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HESI HINTS FOR MED SURG
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MED SURG HESI
Terms in this set (210)
HESI HINT: FEVER
CAN CAUSE DEHYDRATION BECAUSE OF EXCESSIVE FLUID LOSS DUE TO DIAPHORESIS. INCREASED TEMPERATURE ALSO INCREASES METABOLISM AND THE DEMAND FOR 02.
HESI HINT: CLIENTS AT HIGH RISK FOR PNEUMONIA
--ALTERED LEVEL OF CONSCIOUSNESS
--DEPRESSED OR ABSENT GAG AND COUGH REFLEXES
--SUSCEPTIBLE TO ASPIRATING OROPHARYNGEAL SECRETIONS, INCLUDING ALCOHOLICS, ANESTHETIZED INDIVIDUAL
HESI HINT: BRONCHIAL BREATH SOUNDS
ARE HEARD OVER AREAS OF DENSITY OR CONSOLIDATION. SOUND WAVES ARE EASILY TRANSMITTED OVER CONSOLIDATED TISSUE.
HESI HINT: HYDRATION
--THINS OUT THE MUCUS TRAPPED IN THE BRONCHIOLES AND ALVEOLI, FACILITATING EXPECTORATION
--IS ESSENTIAL FOR CLIENT EXPERIENCING FEVER
--IS IMPORTANT BECAUSE 300 TO 400mL OF FLUID IS LOST DAILY BY THE LUNGS THROUGH EVAPORATION
HESI HINT: IRRITABILITY AND RESTLESSNESS
ARE EARLY SIGNS OF CEREBRAL HYPOXIA; THE CLIENT'S BRAIN IS NOT RECEIVING ENOUGH 02
HESI HINT: PNEUMONIA PREVENTIVES--OLDER ADULTS
--FOR THE OLDER ADULTS; FLU SHOTS; PNEUMONIA IMMUNIZATIONS; AVOIDING SOURCES OF INFECTION AND INDOOR POLLUTANTS SUCH AS DUST, SMOKE, AND AEROSOLS; NO SMOKINGING
HESI HINT: PNEUMONIA PREVENTIVES--IMMUNOSUPPRESSED AND DEBILITATED PERSONS
--FOR THESE INDIVIDUALS; FLU SHOTS; PNEUMONIA IMMUNIZATIONS, INFECTION AVOIDANCE, SENSIBLE NUTRITION, ADEQUATE INTAKE, BALANCE OF REST AND ACTIVITY.
HESI HINT: PNEUMONIA PREVENTIVES--COMATOSE OR IMMOBILE INDIVIDUALS
--FOR THESE INDIVIDUALS; ELEVATION OF THE HEAD OF THE BED TO FEED AND FOR 1 HOUR AFTER FEEDING; FREQUENTLY TURNING OF THESE INDIVIDUALS.
HESI HINT: PRIMARY CAUSE OF COPD
EXPOSURE TO TOBACCO SMOKE IS THE PRIMARY CAUSE IN THE UNITED STATES.
HESI HINT: COMPENSATION OCCURS
OVER TIME IN CLIENTS WITH CHRONIC LUNG DISEASE, AND ABG's ARE ALTERED
HESI HINT: AS COPD WORSENS
THE AMOUNT OF 02 IN THE BLOOD DECREASES (HYPOXIA) AND THE AMOUNT OF CARBON DIOXIDE IN THE BLOOD INCREASES (HYPERCAPIA), CAUSING CHRONIC RESPIRATORY ACIDOSIS (INCREASED PACO2), WHICH RESULTS IN METABOLIC ALKALOSIS (INCREASED ARTERIAL BICARBONATE) AS COMPENSATION.
HESI HINT: NOT ALL COPD PATIENTS ARE
C02 RETAINERS, EVEN WHEN LYPOXEMIA IS PRESENT, BECAUSE C02 DIFFUSES MORE EASILY ACROSS LUNG MEMBRANES THAN 02.
HESI HINT: IN ADVANCED CLIENTS WITH WITH EMPHYSEMA
DUE TO THE ALVEOLI BEING AFFECTED, HYPERCAPIA IS A PROBLEM, RATHER THAN IN BRONCHITIS, WHERE THE AIRWAYS ARE AFFECTED.
--IT IS IMPERATIVE THAT BASELINE DATA BE OBTAINED FOR THE CLIENT.
HESI HINT: PRODUCTIVE COUGH AND COMFORT FOR PATIENTS WITH COPD OR EMPHYSEMA CAN BE FACILITATED BY
SEMI-FOWLER OR HIGH-FOWLER POSITION, WHICH LESSENS PRESSURE ON THE DIAPHRAGM BY ABDOMINAL ORGANS. GASTRIC DISTENTION BECOMES A PRIORITY IN THESE CLIENTS BECAUSE IT ELEVATES THE DIAPHRAGM AND INHIBITS FULL LUNG EXPANSION.
HESI HINT: NORMAL ABG VALUES FOR THE ADULT
PH 7.35 - 7.45
Pc02 35 - 45 mm Hg
P02 80 - 100 mm Hg
HCO3 21 - 28mEq/L
HESI HINT: NORMAL ABG VALUES FOR A CHILD
PH 7.36 - 7.44
Pc02 35 - 45 mm Hg
P02 80 - 100 mm Hg
HCO3 21 - 28mEq/L
HESI HINT: PINK PUFFER
BARREL CHEST IS INDICATIVE OF EMPHYSEMA AND IS CAUSED BY USE OF ACCESSORY MUSCLES TO BREATHE. THE PERSON WORKS HARDER TO BREATHE, BUT THE AMOUNT OF 02 TAKEN IN IS ADEQUATE TO OXYGENATE THE TISSUES.
HESI HINT: BLUE BLOATER
INSUFFICIENT OXYGENATION OCCURS WITH CHRONIC BRONCHITIS AND LEADS TO GENERALIZED CYANOSIS AND OFTEN RIGHT-SIDED HEART FAILURE (COR PULMONADE)
HESI HINT: CELLS OF THE BODY DEPEND ON 02 TO CARRY OUT THEIR FUNCTIONS.
INADEQUATE ARTERIAL OXYGENATION IS MANIFESTED BY CYANOSIS AND SLOW CAPILLARY REFILL (<3 SECONDS). A CHRONIC SIGN IS CLUBBING OF THE FINGERNAILS AND A LATE SIGN IS CLUBBING OF THE FINGERS.
HESI HINT: HEALTH PROMOTION--EATING CONSUMES ENERGY NEEDED FOR BREATHING.
OFFER MECHANICALLY SOFT DIETS, WHICH DO NOT REQUIRE AS MUCH CHEWING AND DIGESTION. ASSIST WITH FEEDING IF NEEDED.
HESI HINT: HEALTH PROMOTION--PREVENT SECONDARY INFECTIONS
AVOID CROWDS, CONTACT WITH PERSONS WHO HAVE INFECTIOUS DISEASES, AND RESPIRATORY IRRITANTS SUCH AS TOBACCO SMOKE.
HESI HINT: HEALTH PROMOTION--EDUCATION
TEACH THE PATIENT TO REPORT ANY CHANGE IN CHARACTERISTICS OF SPUTUM.
HESI HINT: ENCOURAGE
ENCOURAGE THE PATIENT TO HYDRATE WELL (3L) PER DAY AND DECREASE CAFFEINE DUE TO DIURETIC EFFECT.
HESI HINT: HAVE THEM OBTAIN THE IMMUNIZATIONS
IMMUNIZATIONS ARE NEEDED SUCH AND THE FLU AND PNEUMONIA VACCINES.
HESI HINT: WHEN ASKED TO PRIORITIZE NURSING ACTIONS ALWAYS USE THE ABC RULE
HESI HINT: LOOK AND LISTEN
IF BREATH SOUNDS ARE CLEAR BUT THE PATIENT IS CYNATOIC AND LETHARGIC--ADEQUATE OXYGENATION IS NOT OCCURRING.
HESI HINT: THE KEY TO RESPIRATORY STATUS IS
ASSESSMENT OF BREATH SOUNDS AS WELL AS VISUALIZATION OF THE PATIENT. ***BREATH SOUNDS ARE BETTER DESCRIBED RATHER THAN NAMED. BREATH SOUNDS SHOULD BE DESCRIBED AS CRACKLES, WHEEZES, OR HIGH-PITCHED WHISTLING SOUNDS RATHER THAN RALES, RHONCHI ETC., WHICH MAY NOT MEAN THE SAME THING TO EACH CLINICAL PROFESSIONAL
HESI HINT:QUESTIONS THAT DEAL WITH O2 DELLIVERY
IN ADULTS, O2 MUST BUBBLE THROUGH SOME TYPE OF WATER SOLUTION SO IT CAN BE HUMIDIFIED IF GIVEN AT >4L/MIN OR DELIVERED DIRECTLY TO THE TRACHEA. IF GIVEN AT 1 TO 4 L/MIN OR BY MASK OR NASAL PRONGS, THE OROPHARYNX AND NASAL PHARYNX PROVIDE ADEQUATE HUMIDIFICATION
HESI HINT: CANCER OF THE LARYNX
THE TONGUE AND MOUTH OFTEN APPEAR WHITE, GRAY, DARK BROWN, OR BLACK AND MAY APPEAR PATCHY
HESI HINT: TRACHEOSTOMY CARE
INVOLVES CLEANING THE INNER CANNULA, SUCTIONING, AND APPLYING CLEAN DRESSINGS
HESI HINT: HUMIDIFICATION
AIR ENTERING THE LUNGS IS HUMIDIFIED ALONG THE NASOBRONCHIAL TREE. THIS NATURAL HUMIDIFYING PATHWAY IS GONE FOR THE CLIENT WHO HAS HAD A LARYNGESCTOMY. IF THE AIR IS NOT HUMIDIFIED BEFORE ENTERING THE LLUNGS, SECRETIONS TEND TO THICKEN AND BECOME CRUSTY
HESI HINT: LARYNGECTOMY TUBE
HAS A LARGER LUMEN AND IS SHORTER THAN THE TRACHEOSTOMY TUBE. OBSERVE THE CLIENT FOR ANY SIGNS OF BLEEDING OR OCCLUSION, WHICH ARE THE GREATEST IMMEDIATE POSTOPERATIVE RISKS (FIRST 24 HOURS)
HESI HINT: LARYNGECTOMY CLIENTS
FEAR OF CHOKING IS VERY REAL FOR LARYNGECTOMY CLIENTS. THEY CANNOT COUGH AS THEY COULD EARLIER BECAUSE THE GLOTTIS IS GONE. TEACH GLOTTAL STOP TECHNIQUE TO REMOVE SECRETIONS (TAKE A DEEP BREATH, MOMENTARILY OCCLUDE THE TRACHEOSTOMY TUBE, COUGH, AND SIMULTANEOUSLY REMOVE THE FINGER FROM THE TUBE)
HESI HINT: TUBERCULOSIS (TB) SKIN TEST
A positive TB skin test is exhibited by an induration 10mm or greater in diameter 48hrs after skin test. Anyone who has received a BCG vaccine will have a positive skin test and must be evaluated using a chest x-ray film.
HESI HINT: TB TEACHING
DRUG THERAPY IS USUALLY LONG TERM (6 MONTHS OR LONGER). IT IS ESSENTIAL THAT THE CLIENT TAKE THE MEDICATIONS AS PRESCRIBED FOR THE ENTIRE TIME. SKIPPING DOSES OR PREMATURELY TERMINATING THE DRUG THERAPY CAN RESULT IN PUBLIC HEALTH HAZARD.
HESI HINT: RIFAMPIN TEACHING POINTS
RIFAMPIN: REDUCES EFFECTIVENESS OF ORAL CONTRACEPTIVES; CLIENTS SHOULD USE OTHER BIRTH CONTROL METHODS DURING TREATMENT; GIVES BODY FLUIDS ORANGE TINGE; STAINS SOFT CONTACT LENSES
HESI HINT: ISONIAZID (INH)
INCREASED PHENYTOIN (DILANTIN) LEVELS
HESI HINT: ETHAMBUTOL
VISION CHECK BEFORE STARTING THERAPY AND MONTHLY THEREAFTER; MAY HAVE TO TAKE FOR 1 TO 2 YEARS
HESI HINT: COMBINATION DRUG THERAPY
TEACH RATIONALE FOR COMBINATION DRUG THERAPY TO INCREASE COMPLIANCE. RESISTANCE DEVELOPS MORE SLOWLY IF SEVERAL ANIT-TB DRUGS GIVEN, INSTEAD OF JUST ONE DRUG AT A TIME
HESI HINT: LUNG TUMORS
SOME TUMORS ARE SO LARGE THAT THEY FILL ENTIRE LOBES OF THE LUNG. WHEN REMOVED, LARGE SPACES ARE LEFT. CHEST TUBES ARE NOT USUALLY USED WITH THESE CLIENTS BECAUSE IT IS HELPFUL IF THE MEDIASTINAL CAVITY, WHERE THE LUNG USED TO BE, FILLS UP WITH FLUID. THIS FLUID HELPS TO PREVENT THE SHIFT OF THE REMAINING CHEST ORGANS TO FILL THE EMPTY SPACE.
HESI HINT: CHEST TUBES
IF THE CHEST TUBE BECOMES DISCONNECTED, DO NOT CLAMP! IMMEDIATELY PLACE THE END OF THE TUBE IN THE CONTAINER OF STERILE SALINE OR WATER UNTIL A NEW DRAINAGE SYSTEM CAN BE CONNECTED.
HESI HINT: ACCIDENTAL REMOVAL OF CHEST TUBE
IS THE CHEST TUBE IS ACCIDENTALLY REMOVED FROM THE CLIENT, THE NURSE SHOULD COVER WITH A DRY STERILE DRESSING. IF AN AIR LEAK IS NOTED, TAPE THE DRESSING ON THREE SIDES ONLY; THIS ALLOWS AIR TO ESCAPE AND PREVENTS THE FORMATION OF A TENSION PNEUMOTHORAX. NOTIFY HEALTH CARE PROVIDER.
HESI HINT: NCLEX-RN CONTENT ON CHEST TUBES
FLUCTUATIONS (TIDALING) IN THE FLUID WILL OCCUR IF THERE IS NO EXTERNAL SUCTION. THESE FLUCTUATING MOVEMENTS ARE A GOOD INDICATOR THAT THE SYSTEM IS INTACT; THEY SHOULD MOVE UPWARD WITH EACH INSPIRATION AND DOWNWARD WITH EACH EXPIRATION. IF FLUCTUATIONS CEASE, CHECK FOR KINKED TUBING, ACCUMULATION OF FLUID IN THE TUBING, OCCLUSIONS, OR CHANGE IN CLIENT'S POSITION, BECAUSE EXPANDING LUNG TISSUE MAY BE OCCLUDING THE TUBE OPENING. REMEMBER, WHEN EXTERNAL SUCTION IS APPLIED, THE FLUCTUATIONS CEASE.
HESI HINT: NURSING DIAGNOSIS- INEFFECTIVE BREATHING PATTERNS
VARIOUS PATHOPHYSIOLOGIC CONDITIONS CAN BE RELATED TO THE NURSING DIAGNOSIS INEFFECTIVE BREATHING PATTERNS.
1. INABILITY OF AIR SACS TO FILL AND EMPTY PROPERLY (EMPHYSEMA, CYSTIC FIBROSIS)
2. OBSTRUCTION OF THE AIR PASSAGES (CARCINOMA, ASTHMA, CHRONIC BRONCHITIS )
3. ACCUMULATION OF FLUID IN THE AIR SACS (PNEUMONIA)
4. RESPIRATORY MUSCLE FATIGUE (COPD, PNEUMONIA)
HESI HINT: KIDNEY URINE EXCRETION
Normally kidneys excrete approximately 1 ml of urine per kg of body weight per hour
For adults, total daily urine output ranges between 1500 and 2000ml depending on the amount and type of fluid intake, amount of perspiration, environmental or ambient temp, and the presence of vomiting or diarrhea.
HESI HINT: ELECTROLYTE BALANCE
Electrolytes are profoundly affected by kidney problems
There must be a balance between extracellular fluid and intracellular fluid to maintain homeostasis.
A change in the number of ions or the amount of fluid will cause a shift in one direction or the other
Na+ and Cl- are the primary extracellular ions.
K+ and phosphate are the primary intracellular ions
HESI HINT: OLIGURIA
In some cases, persons in ARF may not experience the oliguric phase but may progress directly to the diuretic phase, during which the urine output may be as much as 10 l per day
HESI HINT: DAILY WEIGHTS
Body weight is a good indicator of fluid retention and renal status
Obtain accurate weights of all clients with renal failure; obtain weight on the same scale at the same time of the day
HESI HINT: EXCESS FLUID SYMPTOMS
Jug vein distention
HESI HINT: FLUID DEFICIENT SYMPTOMS
Decrease urine output
Decrease skin tugor
HESI HINT: SIGNS OF HYPERKALEMIA
dizziness, weakness, cardiac irregularities, muscle cramps, diarrhea, and nausea.
HESI HINT: POTASSIUM
Potassium has a critical safe range (3.5-5.0) because it affects the heart, and any imbalance must be corrected by medications or dietary modification.
Limit high K+ foods (bananas, OJ, cantaloupe, strawberries, avocados, spinach, fish) and salt substitutes, which are high in K+
HESI HINT: SODIUM
Clients with renal failure retain sodium.
With water retention, the Na+ becomes diluted and serum levels may appear normal
With excessive water retention, the Na+ levels appear decreased (dilution)
Limit fluid and sodium intake in ARF client.
HESI HINT: OLIGURIC PHASE
During oliguric phase minimize protein breakdown and prevent rise in BUN by limiting protein intake
When BUN and creatinine return to normal ARF is determined to be resolved
HESI HINT: UREMIA
Accumulation of waste products from protein metabolism is the primary cause of uremia. Protein must be restricted in CRF clients. However, if protein intake is inadequate, a negative nitrogen balance occurs, causing muscle wasting. The GFR is most often used as an indicator of the level of protein consumption.
HESI HINT: DIFFERENCE BETWEEN HEMODIALYSIS AND PERITONEAL DIALYSIS
The main difference between dialysate for hemodialysis and peritoneal dialysis is the amount of glucose. Peritoneal dialysis dialysate is much higher in glucose. For this reason, if the dialysate is left in the peritoneal cavity too long, hyperglycemia may occur.
HESI HINT: DIALYSIS COVERED BY MEDICARE
*All persons in the US are eligible for medicare as of their first day of dialysis under special end stage renal disease funding
*Medicare card will indicate ESRD
*Transplantation is covered by medicare procedure, coverage is terminated 6 months postoperative if dialysis is no longer required
HESI HINT: RESTRICTED PROTEIN INTAKE
Protein intake is restricted until blood chemistry shows ability to handle the protein catabolites, urea and creatinine. Ensure high calorie intake so protein is spared for its own work, give card candy, jelly beans, flavored carbohydrate powders
HESI HINT: KIDNEY FAILURE
As kidneys fail, medications must often be adjusted. Of particular importance is digoxin toxicity, because digitalis preparations are excreted by the kidneys. Signs of toxicity in adults include nausea, vomiting, anorexia, visual disturbances, restlessness, headache, cardiac arrhythmias, and pulse <60 beats per min.
HESI HINT: RESOLVING UTIs
The key to resolving UTIs with most anitbiotics is to keep the blood level of the antibiotic constant. It is important to tell the client to take the antibiotics around the clock and not to skip doses so that a consistent blood level can be maintained for optimal effectiveness
HESI HINT: LOCATION OF STONES
*Flank pain usually means the stone is in the kidney or upper ureter. If the pain radiates to the abdomen or scrotum, the stone is likely to be in the ureter or bladder.
*Excruciating, spastic-type pain in called colic
*During kidney stone attacks, it is preferable to administer pain meds at regularly scheduled intervals rather than PRN to prevent spasm and optimize comfort.
HESI HINT: PERCUTANEOUS NEPHROSTOMY
A needle or catheter is inserted through the skin into the calyx of the kidney. The stone may be dissolved by percutaneous irrigation with a liquid that dissolves the stone or by ultrasonic sound waves (lithotrpsy) that can be directed through the needle or catheter to break up the stone, which then van be eliminated through the urinary tract.
HESI HINT: BLADDER SPASMS
Bladder spasms frequently occur after TURP (transurethral resection of the prostate gland). Inform the client that the presence of the oversized balloon on the catheter (30-45ml inflated) will cause a continuous feeling of needing to void. The client should not try to void around the catheter because this can precipitate bladder spasms. Medication to reduce or prevent spasms should be given.
HESI HINT: SHIFT IN CELLULAR FLUID
Instillation of hypertonic or hypotonic solution into a body cavity will cause a shift in cellular fluid. Use only sterile saline for bladder irrigation after TURP because irrigation must be isotonic to prevent fluid and electrolyte imbalances.
HESI HINT: RELATIONSHIP OF KIDNEYS TO CARDIOVASCULAR SYSTEM
*Kidneys filter about 1L/blood a min. If cardiac output is decreased, the amount of blood going through the kidneys is decreased; urinary output is decreased. Therefore, a decrease urinary output may be sign of a cardiac problem.
*When the kidneys produce and excrete o.5mL of urine/kg of body weight or average of 30mL/hr output, the blood supply is considered to be minimally adequate to perfuse the vital organs.
HESI HINT: ANGINA
IS CAUSED BY MYOCARDIAL ISCHEMIA.
HESI HINT: NITROGLYCERIN
APPROPRIATE FOR ANGINA; CAUSES DILATION OF THE CORONARY ARTERIES, ALLOWING MORE O2 TO GET TO THE HEART MUSCLE
HESI HINT: ATROPINE
NOT APPROPRIATE FOR ANGINA; INCREASES HEART RATE BY BLOCKING VAGAL STIMULATION, WHICH SUPRESSES THE HEART RATE; DOES NOT ADDRESS THE LACK OF O2 TO THE HEART MUSCLE
HESI HINT: PROPRANOLOL (INDERAL)
NOT APPROPRIATE FOR ACUTE ANGINA ATTACK; HOWEVER, IS APPROPRIATE FOR LONG-TERM MANAGEMENT OF STABLE ANGINA BECAUSE IT ACTS AS A BETA BLOCKER TO CONTROL VASOCONSTRICTION
HESI HINT: MONA
REMEMBER MONA WHEN ADMINISTERING MEDICATIONS AND TREATMENTS IN THE PATIENT WITH MYOCARDIAL INFARCTION. MONA- MORPHINE, OXYGEN, NITROGLYCERIN, ASPIRIN
HESI HINT: BLOOD PRESSURE
Blood pressure is created by the difference in the pressure of the blood as it leaves the heart and the resistance it meets flowing out to the tissues. Therefore, any factor that alters cardiac output or peripheral vascular resistance will alter blood pressure. Diet and exercise, smoking cessation, weight control, and stress management can control many factors that influence the resistance blood meets as it flows from the heart.
HESI HINT: RISK FACTORS FOR HTN
Heredity, race, age, alcohol abuse, increased salt intake, obesity, and use of oral contraceptives.
HESI HINT: HYPERTENSION TEACHING
The number one cause of a stroke with hypertensive clients is non-compliance with medication regimen. Hypertension is often symptomless, and antihypertensive medications are expensive and have side effects. Studies have shown that the more clients know about their anti-hypertensive medications, the more likely they are to take them; teaching is important.
HESI HINT: DECREASED BLOOD FLOW
Results in diminished sensation in the lower extremities. Any heat source can cause severe burns before the client actually realizes the damage is being done.
HESI HINT: DISSECTING AORTIC ANEURYSM
A client is admitted with severe chest pain and states that he feels a terrible, tearing sensation in his chest. He is diagnosed with a dissecting aortic aneurysm. What assessment should the nurse obtain in the first few hours?
-Vital signs every hour
-Neurological vital signs
HESI HINT: AORTIC ANEURYSM REPAIR
During aortic aneurysm repair, the large arteries are clamped for a period of time and kidney damage can result. Monitor daily BUN and creatinine levels. Normal BUN is 10 to 20 mg/dl and normal creatinine is 20:1. When this ratio increases or decreases, suspect renal problems.
HESI HINT: HEPARIN
Heparin prevents conversion of fibrinogen to fibrin and prothrombin to thrombin, thereby inhibiting clot formation. Since the clotting mechanism is prolonged, do not cause tissue trauma which may lead to bleeding when giving heparin subcutaneously. Do not massage area or aspirate; give in the abdomen between the pelvic bones; 2 inches from umbilicus; rotate sites.
HESI HINT: ANTICOAGULANTS
-Antagonist: Protamine Sulfate
-LAB: PTT or APTT determines efficacy
-Keep 1.5 to 2.5 times normal control
-Antagonist: Vitamin K
-LAB: PT determines efficacy
-Keep 1.5 to 2.5 times normal control
-INR: Desirable therapeutic level usually 2:3 seconds (reflects how long it takes a blood sample to clot).
HESI HINT: HOLTER MONITOR
A holter monitor offers continuous observation of the client's heart rate. To make assessment of the rhythm strips, most meaningful, teach the client to keep a record of:
-Medication times and doses
-Chest pain episodes: type and duration
-Valsalva maneuver (straining at stool, sneezing, coughing)
-Exercise and other activities
HESI HINT: CARDIOVERSION
the delivery of synchornized electrical shock to the myocardium
HESI HINT: SYNCHRONOUS PACEMAKERS
AKA: demand pacemaker- fires only when the client's heart rate falls below a rate set on the generator.
HESI HINT: ASYNCHRONOUS PACEMAKERS
AKA: fixed pacemaker fires at a constant rate
HESI HINT: RESTRICTING SODIUM
REDUCES SALT AND WATER RETENTION, THEREBY REDUCING VASCULAR VOLUME AND PRELOAD
HESI HINT: DIGITALIS
-Side effects of digitalis are increased when the client is hypokalemic.
-Has a negative chronotropic effect ( i.e., it shows the heart rate). Hold the digitalis if the pulse rate is <60, >120, or has markedly changed rhythm.
-Bradycardia, tachycardia, or dysrhythmias may be signs of digitalis toxicity: these signs include nausea, vomiting, and headache in adults.
-If withheld, consult with physician.
HESI HINT: INEFFECTIVE ENDOCARDITIS
Damage to heart valves occurs with the growth of vegetative lesions on valve leaflets. These lesions pose a risk of embolization; erosion/perforation of the valve leaflets; or abscesses within adjacent myocardial tissue. Valvular stenosis or regurgitation (insufficiency), most commonly of the mitral valve, can occur depending upon the type of damage inflicted by the lesions, leading to symptoms of left - or right-sided heart failure.
HESI HINT: PERICARDITIS
presence of a friction rub is an indication of pericarditis (inflammation of the lining of the heart). ST segment elevation and T wave inversion are also signs of pericarditis.
HESI HINT: ACUTE INEFFECTIVE ENDOCARDITIS
often affects individuals with previously normal hearts and healthy valves, and carries a high mortality rate
HESI HINT: SUBACUTE ENDOCARDITIS
typically affects individuals with preexisting conditions, such as rheumatic heart disease, mitral valve prolapse, or immunosuppression. Intravenous drug abusers are at risk for both acute and subacute bacterial endocarditis. When this population develops Subacute Infective Endocarditis, the valves on the right side of the heart (tricuspid and pulmonic) are typically affected due to the introduction of common pathogens which colonize on the skin (S. epidermis and Candida) into the venous system.
HESI HINT: MITRAL VALVE STENOSIS
blood is regurgitated back into the left atrium from the left ventricle. In early period, there may be no symptoms; but, as the disease progresses, the client will exhibit excessive fatigue, dyspnea on exertion, orthopnea, dry cough, hemoptysis, or pulmonary edema. There will be a rumbling apical diastolic murmur, and atrial fibrillation is common.
HESI HINT: FOWLER OR SEMI-FOWLER POSITION
beneficial in reducing the amount of regurgitation as well as preventing the encroachment of the stomach tissue upward through the opening in the diaphragm.
HESI HINT: STRESS
can cause or exacerbate ulcers. Teach stress reduction methods and encourage those with a family history of ulcers to obtain medical surveillance for ulcer formation.
HESI HINT: CLINICAL MANIFESTATIONS OF GI BLEEDING
-Pallor: conjuctival, mucous membranes, nail beds
-Dark, tarry stools
-Bright red or coffee-ground emesis
-Abdominal mass or bruit
-Decreased BP, rapid pulse, cool extremities (shock).
HESI HINT: FLUID LOSS
The GI tract usually accounts for only 100 to 200 ml fluid loss per day, although it filters up to 8 liters per day. Large fluid losses can occur if vomiting and/or diarrhea exists.
HESI HINT: OPIATE DRUGS
tend to depress gastric motility. However, they should be given with care, and those receiving them should be closely monitored because a distended intestinal wall accompanied by decreased muscle tone may lead to intestinal perforation.
HESI HINT: DIVERTICULITIS
Diverticulosis is the presence of pouches in the wall of the intestine. There is usually do discomfort, and the problem goes unnoticed unless seen on radiological examination (usually prompted by some other condition). Diverticulitis is an inflammation of the diverticula (punches), which can lead to perforation of the bowel.
HESI HINT: NUTRITIONAL NEEDS FOR DIVERTICULITIS
A client admitted with complaints of severe lower abdominal pain, cramping, and diarrhea is diagnosed with diverticulitis. What are the nutritional needs of this client throughout recovery?
-Acute phase: NPO graduating to liquids.
-Recovery phase: no fiber or foods that irritate the bowel.
-Maintenance phase: high-fiber diet, with bulk-forming laxatives to prevent pooling of foods in the pouches where they can become inflamed. Avoid small, poorly digested foods such as popcorn, nuts, seeds, etc.
HESI HINT: MECHANICAL BOWEL OBSTRUCTION
Due to disorders outside the bowel (hernia, adhesions), due to disorders within the bowel (tumors, diverticulitis), or due to blockage of the lumen in the intestine (intussusception, gall stone).
HESI HINT: NONMECHANICAL BOWEL OBSTRUCTION
Paralytic ileus, which does not involve any actual physical obstruction, but results from inability of the bowel itself to function.
HESI HINT: NURSING PRIORITIES FOR RECTAL MASS
A client admitted with complaints of constipation, thready stools and rectal bleeding over the past few months is diagnose with a rectal mass. What are the nursing priorities for this client?
-NG tube (possibly an intestinal tube such as a Miller-Abbott)
-Surgical preparations of bowel (if obstruction is complete)
-Foods and fluids are restricted for 8 to 10 hours before surgery
-Oral erythromycin and neomycin are given to further decrease the amount of colonic and rectal bacteria
-if possible, all clients who require surgery for obstruction undergo NG intubation and suction before surgery.
-Teaching (preoperative, nutrition, etc.)
HESI HINT: DIET RECOMMENDATION BY THE AMERICAN CANCER SOCIETY TO PREVENT BOWEL CANCER
-Eat more cruciferous vegetables (from the cabbage family such as broccoli, cauliflower, Brussels sprouts, cabbage, and kale).
-Increase fiber intake.
-Maintain average body weight
-Eat less animal fat.
HESI HINT: AMERICAN CANCER SOCIETY RECOMMENDATIONS FOR EARLY DETECTION OF COLON CANCER
-A digital rectal examination every year after 40.
-A stool blood test every year after 50.
-A colonoscopy or sigmoidoscopy examination every 10 years after the age of 50 in average-risk clients, or more often based on the advice of a physician.
HESI HINT: EARLY SIGN OF COLON CANCER
IS RECTAL BLEEDING. ENCOURAGE PATIENTS 50 YEARS OF AGE OR OLDER AND THOSE WITH INCREASED RISK FACTORS TO BE SCREENED YEARLY WITH FECAL OCCULT BLOOD TESTING. ROUTINE COLONOSCOPY AT 50 IS ALSO RECOMMENDED
HESI HINT: CLINICAL MANIFESTATIONS OF JAUNDICE
-Yellow skin, sclera, and/or mucous membranes (bilirubin in skin)
-Dark-colored urine (bilirubin in urine)
-Chalky or clay-colored stools (absence of bilirubin in stools)
HESI HINT: FECTOR HEPATITIS
Is a distinctive breath odor of chronic liver disease. It is characterized by a fruity or musty odor which results from the damaged liver's inability to metabolize and detoxify mercaptan which is produced by the bacterial degradation of metionine, a sulfurous amino acid.
HESI HINT: LEVEEN AND DENVER SHUNTS
For treatment of ascities, paracentesis and peritoneovenous shunts may be indicated.
HESI HINT: ESOPHAGEAL VARICES
May rupture and cause hemorrhage. Immediate management includes insertion of an esophagogastric balloon tamponade - a Blakemore-Sengstaken or Minnesota tube. Other therapies include vasopressors, vitamin K, coagulation factors, and blood transfusions.
HESI HINT: AMMONIA
Not broken down as usual in the damaged liver; therefore, the serum ammonia level rises. The metabolism of drugs is not broken down so they remain in the system longer
HESI HINT: ENVIRONMENT CONDUCTIVE TO EATING
For clients who are anorexic or nauseated:
- remove strong odors immediately; they can be offensive and increase nausea
- encourage client to sit up for meals; this can decrease the propensity to vomit
- serve small, frequent meals
- give antiemetic prior eating
HESI HINT: LIVER TISSUE
Liver tissue is destroyed by hepatitis. Rest and adequate nutrition are necessary for regeneration of liver tissue being destroyed by the disease. Since many drugs are metabolized in the liver, drug therapy must be scrutinized carefully. Caution the client that recovery takes many months, and previously taken medications should not be resumed without the healthcare provider's directions
HESI HINT: ACUTE PANCREATIC PAIN
Is located retroperitoneally. Any enlargement of the pancreas causes the peritoneum to stretch tightly. Therefore, sitting up or leaning forward will reduce the pain.
HESI HINT: ENDOSCOPIC RETROGRADECHOLANGIOPANCREATOGRAPHY (ERCP)
Following this procedure, the client may feel sick. The scope is placed in the gallbladder and the stones are crushed and left to pass on their own. These clients may be prone to pancreatitis.
HESI HINT: NONSURGICAL MANAGEMENT OF CHOLECYSTITIS
-Medications for pain and clotting if required
-Decompression of the stomach via NG tube
HESI HINT. ABCs ASSESSMENT
Airway, Breathing, Circulation
HESI HINT. CHANCRE TREATMENT
A client comes to the clinic with a chancre on his penis. What is the usualy treatment?
-IM dose of penicillin (such as Benzathine penicillin G 2.4 million units).
-Obtain sexual history, including the names of his sex partners, so that they can receive treatment.
HESI HINT. PELVIC INFLAMMATORY DISEASE
Pelvic inflammatory disease (PID) involves one more of the pelvic structures. The infection can cause adhesions and eventually result in sterility. Manage the pain associated with PID with analgesics and warm sitz baths. Bedrest in a semi-Fowler's position may increase comfort and promote drainage. Antibiotic treatment is necessary to reduce inflammation and pain.
HESI HINT. CHLAMYDIA
Chlamydia is the most commonly reported communicable disease in the US.
HESI HINT. STDs IN CHILDREN
STDs in infants and children usually indicate sexual abuse and should be reported. The nurse is legally responsible to report cases of child abuse.
HESI HINT: STEROID NURSING INTERVENTIONS
Focus on the need to teach clients the importance of precisely following the prescribed regimen. They should be cautioned against suddenly stopping the medications and be informed that it is necessary to taper off taking steroids.
HESI HINT. TESTICULAR CANCER
Men whose testes have not descended into the scrotum or whose testes descended after age 6 are at high risk for developing testicular cancer. The most common symptom is the appearance of a small, hard lump about the size of a pea on the front or side of the testicle. Manual testicular examination should be done after a shower by gently palpating the testes and cord to look for a small lump. Swelling may also be a sign of testicular cancer.
HESI HINT. BREAST EXAMINATION
The importance of teaching female clients how to do self-breast examination cannot be overemphasized. Early detection is related to positive outcomes.
HESI HINT. NURSING MANAGEMENT OF REPRODUCTIVE CANCER
The major emphasis in nursing management of cancers of the reproductive tract is early detection.
HESI HINT. PAP SMEARS
Pap smears should begin within 3 years of having intercourse or no later than age 21, whichever comes first. Should be done annually until age 30 and then may be done every 2 to 3 years if a woman has 3 consecutive normal results. After age 70 may stop if woman has 3 consecutive normal and no abnormal pap smears in last 10 years. Women at high risk should have annual screenings.
HESI HINT. CANCER TREATMENTS
Laser therapy or cryosurgery is used to treat cervical cancer when the lesion is small and localized. Invasive cancer is treated with radiation, conization, hysterectomy, or pelvic exenteration (a drastic surgical procedure where the uterus, ovaries, fallopian tubes, vagina, rectum, and bladder are removed in an attempt to stop metastasis). Chemotherapy is not useful with this type of cancer.
HESI HINT. SIGNIFICANCE OF PROLAPSED UTERUS
What is the anatomical significance of a prolapsed uterus? When the uterus is displaced, it impinges on other structures in the lower abdomen. The bladder, rectum, and small intestine can protrude through the vaginal wall.
HESI HINT. BENIGN UTERINE TUMORS
Menorrhagia (profuse or prolonged menstrual bleeding) is the most important factor relating to benign uterine tumors. Assess for signs of anemia.
HESI HINT. HODGKINS DISEASE
Hodgkin's is one of the most curable of all adult malignancies. Emotional support is vital. Career development is often interrupted for treatment. Chemotherapy renders many male clients sterile. May bank sperm prior to treatment, if desired.
HESI HINT. ONCOLOGIC DRUGS
Most oncologic drugs cause immunosuppression. Prevention of secondary infections is vital! Advise client to stay away from persons with known infections such as colds. In the hospital, maintain an environment as sterile and as clean as possible. These persons should not eat raw vegetables or fruits - only cooked to destroy any bacteria.
HESI HINT. INFECTION IN THE IMMUNOSUPPRESSED
Infection in the immunosuppressed person may not be manifested with an elevated temperature. It is imperative, therefore, that the nurse performs a total and thorough assessment of the client frequently.
HESI HINT. ACUTE MYELOGENOUS LEUKEMIA
A 24-year old is admitted with large areas of ecchymosis on both upper and lower extremities. She is diagnosed with acute myeologenous leukemia. What are the expected laboratory findings for this client and what is the expected treatment?
--Lab: Decreased Hgb, decreased Hct, decreased platelet count, altered WBC (usually quite high).
--Treatment: Prevention of infection; prevention and/or control of bleeding; high protein, high calorie diet; assistance with ADL; drug therapy.
HESI HINT. CHEMOTHERAPY
Many health care delivery systems require the nurse to be credentialed in order to adminsiter parental chemotherapy. The practical nurse should recognize complications of chemo related to administration, safety, side effects, and nursing assessment parameters and should report these to the registered nurse and health care provider.
HESI HINT. BLOOD ADMINISTRATION
ONLY use normal saline to flush IV tubing or to run with blood. NEVER add medications to blood products. TWO registered nurses should simultaneously check the physician's prescription, client's identity, and blood bag label.
HESI HINT. PHYSICAL SYMPTOMS
Occur as a compensatory mechanism when the body is trying to make up for a deficit somewhere in the system. For instance, cardiac output increases when hemoglobin levels drop below 7g/dl.
HESI HINT. REASON FOR STEROID AND H2 ADMINISTRATION
Steroids are administered after a stroke to decrease cerebral edema and retard permanent disability. H2 inhibitors are administered to prevent peptic ulcers.
HESI HINT. WORDS THAT DESCRIBE LOSSES IN STROKES
-Apraxia: inability to perform purposeful movements in the absence of motor problems.
-Dysarthria: difficulty articulating
-Dysphasia: impairment of speech and verbal comprehension
-Aphasia: loss of the ability to speak
-Agraphia: loss of the ability to write
-Alexia: loss of the ability to read
Dysphagia: dysfunctional swallowing
HESI HINT. FAMILY INFORMATION ABOUT STROKE RECOVERY
--The quicker movement is recovered, the better the prognosis is for more or full recovery. She will need patience and understanding from her family as she tries to cope with the stroke. Mood swings can be expected during the recovery period, and bouts of depression and tearfulness are likely.
HESI HINT. CNS INVOLVEMENT OF STOKE
-Hemorrhagic: caused by a slow or fast hemorrhage into the brain tissue - often related to hypertension.
-Embolytic: caused by a clot, which has broken away from some vessel and has lodged in one of the arteries of the brain, blocking the blood supply. It is often related to atherosclerosis (may happen again).
HESI HINT. TREATMENT FOR PARKINSON DISEASE
An important aspect of Parkinson's treatment is drug therapy. Since the pathophysiology involves an imbalance between acetylcholines and dopamine, symptoms can be controlled by administering dopamine precursor (Levodopa).
HESI HINT. PARKINSON DISEASE
NCLEX-RN questions often focus on the features of Parkinson's disease - tremors (a coarse tremor of fingers and thumb on one hand which disappears during sleep and purposeful activity - also called "pill rolling"), rigidity, hypertonicity, and stooped posture. Focus: SAFETY!
HESI HINT. TENSILON TEST
Myasthenic crisis is associated with a positive edrophonium (Tensilon) test, while a cholinergic crisis is associated with a negative test.
HESI HINT. BLADDER AND RESPIRATORY INFECTIONS
Bedrest often relieves symptoms. Often a recurring problem. Need for health promotion teaching.
HESI HINT. MYASTHENIA GRAVIS
Be alert for changes in respiratory status - the most severe involvement may result in respiratory failure.
HESI HINT. DRUG THERAPY FOR MS CLIENT
ACTH, cortisone, Cytoxan, and other immunosuppressive drugs. Nursing implications for administration of these drugs should focus on prevention of infection.
HESI HINT. SYMPTOMS INVOLVING MOTOR FUNCTION
Usually begin in the upper extremities with weakness progressing to spastic paralysis. Bowel and bladder dysfunction occurs in 90% of the cases. MS is more common in women. Progression is not "orderly."
HESI HINT. CRANIOTOMY PREOPERATIVE MEDICATIONS
-Corticosteroids to reduce swelling
-Agents and osmotic diuretics to reduce secretions (atropine, robinul)
-Agents to reduce seizures (phenytoin)
HESI HINT. BENIGN TUMORS
Benign tumors continue to grow and take up space in the confined area of the cranium causing neural and vascular compromise for the brain, increased intracranial pressure, and necrosis of brain tissue - even benign tumors must be treated as they may have malignant effects.
HESI HINT. SPINAL CORD INJURY AND UTI
A common cause of death after spinal cord injury is urinary tract infection. Bacteria grow best in alkaline media, so keeping urine diluted ad acidic is prophylactic against infection. Also, keeping the bladder emptied assists in avoiding bacterial growth in urine, which is stagnated in the bladder.
HESI HINT. SPINAL SHOCK
It is imperative to reverse spinal shock as quickly as possible. Permanent paralysis can occur if a spinal cord is compressed for 12 to 24 hours.
HESI HINT. INJURY AT C3-C5
Physical assessment should concentrate on respiratory status, especially in clients with injury at C-3 to C-5, as cervical plexus innervates diaphragm.
HESI HINT. WHAT NOT TO USE
Try not to use restraints; they only increase restlessness. AVOID narcotics since they mask level of responsiveness.
HESI HINT. CSF LEAKAGE
CSF leakage carries the risk of meningitis and indicates a deteriorating condition. Because of CSF leakage, the usual signs of increased ICP may not occur.
HESI HINT. INTER-CRANIAL PRESSURE
Even subtle behavior changes, such as restlessness, irritability, or confusion, may indicate increased ICP.
HESI HINT. TRAUMATIC BRAIN INJURY
The forces of impact influence the type of head injury. They include acceleration injury, which is caused by the head in motion, and deceleration injury, which occurs when the head stops suddenly. Helmets are a GREAT preventive measure for motorcyclists and bicyclists.
HESI HINT. RESTLESSNESS
Restlessness may indicate a return to consciousness but can also indicate anoxia, distended bladder, covert bleeding, or increasing cerebral anoxia. Do not over-sedate, and report any symptoms of restlessness.
HESI HINT. SAFETY MEASURES FOR IMMOBILIZED PATIENTS
-Prevent skin breakdown with frequent turning.
-Maintain adequate nutrition.
-Prevent aspiration with slow, small feedings or NG feedings.
-Monitor neurological signs to detect the first signs that intracranial pressure may be increasing.
=Provide range of motion exercises to prevent deformities.
-Prevent respiratory complications -- frequent turning and positioning for optimal drainage.
HESI HINT. FEVER WITH CEREBRAL METABOLISM
If temperature elevates, take quick measures to decrease it since fever increases cerebral metabolism and can increase cerebral edema.
HESI HINT. BED REST OR IMMOBILIZED PATIENTS
Any client on bedrest/immobilized must have range of motion exercises often and very frequent position changes. Do not leave the client in any one position for longer than 2 hours. Any position that decreases venous return is dangerous, i.e., sitting with dependent extremities for long periods.
HESI HINT. COMATOSE PATIENTS
Paralytic ileus is common in comatose clients. Gastric tube aids in gastric decompression.
HESI HINT. ENTERNAL FEEDING WITH ALTERED CONSCIOUSNESS
Clients with an altered state of consciousness are fed by enteral routes since the likelihood of aspiration with oral feedings is great. Residual feeding is the amount of previous feeding still in the stomach. The presence of 100 ml residual in adults usually indicates poor gastric emptying and the feeding should be held.
HESI HINT: DEFORMITY
In the joint, the normal cartilage becomes soft, fissures and pitting occur, and the cartilage thins. Spurs form and inflammation sets in. The result is deformity marked by immobility, pain, and muscle spasm. The prescribed treatment regimen is corticosteroids for the inflammation; splinting, immobilization, and rest for joint deformity; and NSAIDS for the pain.
HESI HINT: CATARACT
When the cataract is removed, the lens is gone, making prevention of falls important. If the lens is replaced with an implant, vision is better than if a contact lens is used (some visual distortion) or if glasses are used (greater visual distortion - everything has a curved shape).
HESI HINT: GLASCOW COMA SCALE
Eliminates ambiguous terms to describe neurologic status such as lethargic, stuporous, or obtunded.
HESI HINT: NANDA DIAGNOSIS
Almost every diagnosis in the NANDA format is applicable, as severely neurologically impaired persons require total care.
HESI HINT: EXTERNAL AND MIDDLE EAR
External and middle ear problems (conductive) may result from infection, trauma or wax buildup. These types of disorders are treated more successfully with hearing aids.
HESI HINT: COMMUNICATING WITH OLDER ADULTS WHO ARE HEARING IMPAIRED
-Speak in a low-pitched voice, slowly, and distinctly.
-Stand in front of the person with the light source behind the client.
-Use visual aids if available.
HESI HINT: INNER EAR
Or disorders of the sensory fibers going to the CNS., often are neurogenic in nature and may not be helped with a hearing aid.
HESI HINT: EAR
The ear consists of three parts: the external ear, middle ear, and the inner ear.
HESI HINT: LENS OF THE EYE
Is responsible for projecting light, which enters onto the retina so that images can be discerned. Without the lens, which becomes opaque with cataracts, light cannot be filtered and vision is blurred.
HESI HINT: HIP REPLACEMENT
After a hip replacement, instruct the client not to lift the leg upward from a lying position or to elevate the knee when sitting. This upward motion can pop the prosthesis out of the socket.
HESI HINT: CONSTIPATION IN OLDER ADULTS
Older clients are prone to problems associated with constipation. Therefore, the nurse should assess these clients for constipation and postoperative complications associated with constipation, and implement a plan of care directed at prevention, and, if necessary, treatment for constipation.
HESI HINT: GLAUCOMA
is often painless and symptom-free. It is usually picked up as part of a regular eye exam.
HESI HINT: EYE DROPS
Eye drops are used to cause pupil constriction since movement of the muscles to constrict the pupil also allows aqueous humor to flow out, thereby decreasing the pressure in the eye. Pilocarpine is often used. Caution client that vision may be blurred 1 to 2 hours after administration of pilocarpine and adaptation to dark environments is difficult because of pupillary constriction (desired effect of the drug).
HESI HINT: RESIDUAL LIMB
should be elevated on one pillow. If the residual limb (stump) is elevated too high, the elevation can cause contracture.
HESI HINT: IMMOBILE PATIENTS
are prone to complications: skin integrity problems, formation of urinary calculi (may limit milk intake), and venous thrombosis (may be on prophylactic anticoagulants).
HESI HINT: PREDISPOSITION OF FRACTURES
Is anemia, especially if long bones are involved. Check hematocrit every 3 to 4 days to monitor erythropoiesis.
HESI HINT: ORTHOPEDIC WOUNDS
Have a tendency to ooze more than other wounds. A suction drainage device usually accompanies the client to the postoperative floor. Check drainage often.
HESI HINT: JOINT REPLACEMENT
A big problem after joint replacement is infection.
HESI HINT: THE 5 P'S OF NEUROVASCULAR FUNCTIONING
pain, paresthesia, pulse, pallor and paralysis.
HESI HINT: THROMBOEMBOLISM
the most common complication in clients with hip fractures. Prevention includes passive range of motion exercises, elastic stocking use, elevation of the foot of the bed 25 degrees to increase venous return, and low-dose heparin therapy.
HESI HINT: NEUROVASCULAR ASSESSMENT
Clients with fractures, casts, or edema to the extremities need frequent neurovascular assessment distal to the injury. Skin color, temperature, sensation, capillary refill, mobility, pain and pulses should be assessed.
HESI HINT: LUPUS ERYTHEMATOSUS
avoiding sunlight is key in management of lupus erythematosus - this is what differentiates it from other connective tissue diseases.
HESI HINT: OSTEOPOROSIS RISK FACTOR
Postmenopausal, thin, Caucasian women are at highest risk for development of osteoporosis.
HESI HINT: FAT EMBOLISM
The risk of a fat embolism, a syndrome in which fat globules migrate into the bloodstream and combine with platelets to form emboli, is greatest in the first 36 hours after a fracture. It is more common in clients with multiple fractures, fractures of long bones, and fractures of the pelvis. The initial symptom of a fat embolism is confusion due to hypoxemia (check blood gases for PO2). Assess for respiratory distress, restlessness, irritability, fever, and petechiae. If an embolus is suspected, notify physician STAT, draw blood gases, administer oxygen, and assist with endotracheal intubation.
HESI HINT: OSTEOPOROSIS TEACHING
Encourage exercise, a diet high in calcium, and supplemental calcium. While TUMS is an excellent source of calcium, it is also high in sodium and hypertensive or edematous individuals should seek another source for supplemental calcium.
HESI HINT: ASSISTIVE DEVICES
Improper use of assistive devices can be very risky. When using a nonwheeled walker, the client should lift and move the walker forward and then take a step into it. The client should avoid scooting the walker or shuffling forward into it; these movements take more energy and provide less stability than does a single movement
HESI HINT: OSTEOPOROSIS
Is the main cause of fractures in the elderly, especially women. The main fracture sites seem to be hip, vertebral bodies, and Colles' fracture of forearm.
HESI HINT: TYPES OF FRACTURES
What type of fracture is more difficult to heal, an extra capsular fracture (below the neck of the femur) or an intracapsular fracture (in the neck of the femur)?
The blood supply enters the femur below the neck of the femur. Therefore, an intra-capsular fracture is much more harder to heal and has a greater likelihood of necrosis since it is cut off from the blood supply.
HESI HINT: RHEUMATOID ARTHRITIS ACTIVITY
-Do not exercise painful, swollen joints.
-Do not exercise any joint to the point of pain.
-Perform exercises slowly and smoothly; avoid jerky movements.
HESI HINT: SYNOVIAL TISSUE
lines the bone of the joints. Inflammation of this lining causes destruction of tissue and bone. Early detection of rheumatoid arthritis can decrease the amount of bone and joint destruction. Often the disease will go into remission. Decreasing the amount of bone and joint destruction will reduce the amount of disability.
HESI HINT: RHEUMATOID ARTHRITIS ASSESSMENT
A client comes to the clinic complaining of morning stiffness, weight loss, and swelling of both hands and wrists. Rheumatoid arthritis is suspected. Which methods of assessment might the nurse use and which methods would the nurse not use?
-Use inspection, palpation, and strength testing.
-Do not use range of motion (this activity promotes pain because ROM is limited).
HESI HINT: CORRECTION FACTOR
The amount of insulin needed to correct hyperglycemia, usually given pre-meal.
HESI HINT: BOLUS INSULIN
Mealtime limits hyperglycemia after meals.
HESI HINT: BASAL INSULIN
(long-acting and intermediate acting insulin) suppresses glucose production between meals and overnight
HESI HINT: GLYCOSYLATED Hgb
-Indicates glucose control over previous 120 days (life of RBC)
-Valuable measurement of diabetes control.
HESI HINT: BODY'S RESPONSE TO ILLNESS/STRESS
Is to produce glucose. Therefore, any illness results in hyperglycemia.
HESI HINT: INSULIN THERAPY
Insulin is prescribed in basal/bolus and correction factor therapy. The goal of insulin therapy is to mimic the body's natural basal/bolus secretion of insulin.
HESI HINT: TREAT HYPOGLYCEMIA
If in doubt whether the client is hyperglycemic or hypoglycemic
HESI HINT: SELF-MONITORING OF BLOOD GLUCOSE (SMBG)
-Provides tight glucose control thereby decreasing the potential for long-term complications
-Technique is specific to each meter if meter is used.
-Monitor before meals, at bedtime, and any time symptoms occur.
-Record results and report to healthcare provider at time of visit.
HESI HINT: DIABETIC WOUND HEALING
High blood glucose contributes to damage of the smallest vessels, the capillaries. This damage causes permanent capillary scarring, which inhibits the normal activity of the capillary. This phenomenon causes disruption of capillary elasticity and promotes problems such as diabetic retinopathy, poor healing or breaks in the skin, cardiovascular abnormalities, etc.
HESI HINT: STEROID TEACHING
Teach clients to take steroids with meals to prevent gastric irritation. They should never skip doses. If they have nausea or vomiting for more than 12 to 24 hours, they should contact the physician.
HESI HINT. NEED FOR ADJUVANT THERAPY
The presence or absence of hormone receptors is paramount in selecting clients for adjuvant therapy.
HESI HINT: MYXEDEMA COMA
Can be precipitated by acute illness, withdrawal of thyroid medication, anesthesia, use of sedatives, or hypoventilation (with the potential for respiratory acidosis and carbondioxide narcosis). The airway must be kept patent, and ventilator support as indicated.
HESI HINT: ADDISON'S CRISIS
IS A MEDICAL EMERGENCY: Brought on by sudden withdrawal of steroids or a stressful event (trauma, severe infection)
-Vascular Collpase: Hypotension and tachycardia occur; administer IV fluids at rapid rate until stabilized.
-Hypoglycemia: Administer IV glucose
-ADMINISTER PARENTERAL HYDROCORTISONE: Essential for reversing the crisis.
-ALDOSTERONE REPLACEMENT: Administer fludrocortisone acetate(Florinef) PO (only available as oral preparation) with simultaneous administration of salt (sodium chloride) if client has a sodium deficit.
HESI HINT: TETANY
If two or more parathyroid glands have been removed, the chance of tetany increases dramatically:
-Monitor serum calcium levels (9.0 to 10.5 mg/dl is normal range)
-Check for tingling of toes, fingers, and around the mouth.
-Check for Chvostek's sign (tap over the parotid gland and which for twitching of lip = positive)
-Check Trousseau's sign (carpopedal spasm after inflating BP cuff above systolic pressure = positive).
HESI HINT: POSTOPERATIVE THYROIDECTOMY
Be prepared for the possibility of laryngeal edema. Put a tracheostomy set at bedside along with oxygen and a suction machine; Ca++ gluconate easily accessible.
HESI HINT: NORMAL SERUM CALCIUM
Is 9.0 to 10.5 mEq/L. The best indicator of parathyroid problems is a decrease in the client's calcium compared to the preoperative value.
HESI HINT: THYROID STORM
Is a life-threatening event that occurs with uncontrolled hyperthyroidism due to Grave's disease. Symptoms include fever, tachycardia, agitation, anxiety, and hypertension.
-Primary nursing interventions include maintaining an airway and adequate aeration.
-Propylthiouracil (PTU) or methimazole (Tapazole) are antithyroid drugs used to treat thyroid storm. Propanolol (Inderal) may be given to decrease excessive sympathetic stimulation.
HESI HINT. BURNS
Infection is a life-threatening risk for those with burns.
HESI HINT. BURN CARE
Massive volumes of IV fluids are given. It is not uncommon to give over 1000 mL/hr during various phases of burn care. Hemodynamic monitoring must be closely observed to be sure the client is supported with fluids but is not overloaded.
HESI HINT. INFLUENCE BURNS
Preexisting conditions that might influence burn recovery are age, chronic illness (diabetes, cardiac problems, etc.), physical disabilities, disease, medications used routinely, and drug or alcohol abuse.
HESI HINT. DRESSING CHANGING
Dressing changes are very painful! Medicate client prior to procedure!
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