhea, thinning of skin
Lab findings in Cushings HypErglycemia, HypErnatremia, HypOkalemia, increased cortisol,
NI for Cushing's protect from infection, monitor for s/s of infection, teach safety measures, low sodium diet, encourage vit D & calcium, wean from steroids.
Steroid Admininstration (hesi hint) teach clients to take steroids with meals to prevent gastric irritation. dont skip doses,
Diabetic ketoacidosis glucose >350, ketonuria, venous PH 6.8-7.2
TX of DKA isotonic IV fluids, slow infusion of regular insulin, potassium replacement,
non ketotic hyperosmolar hyperglycemia no ketones hyperglycemia, dehydration, plasma hyperosmolity, changed mental status
tx non ketotic hyperosmolar hyperglycemia isotonic IV fluids, IV insulin (if needed)
Why do diabetics have trouble with wound healing? (hesi hint) high blood glucose adds to damage of capillaries causing permanent scarring. causes disruption of capillary elasticity, promoting probs such as diabetic retinopathy, poor healing, cardiovascular issues
What is glycosylated hgb (A1C)? Hesi hint indicates glucose control over previous 120 days (life of red blood cells). valuable measure of diabetic
Insulin lift skin/90degree angle; refrig or room temp (28 days); rotate injection sites, clear(reg) before cloudy)
DM Diet carb counting/exchange lists; time meals to med peak times; 55-60% carbs/12-15% protein/ 30% or less fat. choose complex carbs, fiber low fat. Bedtime snack prevent insulin reaction to long acting insulin peaks.
Sick day rules for insulin keep taking insulin; monitor glucose more frequently, watch for hypEr glycemia
Body response to illness & stress regarding Blood sugar (hesi hint) bodies response is to produce glucose therefore any illness results in hypErglycemia
Exercise regimen r/t DM regular non strenuous exercise; after mealtime & with someone; snack might be needed before or during exercise;
what to do if unable to determine if client is hypO or hypEr glycemic (hesi hint) treat for hypOglycemia
Rapid acting insulin (humalog/novolog) 5-15min onset, 2-3hr peak or less; give within 15 mins of a meal
Short Acting (regular) 30-60min onset, 2-3hr peak, can be given IV
Intermediate acting (NPH) 1-2hr onset, 6-12 hr peak; mix with rapid acting
Long acting (ultralente/lantus) 4-8hr onset, 14-20 hr peak, once daily @bedtime, do not mix
S/S of hypErglycemia 3 P's, blurred vision (type2), weaknness, weight loss, syncope
Tx of hypErglycemia water, check BG, assess for ketoacidosis
S/S of hypOglycemia HA, nausea, sweating, tremors, lethargy, hunger, confusion, slurred speech, tingling around mouth, anxiety, nightmares
tx of of hypOglycemia occurs rapidly and can be life threatening. give complex carbs such as graham cracker & peanut butter and seek medical attention, check BG
SMBG (hesi hint) provides tight glucose control to prevent long term complications; monitor before meals, bedtime and when symptoms occur; record results and report to provider
Foot care for DM checked daily, washed with mild soap & warm water dried well esp between toes; moisturize but not between toes; clean socks, nails filed straight across.
Urinary tract obstruction-BPH enlargement or hypertrophy of the prostate in men over 40years old.
NA of BPH increaed freq of voiding; nocturia, dribbling, hesitancy, decrease size/force of stream, acute urinary retention, bladder distention
Bladder spasm with Turp (hesi hint) ballon causes continuous feeling of needing to void, do not try and void around catheter or it will cause bladder spasms. medications to prevent spasms given.
Bladder irrigation with TURP (hesi hint) use only sterile saline to prevent cellular fluid shifts
Drainage after TURP reddish pink clearing to pink. some small clots. monitor for bright red bleeding w/large viscous clots. normal for some bleeding & small clots to be passed. If large amts sh/be reported
Prostate Cancer rarely before age 40, 2nd leading cause of male death; high risk-multiple sex partners, STD's and some viral infections
NA for prostate cancer Elevated PSA
Identify interventions related to Orchitis? rest with scrotal elevation, application of ice, admin of analgesics and antibiotics. Treat partner if bacterial, mumps vaccine, nsaids or antiinflammatories
Identify nursing education related to orchiectomy? decreased hormone levels after the removal. Avoid sexual activity for 2-4 weeks after surgery, avoid lifting heavy weights or strenuous activity, s/s of infection. Increase fluids & high fiber diet to avoid constipation. Will also need follow up appt
Identify nursing assessments related to toxic shock syndrome (TSS)? Sudden onset, high temp (>102), HA, sore throat, vomiting, diarrhea, generalized rash, hypotension, Rash on palms and soles of hands/feet, confusion, muscle aches, redness of eyes/mouth/throat and headaches
Uterine Prolapse downward displacement of uterus. Can impinge on other structures. bladder, rectum, small intestine can protrude thru vaginal wall
Cystocele relaxation of anterior vaginal wall with prolapse of bladder
Rectocele relaxation of posterior vaginal wall with prolapse of rectume
Benign Tumors - uterine more common in black women, non parity women. most common symptom is abnormal uterine bleeding. TX D&C, ablation
Cervical cancer 95% squamous cell cancer; HPV vaccine;
Hesi hints for Cervical cancer pap smear annually to age 39, then 2-3 years; laswer/crysurgery for small lesions; invasive cancer radiation / hysterectomy/conization. chemo not effective
Care of pt with radiation implants transmission precautions; isolation (provide support); leadlined container; client must remain in bed; limit time with client
ovarian cancer germ cells
Created by: rivabard