NUR 265 HESI Med Surg latest updated version with expert interventions (ACCURATE DIAGRAMS AVAILABLE)

ARF Post Renal

Renal Calculus: Lithiasis, BPH

Risk for Hyperparathyroidism ^ Calcium

Pathological Fractures

Prevent Volume Depletion

Manif: low urine output, decreased BP / Pulse

Orthostatic Hypotension, thirst

^ Blood Osmolarity

Hemodialysis

Pharmokenetic excretion adversely affected

Monitor for digtoxicity / hyperkalemia / dillusional hyponatremia

3 requirements: access to blood, semipermeable membrane, dialysate

More Effective/ Shorter time

#1 Complication - Disequilibrium Syndrome causing ICP

Admin Anticonvulsants (Dilantin)

Peritoneal Dialysis

Monitor Albumin

#1 Complication - Peritonitis leads to septic shock

Ridge Board Like Abdomen

Cloudy Excretion - Infection

Interventions: heparinization required

weigh before / after, acquire baselines

^ protein intake - excreted at dialysis

Teaching: know signs for peritonitis, cloudy excretion, monitor

glucose for hyperglycemia

Dialysis Air Embolism

clamp catheter

Patient Left Lateral Trendelenburg

Notify Physician

Admin Oxygen

DKA

Lacks insulin, DMI (insulin dependent), Ketones

Sudden Onset - infection, injury, stress

Uncontrolled hyperglycemia

Met. Acidosis - Kussmaul Respirations

Polyuria / dipsia / phagia

Dehydration, Osmotic Diuresis 6 - 10 L

Glucose >250

Interventions: #1 assess airway, #2 LOC, #3 Hydration (Dextrose)

Admin Insulin

Before Admin IV K+ assure output 30ml +

HHNKS

DMII, Insulin Resistant, Gradual Onset

Glucose >600

Major factor is obesity

Worse Diuresis / Dehydration

Neurological - coma, seizures, stroke

Met. Alkalosis

Interventions: #1 Hydration, #2 LOC

Admin Insulin restoring glucose w/I 72hrs

Evaluate Fluid Volume / Daily Weights

Teaching: store unopened insulin vials in refrigerator or room temp

for 28 days

Draw regular insulin into syringe first when mixing insulins

Exercise decreases blood sugar levels

Sick Days: keep taking insulin

monitor glucose more frequently

watch for signs of hyperglycemia

**If in doubt if hyper / hypo glycemic, treat for hypoglycemia

Hypoglycemia

Glucose <70, rapid decline

Excess Insulin, wrong time / type

Manif: #1 early -Neurogenic (Cholinergic / Adrenergic)

#2 Central Neuroglycopenic: confusion, seizure, coma

Interv: Mild - admin carbs / protein

Severe -admin Glucagon

Teach: avoid exercise / alcohol

New bottle Insulin / more potent

Change injection site

Med Alert Bracelet / Carry carb snack

Drink alcohol with food / after meal

**Taking Beta Blockers: manif less intense

**Does not always experience warning symptoms

DI Pituitary (Hypothalamus)

Lack ADH - Vasopressin

Fluid Deficit / ^ Output

Causes: Lithium, Trama, Surgical, Tumors, Hemorrhage, Cerebral

Aneurysm, Hypophesectomy (pituitary removal)

Manif: dehydration, polyuria, thirst, hyperthermia, coma, ataxia, hypotension, tachy, hypovolemia / shock, ^Hct / Hgb / BUN

Interv: Admin Desmopressin (nasal, 10x stronger, long acting)

Admin Vasopressin (oral, short acting, use for upper

respiratory infection)

*Never deprive fluids more than 4 hrs

Accurate I&O, daily weights

Drugs: Lifelong Therapy

SIADH Pituitary (Hypothalamus)

Excess ADH (vasopressin), fluid overload

Cause: SSRI's, Small Cell Lung Therapy

Manif: Dillusional Hyponatremia (below 115), LOC, seizure, coma,

loss deep tendon reflexes, hypothermia, bounding pulse

Interv: Tolvaptan / Conovaptan - promotes water excretion w/o NA

loss, Admin in Hospital (Black Box)

Diuretics

Hypertonic Saline #% Sodium Chloride

Restrict fluid intake 600mL

#1 monitor lung sounds (ABC's)

Hyperparathyroidism PTH

^ Calcium, 120+, benign tumor

Bone density decreased / pathological fractures

^ Osteoclast activity (destruction)

Post Renal Failure (calcui Stones)

Manif: weight loss, arthritis, waxy pallor

bone deformities, mental confusion > coma,

epigastric pain, constipation, peptic ulcer

Interv: #1 hydration -Saline

Diuretics - Furosemide (Laxis) >calciurea

Oral Phosphates - decrease calcium

Calcitonin - decrease release of skeletal calcium

Enhanced w/Glucocorticosteroids

Use lift sheet, monitor cardiac, I&O

Surgery - parathyroidectomy

Hypocalcemia Crisis (Trousseau / Chvostek)

Hoarseness

Hypoparathyroidism PTH

Decrease Calcium

Cause: removal of parathyroid / subtotal thyroidectomy

Manif: tingling / numbness @ mouth / hands /feet (mild)

muscle cramps, spasms, seizures (severe)

Interv: Calcium Gluconate

Calcitrol

Magnesium, Sulfate - Magnesemia

Eat ^ calcium - dark green leafy vegs

Avoid milk / yogurt, processed cheese

Drugs: Lifelong Therapy

Addisons (Adrenalcorticol)

Low Cortisol / Aldosterone

Occurs gradually / quickly due to stress; life threatening

Cortisol - anti inflammatory / histamine

Cause: #1 tumor necrosis / hypophysectomy / radiation

#2 Cessation on glucocorticoid therapy, immunodeficient

(TB / Cancer / Aids / Toxins), hemorrhage, adrenalectomy

Manif: Hypo GNVT - glycemia / natremia / volemia / tension

Hyperkalemia

Salt cravings, GI / menstrual / impotence changes

hyperpigmentation, shock, loss of body hair

Interv: Fludrocortison (Florinef) - maintain K+ / Na, like aldosterone

(Reabsorbs Na / Excrete K+)

Hydrocortison - corrects glucocorticoid deficiency

Prednisone - corticol replacement

#1 Rapid Infusion Normal Saline

#2 Solucortef - glucocorticoid hydrocortisone

Kayexalate - hyperkalemia

Glucose / Glucagone - Hypoglycema

Weigh Daily

Monitor hemoconcentration - Hct / BUN

Diet: ^ sodium / carbs, low potassium

Cushings

^ Cotisol / Aldosterone, Immunosuppressed

Defense Mech: Inflammation

Cause: Stress / Excess Glucocorticosteroids; tumors

Immunosuppressed > ^ cortisol

Manif: Hyper GNVT glycemia / natremia / volemia / tension

Hypokalemia

Truncal Obesity, buffalo hump / moon face

Muscle atrophy, osteoporosis

Skin paper thin @ risk for infection

striae

Fluid overload, pulmonary edema

Interv: monitor lung sounds, weight, output, electrolytes

Protect from infection; handwashing

Safety measures: bed close to floor / side rails

Drug: Aminoglutethimide - decrease cortisol

Hyperkalemia - admin Insulin w/ Kayexalate

Diet: Low Sodium

Take steroids with meals to prevent gastric irritation; never skip

doses; Excessive N/V contact physician

Addisonian Crisis

Life Threatening, Insufficiency

Need fro Cortisol / Aldosterone greater than supply

Response to stressful event

No Intervention: Na fall / K+ rapidly ^

Interv: Same as Addisons - admin IV Glucose / Glucocorticosteroid

Severe Hypotension / Hypovolemia

Glucocorticosteroid therapy for life

Pheochromocytoma

Epi / Norepinephrine

Benign tumor of adrenal medulla

Risk: stroke, cerebral hemorrhage

Sympathetic kicks in

Manif: Hypertension, doom, chest / abdominal pain / pressure,

heat intolerance, tremors

Sudden ^ BP due to cessation of antihypertensive meds

Hypertensive Crisis - No reason

BP up to 300 - blow in cerebral arteries (hemorrhage)

Diagnostic - 24hr urine collection for VMA

Interv: no foods / beverages with ^ tyramine (aged cheese,

red wine)

Do not palpate as stimulates catecholamine release

triggering severe hypertension

Diet ^ calories, vitamins, minerals

Maintain hydration

Decrease in BP > ICU

Drugs: Pheoxybenzamine - start several weeks before surgery

(massive vasodilator)

Hyperthyroidism

^ T3/T4, regulate basil metabolic rate

Acute Complication -thyrotoxicosis

Hypermetabolic State

Manif: Exophthalamos - wide eyed startled look

Lost blinking reflex - eyelid lag, goiter

Hallmark -intolerance to heat

Tachy, hypertension, diarrhea, hyperthermia

Interv: 1* temp ^ > Thyroid Storm

Assess cardiac / dysrhythmias

Exophthalmos Treatment:

Eye patches at night

Corticosteroids / Antibiotics

Tape eyelids shut, artificial tears

Surgical: orbital compression-relieves pressure

myectomy-reduces size

blepharoplasty-reconstruct eyelids for closure

keratoplasty-corneal reshaping

corneal transplantation

Drugs: PTU prevents conversion of T3 to T4

Black Box - liver failure -dark urine / clay colored stools

Beta Blocker - decrease HR, never Aspirin

Radioactive Iodine - produces T3 / T4, destroys part of gland

Calcitonin - lowers calcium

Hypothyroidism

Low T3 / T4, Hypometabolic State

Early Symptoms: nonspecific

Endemic Goiters: where deficit of iodine

Iodized Salt prevents

Manif: brady, constipation, anorexia with weight gain, fatigue, thin

hair / skin, thick brittle nails, goiter, periorbital edema,cold

intolerance

Interv: monitor cardiac

hypothermia blanket

maintain airway

Admin Levothyroxine

No switch brands of drugs

Med aherance

Bowel Elimination plan - 3L, ^ fiber / fruits / vegs

^ activity, no enemas / laxatives

If in MVA caution admin of Morphine Sulfate- may place in

Myxedema Coma

Post Op: Thyroidectomy Complication - airway obstruction

Respiratory caution, stridor, laryngeal nerve damage

Trach Tray / suction / oxygen at Bedside

Semi Fowlers / avoid neck extension

Assess dressing

Monitor: hemorrhage, respiratory distress, parathyroid injury,

hypocalcemia

Admin: Calcium Gluconate

Beta Blocker (Propanolol) decrease HR

Glucocorticosteroids - inflammation

Non Salicylate Antipyretic (Tylenol / non aspirin) - fever

Myxedema Coma: caused by hypothyroidism

(undertreated / non compliant)

VTE Pulmonary Embolism

DVT, perfusion

Risk Factors: immodility, surgery, obesity, age

Complication with DM, HHNKS (like stroke)

Prevention: ROM, compression devices, nonconstrictive clothing,

no pressure @ popliteal, no massage / cross legs /

valsalva maneuver, smoking cessation

SCIP: Surgical complication improvement DVT / PE

Manif: Sudden onset dyspnea, chest pain, doom, petechial at chest

/ axillae, flu symptoms, JVD, syncope, crackles

Interv: reassure patient, #1 admin oxygen then high fowlers, IV

access

Drugs: heparin IV; antidote Protamine Sulfate; monitor PTT

(prevents conversion of fibrinogen to fibrin)

Warfarin; antidote Vitamin K; monitor INR

(blocks formaton of prothrombin from Vitamin K)

(Adverse Affect - Hemorrhage)

Fibrinolytic Antidote

clotting factors, fresh frozen plasma, aminocaproic acid

Determine Fibrinolytic Outcome

assess ABG's - gas exchange / oxygenation

HF Left Sided

Mitral / Aortic Valve

Inadequate tissue perfusion

Pulmonary Congestion: pink frothy sputum, SOB, crackles,

nocturnal cough, decreased cardiac output, fatigue, oliguria /

nocturia, confusion, tachycardia

# pillows used at night

Restlessness /confusion

HF Right Sided

L ventricular failure, pulmonary hypertension, cannot empty

ARDS, systemic congestion

Manif: jugular vein distention, increased thirst (sodium retention)

Hepatomegaly (liver engorgement)

Hypoxia compensatory response - sympathetic nervous system

Reduced blood flow to the kidneys activate renin angiotensin

system causing ventricular remodeling

Weight is most reliable indicator of fluid gain / loss

Microalbuminuria: early indicator of decreased compliance of heart

Sodium Restriction: retaining sodium in edema (when edema

reduced causes hypernatremia)

Admin Diuretics in Am; rest

Respiratory Alkalosis

hyperventilation

Respiratory Acidosis

Carbon Dioxide Retention

Metabolic Acidosis

Accumulation of lactic acid

MI Myocardial Infarction

necrosis of myocardial tissue; sudden onset

Causes: thrombus ; shock / hemorrhage

Manif: viselike pain radiates to shoulders down arms to neck / jaw;

substernal / retrosternal / epigastric areas

Not relieved by rest / nitroglycerin; persists for hours / days

May not have pain (silent) with diabetic neuropathy

Rapid / irregular / feeble pulse

Decreased LOC

Left Heart Shift post MI

Cardiac Dysrhythmias, ECG changes

Cardiogenic shock / fluid retention

Bowel sounds absent

Wet lung sounds

Nursing Diagnoses: Ineffective Tissue Perfusion, Decreased

Cardiac Output, Activity Intolerance, Acute Pain

Interv: Pain: ^ O2 Perfusion, Morphine Sulfate

Nitrates, Beta Blockers, Calcium Channel Blockers,

Aspirin, Antiplatelets

Quiet Restful Environment

Assess Breath Sounds

Semi Fowler Position

Resume Activity Gradually

Encourage verbalization of fears

Thrombolytic agents within 30minutes; monitor bleeding

Intraaortic Balloon Pump (IABP) to improve myocardial

perfusion

Serum Cardiac Markers

Creatine Kinase CK, returns to normal in 2 - 3 days

Cardiac Specific Troponin, returns to baseline in 5 - 14 days

Myoglobin, returns to baseline in 2 days, lacks cardiac specificity

Nitrates

Adverse Reactions: headaches, hypotension

Interventions: rest, store med in original container

protect from light

Beta Blockers

Reduces O2 demand

Adverse Reactions: Hallucinations, impotence, HF, wheezing

Interventions: do not stop medication abruptly

Calcium Channel Blockers

Inhibits influx of calcium

Adverse Reactions: syncope, peripheral edema, hypokalemia,

dysrhythmias

STEMI

whole wall - occlusive

NON STEMI

partial blockage

denial results in Vtach / Vfib

Anticoagulant Therapy

Interv: use lift sheet, avoid IM / venipunctures, use smallest needle,

pressure on needle stick for 10 minutes, ice to trauma areas,

occult blood test, observe IV sites, not bleeding / bruising, no

rectal temp / enema, electric shaver

PT / PTT

determines efficacy

INR

reflects how long it takes blood sample to clot

AAA Abdominal Aortic Aneurysm

most common cause is atherosclerosis

Manif: abdominal pain / low back pain, feel heart beating

Antihypertensive at risk

Avoid palpation

Assess: bruit over abdominal aorta

Abdominal Radiograph: diagnosis if aneurysm is calcified

Raynauds Disease

Associated with Sclerosis

Intermittent by cold / stress

Ulcer > Gangrene of Digits

Interv: relieving / preventing vasoconstriction

Minimizing exposure to cold, reduce caffeine, smoking

cessation, reducing stress

Drug: Cardizem - relaxes smooth muscles of arterioles

Pulmonary Edema

Pink Frothy Sputum

When L ventricle fails to eject sufficient blood / pressure increases

in lungs

Manif: hypoxemia, tachy, restlessness, muscle cramps, dizziness

Interv: high fowlers, O2, assess client / lungs sounds, ensure IV

access in place

Admin Diuretic - morphine sulfate (reduce anxiety / lowers

respirations / HR)

Cardiogenic Shock w/ Pulmonary Edema: high fowlers with legs

down to decrease further venous return

Restoration of Cardiac Function Priority

Admin Digitalis (Dopamine / Norepinephrine)

Arterial Peripheral Disease PAD

Thickening of artery walls

Narrowing Extremities

Leading cause of peripheral artery disease - atherosclerosis

Occur when arteries are occluded 60 - 75%

Ventricular Fibrillation

No cardiac output or pulse

Fatal if not ended w/I 3 - 5 minutes

Manif: apneic (no breathing), no BP / heart sounds, seizures

Acidosis, pupils fixed / dilated

Interv: CPR while waiting for defibrillator to come

Admin Vasopressin / Epinephrine / Amiodarone / Lidocaine /

Magnesium Sulfate

Asystole

Flatline, full cardiac arrest

Admin epicardiograme / IV Epinephrine

hoping to get into a fine Vfib then use defibrillator

DNR?

Rhythm Strip: consistent hills

Nitrates / Viagra

both cause muscles to control the size of blood vessels to relax

Vessels enlarge in diameter / BP drops

Detrimental to patients who have angina

Higher BP is necessary to supply the heart with blood

HPA1C

3 month test, how glucose is managed

Albuminuria: look at labs for microalbuminuria

linked to renal disease

Insulin -long acting

IM, SubQ

Admin once daily

Do not shake solution or mx with other insulins

Use cautiously if NPO

Insulin Premix

Offer when food is readily available

Pancreatitis

3 enzymes: amylase (carbs), *lipase (lipids), trypsin (protein)

Manif: abdominal pain in mid epigastric area of left upper quadrant

radiating to back / left flank / left shoulder

worsened by lying in supine

Grey Blue Abdomin

Interv: ABC's; assess / support; oxygen / respiratory support

Hydrate w/ IV fluids;fasting / rest

NPO: oral hygiene

Small frequent meals ^ carb / protein, low fat

Admin Morphine

Admin pancrelipase w/ meals or snacks

powdered forms mix with fruit juice / applesauce

no mix with proteins

GERD

Positive Diagnosis: fluoroscopy / barium swallow / gastroscopy

Interv: small frequent meals

stop eating 3 hours before bedtime

elevate HOB on blocks

Teaching: differentiate between hiatal hernia / MI

Possible aspiration

Peptic Ulcer Disease PUD

Risk Factors: NSAIDS, corticosteroids

Alcohol, Smoking

Med Crisis / trauma

Manif: belching, bloating, epigastric pain radiating to back

Complications: hemorrhage, perforation, obstruction

Teach: stress reduction methods

GI Bleed Manif: pallor, dark tarry stools

Bright red / coffee ground emesis

Abdominal mass / bruit

Decreased BP, rapid pulse, cool extremities, ^ respirations

Bright red rectal bleeding or Severe abdominal pain -

CONTACT PHYSICIAN

Diverticulitis

inflammation causes obstruction, infection,hemorrhage

leads to performation of bowel

Manif: left lower quadrant pain, ^ flatus, rectal bleeding

intestinal obstruction: constipation with diarrhea

abdominal distention, anorexia, low grade fever

Interv: ^ fiber diet unless inflammation is present - NPO with low

residue bland foods

Metamucil, 3L, avoid constipation

Acute Phase: NPO

Recovery Phase: no fiber / foods that irritate bowel

Maintenance Phase: ^ fiber, laxatives, avoid popcorn/nuts/seeds

Cirrhosis

liver enlargement, fibrosis, scarring

Hepatomegaly with liver hardening / nodular

Causes: alcohol, hepatitis, hepatotoxins, infections, R HF

Manif: abdominal girth ^, jaundice, fetor hepaticus, bruising,

ascites, hematemesis (vomit of blood)

Damaged liver: ammonia ^

metabolism of drugs slowed and remain in system longer

Interv: bleeding precautions

Esophageal Varices

blood backs up from liver / enters esophageal

Interv: #1 assess melena (occult blood), black tarry stools

Hematemesis / coffee grounds, partially digested blood

Rupture by spicy foods, heavy lifing, straining at stool,

vomiting, abdominal pressure ^ thoracic / ICP

Teach: avoid heavy lifting or activities that ^ abdominal pressure /

straining

TPN

metabolic complication: hyperglycemia

monitor glucose

Insulin can be added to TPN solution

PRBC infusion

packed RBC's to replace erythrocytes

infused within 20 minutes upon receiving from blood bank

Infusion time: 250ml in 2 - 4 hrs

Check effectiveness by Hgb / Hct 4 - 6 hrs post transfusion

For each unit of PRBC: Hgb ^ by 1g/dL

Hct ^ by 2 - 3%

Platelet Transfusion

to prevent / stop bleeding

Platelet Normal 150 - 400K

Needed when less than 50K

infused rapidly over 15 - 30 minutes

transfusion immediately upon receiving from blood bank

Check effectiveness by rechecking platelet counts 1 hour and

18 - 24hrs post transfusion

^ by 10K

AIDS Opportunistic Infections

Pneumonia: #1

Kaposi's Sarcoma: #2

purple blue lesions on arms / legs

Invasion of GI, lymphatic system, lungs, brain

AIDS Communicable Disease

TB: PPD test may be false negative

Airborne / Standard Precautions until confirmed negative

Shingles Pain

burning / itching sensation present before rash;

Symptoms last from 1 -3 weeks

Abdominal / joint pain

Admin Antiviral (Acyclovir) - shorten course of outbreak

Not a cure; shortens the vesicle (blister) life

Admin Opiod combinations: no take acetaminophen / alcohol

Patients who develop postherpatic neuralgia may experience pain

at site of rash for months - years

Operating Room Banana Allergy

occurs in those with immediate latex allergy

contains proteins similar to those found in latex

Interv: coordinate procedure with hospital

avoid using latex during procedure

1st surgery of day (no latex contamination from prior surgeries)

thoroughly clean operating room night before

Administration of Blood Products

Run blood products with saline

Run infusion as prescribed rate, remain with client for first 15 - 30

minutes of infusion

Blood should be admin ASAP

Check vitals frequently before / during / immediately following

infusion; not any ^ in temperature

Check / Double Check product before infusing to see that it is:

correct product - double check with second licensed person

correct blood type / Rh factor, matched with client, note

expiration date

Systemic Lupus Erythematosis SLE Skin Care

multi system microvascular inflammation

no specific cause

avoid sunlight

clean skin with mild soap

Risk Factors: sun exposure / sunburn

Anemia Iron Rich Foods

meat (red / organs)

Green Leafy Vegs

Fish

Liver

Whole Grains

Legumes

Carrots

Herpes Zoster Vaccine

Admin Zostavax

adults older than 60 who previously had chicken pox

Pruritis

avoid irritating clothes

tepid water for bathing

non-irritating soaps / detergents

do not rub skin

apply emollient creams / lotions

maintain cool environment / adequate humidity

keep fingernails short

use cotton gloves at night

anti-pruritic meds

Burn Pain

Admin Opiod Analgesics - Morphine Sulfate, Hydromorphone,

Dilaudid, Fentanyl

Admin via IV as absorption probs within muscle / stomach

Depresses Respiratory Function / Intestinal Motility

Slowed / impaired GI function (shock / paralytic ileus)

Inadequate absorption of IM injection (pooled meds in tissues)

Admin pain med prior to dressing change

Vesicant Extravation

Vesicant: drug capable of causing serious tissue damage / necrosis

try to aspirate as much drug as possible (infuse known aspirate thru

needle) remove needle if unable to aspirate

Do not apply pressure on exravasated area

Use cold compress on all extravation

Use warm compress for extravasation for Hyaluronidase antidote

for Vinblastin

Debridement

during hydrotherapy with mild soap / detergent / room temp water

Topical Enzyme Colagenase (Santyl): digests collagen in necrotic

tissue

Admin Polysporin Powder: prevents infection

Topical Antibiotics

Daily up to 3 times a day

Wet / Dry dressing changes 2 - 3 times a day remove necrotic

tissue / debris

Traction Pin Sites

long term pull that keeps injured bones / joints aligned

Skeletal Traction Pin Site Care:

observe for inflammation

regular removal of exudate

rinse pin site and dry area

Rheumatoid Arthritis

Progressive deterioration of connective tissue of joints

Use inspection, palpation, strength testing

NO ROM

Normal cartilage becomes soft, pitting occurs, cartilage thins

Spurs form, inflammation sets in

immobility, pain, muscle spasm

Synovial tissues: inflammation causes destruction of tissue / bone,

early detection decreases amount of bone / joint destruction

Goes into remission reducing the amount of disability

Manif: warmth, edema

Interv: splint, immobilization, periods of rest after activity,

Avoid overexertion and maintain proper posture / joint

position

Pain relief measures; moist heat

Encourage use of assistive devices

ROM / stretching exercises tailored to specific client needs

Admin Corticosteroids - inflammation

NSAIDS - pain

Positive Rheumatoid Factor (RF): 80% of patients

antinuclear antibody titers rise during active disease

indicators of active inflammation: ESR, C-Reactive Protein

(CRP)

Parkinsons Sinemet

Carbidopa / Levodopa (Sinemet) - enhances dopamine release

Monitor for: uncontrolled movement of face, eyelids, mouth,

tongue, arms, hands

mental changes

N/V

Difficulty urinating

Freezing: indicates Levodopa overdose

Takes months to achieve desired effects

Avoid sudden position changes

Avoid foods ^ in Vitamin B6

Insomnia: take last dose earlier in day

Myasthenia Gravis

defect in transmission of nerve impulses to muscles

Precipitated by: emotional distress, pregnancy, menses,

temp extremes

Manif: diploplia, ptosis (eyelid drooping), dysphagia / choking /

difficulty speaking

Monitor Respiratory Status > failure

Interv: trach kit @ bedside

Schedule nurse activities to conserve energy

Encourage coughing / deep breathing 4 - 6 hrs

Stroke Dysphagia

Impairment of speech / verbal comprehension

Speech Therapist - evaluate swallow / gag reflex

mouth care before meals - stimulates sensory awareness /

salivation > facilitates swallowing

food content could be easy to swallow / provide enough texture

temperature (warm / cold, flavor (stimulates swallow reflex)

may use crushed ice as stimulant

Avoid milk products - increases mucus viscosity / salivation

Place food on un-affected side of mouth

Good oral hygiene after feedings

Follow up speech program: ensure consistency

reassure slow process

Stroke Vision R/L Hemisphere

Left Hemisphere:

unable to discriminate words / letters

reading problems

deficits in right visual field

Right Hemisphere:

Visual / Spatial Deficits

Neglect of Left Visual Fields

Loss of Depth Perception

Amputation Pain

Elevate on one pillow; not too high as will cause contracture

Phantom Pain: will eventually disappear

responds to pain medication

Seizure / unconscious Client

Interv: maintain patent airway

protect patients head

turn patient to the side

loosen constrictive clothing

ease patient to floor

do not restrain

do not place any objects in mouth

observe / record details of event (onset, course, nature)

AFTER SEIZURE: reposition patient to open / maintain airway

Malignant Hyperthermia

rigidity of skeletal muscles may result in death

Causes: anesthetic agents

occurs during general anesthesia / recovery period

Interv: admin Dantrolene (Dantrium) - slows metabolism, reduces

muscle contraction

Prevention: obtain family history (autosomal dominant trait)

Post Op Hypothermia (Shivering)

core temp <95*

Shivering ^ O2 consumption / CO2 production

Cause: using cold irrigation materials / unwarmed inhaled gases

for anesthesia

High Risk: elderly, debilitated, intoxicated patients

Interv: warm blankets, heated aerosols, radiant warmers,

foxed air warmers, heated water mattress

O2 Therapy

Admin meperidine (Demerol) IV - relaxes involuntary muscles

Bariatric Surgery Postop

Pain Interv: admin pain meds as frequently as needed during first

24 hrs

Assess / monitor pain (can be from anastomosis leak then

typical surgical pain)

Elevate HOB 35 - 40 degrees - reduces abdominal pressure

ARF Hyperkalemia

Manif: dizziness, weakeness, cardiac irregularities, muscle cramps,

diarrhea, nausea

limit ^ K+ foods / Salt Substitues

BPH Benign Prostatid Hyperplasia

Enlargement of prostate (hypertrophy)

Manif: ^ frequency / decreased urination, bladder distention

nocturia, hesitancy, dribbling, decrease in size of stream

Nursing Diagnosis: Chronic Pain, Risk for Injury / Infection

Oversized balloon on catheter causes continuous feeling of needing

to void, should try to NOT void around catheter; bladder spasms

Sterile saline for bladder irrigation after TURP must be isotonic to

prevent fluid / electrolyte imbalance

Urinary Output after prostate surgery is reddish pink, clearing to

light pink within 24 hrs, small to medium sized clots

Bright red (frank) bleeding with large clots- notify physician

Monitor Hgb /Hct decreasing indicates bleeding

Avoid Strenuous activity, lifting, intercourse, sports 3 - 4 weeks

COPD Cor Pulmonale

Blue Bloater - insufficient oxygen

Chronic Bronchitis

Generalized Cyanosis

Right HF

Sinusitis

Manif: postnasal drip, thick yellow / green mucus

cough (worse at night), ear pain / pressure

headache / dental pain

fever /fatigue

facial pain /pressure

congestion / fullness

Interv: antibiotic (Amoxicillin)

decongestant

Nasal Corticosteroids / Antihistamines

^ Fluid Intake

HOB 30* +

TB Admission Protocol

Infectious; transmission is airborne

Manif: coughing / hemoptysis, dyspnea

+ AFB sputum smear

poor response to drug therapy

fever w/night sweats, anorexia / weight loss, fatigue,

calcification

Interv: airborne isolation

Private room w/negative pressure airflow

HEPA mask ensure accurate fit

Report symptoms of deteriorating condition (hemorrhage)

May return to work after 3 negative cultures

Remain in isolation 3 consecute negative sputum smears collected

on different days & demonstrate clinical improvement

Bacillus Calmette Guerin BCG vaccine will have positive skin test

and must be evaluated with chest radiograph

Teaching: cover mouth / nose with paper tissue

Discard used tissues properly

Adhere to drug treatment

Pneumonia

Causative Agent: bacterial, viral, fungal, chemical

Community acquired or nosocomial

High Risk: debilitated, smokers, immobile, immunosuppressed,

depressed gag reflex, sedated, neuromuscular disorders

Manif: tachypnea, fever, productive cough with pleuritic pain,

rapid bounding pulse, crackles, ^ WBC, ABC indication of

hypoxemia, drop in O2

Interv: assess sputum, cough productively, 3L, Monitor ABG's / O2,

Admin O2

Epididymitis

acute inflammatory painful

Risk Factors: STD (gonorrhea / chlamydia), trauma, urinary reflux

down vas deferens, <35 Yrs

Interv: antibiotic for both partners

refrain from sex during acute phase

use condoms

Conservative treatment: bed rest with elevation of scrotom

ice packs

analgesics

Cataract Postop

Teaching: do not rub / put pressure on eye

glasses / shaded lens worn

eye shield during sleep hours

Avoid lifting objects over 15lbs, bending, straining, coughing

increasing IOP

Stool softener to prevent straining

Avoid ling on operative side

Keep water from getting into eye

Observe / report signs of ^ IOP / infection

Prevention of falls