HESI MILESTONE EXAM 2 MEDSURG
2/OB/PEDS
24 hour jaundice: - ANS-manufacturing and elimination of bilirubin, threat factors include
:polycythemia, shortened erythrocyte existence, immature hepatic uptake and conjugation
procedures. Management: nurse 8-12 instances a day, phototherapy.
Acute pancreatitis evaluation: - ANS-fulfillment of ⅔, history of upper abdominal ache,
biochemical changes with serum amylase or lipase level more than three times the ordinary
restrict, or traditional locating on ct. Elevated serum amylase and lipase ranges
Acute renal failure priorities: - ANS-screen fluid and electrolyte imbalance inclusive of
hyperkalemia, selling pulmonary function (turning patient deep respiration), metabolic fee (deal
with fever promptly), prevent infection (aseptic approach), skin care,
Acute respiratory misery findings: - ANS-rapid onset of severe dyspnea, arterial hypoxia that
does not respond to supplemental oxygen
Addison's disaster hypoglycemia: - ANS-sweating and headache. 5% dextrose and normal
saline (0.Nine%) The lack of glucocorticoids consequences in hypoglycemia with complaints of
muscle weakness, lethargy, and GI signs and symptoms together with anorexia, weight loss,
nausea and vomiting.Must take medicinal drugs dailY
Alc hepatitis teaching: - ANS-sodium limit, keep away from raw shellfish,
Ards abg - ANS-:display consumer for signs of o2 toxicity and hypoxia. PH high way alkalosis,
low approach acidosis,
Cancer intractable pain - ANS-: pioid remedy (morphine, fentanyl, codeine, oxycodone,
hydromorphone). IV and oral. Most common plan of care is palliative sedation
Chemo side effects: - ANS-nausea and vomiting, myelosuppression (decreased wbc),
accelerated serum creatine and serum electrolytes, cardiac problems, infertility, peripheral
neuropathy, mood modifications, hair loss, ulcers,
Cirrhosis ascites: - ANS-spironolactone is used in cirrhosis, the therapeutic reaction could be
reduced ascites, A. Paracentesis and peritoneovenous shunts (LeVeen and Denver shunts) can
be indicated. (hesi e-book)
, CKD metabolic acidosis - ANS-: kidneys are not able to excrete extended hundreds of acid,
decreased acid secretion effects from the kidneys now not being able to excrete ammonia, and
to reabsorbed sodium bicarb.
Compartment syndrome: - ANS-compromises blood glide, there may be potential for irreversible
harm. You ought to maintain hand elevated to keep arterial perfusion
Cushing's syndrome: - ANS-surgical removal of the tumor, publish op adrenal disaster is
handled with hydrocortisone. Monitor blood glucose Clients with Cushing syndrome frequently
develop diabetes mellitus.
Cystic fibrosis complications - ANS-: Lung insufficiency (most vital trouble). ALWAYS MONITOR
RESP. Hemoptysis, pneumothorax, bacterial colonization, cor pulmonale, volvulus,
intussusception, intestinal obstruction, rectal prolapse, gastroesophageal reflux sickness,
diabetes, portal high blood pressure, liver failure, gallstones, and decreased fertility. Avoid lung
infections, wash palms,
Diabetes insipidus: - ANS-affected person can also experience very thirsty due to lack of ADH
hormone, do now not try to limit water intake due to the fact it could purpose excessive
dehydration and hypernatremia, the drug of desire for DI is desmopressin, use with warning with
humans who have CAD.
Dialysis HTN edema: - ANS-dialysis can be used for hypertension and edema that doesn't reply
to other treatments. Swelling, SOB, weight advantage, HTN, display na and K.
End of life care plan: - ANS-palliative care is give up of life making them snug
Engorgement: - ANS-postnatal physiologic painful circumstance in which distention and swelling
of the breast tissue takes place because of an increase in blood and lymph supply as a
precursor to lactation. Usually peaks within 4-five days postpartum. Apply warmth or cold
compress, breast massage, milk expression, ultrasound, breast pumping, and antiinflammatory
marketers
Fetal rate tachycardia: - ANS-extra than one hundred sixty for 10 mins or longer. -Caused with
the aid of reduced fetal oxygen supply, Turn customer onto left aspect Discontinue oxytocin
(Pitocin) if infused. Administer O2 at 10 L by means of a tight facemask. Bolus IV fluids Notify
health care offer
FHR decels: - ANS-early decels do now not require intervention, No nursing interventions are
required except to monitor the progress of labor. Document the tactics of labor. Overdue decels
are normally because of uteroplacental insufficiency. Heart rate slowly and easily decelerates at
beginning of contraction and returns to baseline at give up of contraction
2/OB/PEDS
24 hour jaundice: - ANS-manufacturing and elimination of bilirubin, threat factors include
:polycythemia, shortened erythrocyte existence, immature hepatic uptake and conjugation
procedures. Management: nurse 8-12 instances a day, phototherapy.
Acute pancreatitis evaluation: - ANS-fulfillment of ⅔, history of upper abdominal ache,
biochemical changes with serum amylase or lipase level more than three times the ordinary
restrict, or traditional locating on ct. Elevated serum amylase and lipase ranges
Acute renal failure priorities: - ANS-screen fluid and electrolyte imbalance inclusive of
hyperkalemia, selling pulmonary function (turning patient deep respiration), metabolic fee (deal
with fever promptly), prevent infection (aseptic approach), skin care,
Acute respiratory misery findings: - ANS-rapid onset of severe dyspnea, arterial hypoxia that
does not respond to supplemental oxygen
Addison's disaster hypoglycemia: - ANS-sweating and headache. 5% dextrose and normal
saline (0.Nine%) The lack of glucocorticoids consequences in hypoglycemia with complaints of
muscle weakness, lethargy, and GI signs and symptoms together with anorexia, weight loss,
nausea and vomiting.Must take medicinal drugs dailY
Alc hepatitis teaching: - ANS-sodium limit, keep away from raw shellfish,
Ards abg - ANS-:display consumer for signs of o2 toxicity and hypoxia. PH high way alkalosis,
low approach acidosis,
Cancer intractable pain - ANS-: pioid remedy (morphine, fentanyl, codeine, oxycodone,
hydromorphone). IV and oral. Most common plan of care is palliative sedation
Chemo side effects: - ANS-nausea and vomiting, myelosuppression (decreased wbc),
accelerated serum creatine and serum electrolytes, cardiac problems, infertility, peripheral
neuropathy, mood modifications, hair loss, ulcers,
Cirrhosis ascites: - ANS-spironolactone is used in cirrhosis, the therapeutic reaction could be
reduced ascites, A. Paracentesis and peritoneovenous shunts (LeVeen and Denver shunts) can
be indicated. (hesi e-book)
, CKD metabolic acidosis - ANS-: kidneys are not able to excrete extended hundreds of acid,
decreased acid secretion effects from the kidneys now not being able to excrete ammonia, and
to reabsorbed sodium bicarb.
Compartment syndrome: - ANS-compromises blood glide, there may be potential for irreversible
harm. You ought to maintain hand elevated to keep arterial perfusion
Cushing's syndrome: - ANS-surgical removal of the tumor, publish op adrenal disaster is
handled with hydrocortisone. Monitor blood glucose Clients with Cushing syndrome frequently
develop diabetes mellitus.
Cystic fibrosis complications - ANS-: Lung insufficiency (most vital trouble). ALWAYS MONITOR
RESP. Hemoptysis, pneumothorax, bacterial colonization, cor pulmonale, volvulus,
intussusception, intestinal obstruction, rectal prolapse, gastroesophageal reflux sickness,
diabetes, portal high blood pressure, liver failure, gallstones, and decreased fertility. Avoid lung
infections, wash palms,
Diabetes insipidus: - ANS-affected person can also experience very thirsty due to lack of ADH
hormone, do now not try to limit water intake due to the fact it could purpose excessive
dehydration and hypernatremia, the drug of desire for DI is desmopressin, use with warning with
humans who have CAD.
Dialysis HTN edema: - ANS-dialysis can be used for hypertension and edema that doesn't reply
to other treatments. Swelling, SOB, weight advantage, HTN, display na and K.
End of life care plan: - ANS-palliative care is give up of life making them snug
Engorgement: - ANS-postnatal physiologic painful circumstance in which distention and swelling
of the breast tissue takes place because of an increase in blood and lymph supply as a
precursor to lactation. Usually peaks within 4-five days postpartum. Apply warmth or cold
compress, breast massage, milk expression, ultrasound, breast pumping, and antiinflammatory
marketers
Fetal rate tachycardia: - ANS-extra than one hundred sixty for 10 mins or longer. -Caused with
the aid of reduced fetal oxygen supply, Turn customer onto left aspect Discontinue oxytocin
(Pitocin) if infused. Administer O2 at 10 L by means of a tight facemask. Bolus IV fluids Notify
health care offer
FHR decels: - ANS-early decels do now not require intervention, No nursing interventions are
required except to monitor the progress of labor. Document the tactics of labor. Overdue decels
are normally because of uteroplacental insufficiency. Heart rate slowly and easily decelerates at
beginning of contraction and returns to baseline at give up of contraction
