HESI Med-Surg II(Review for Exit exam1)

HESI Med-Surg II(Review for Exit exam1) when is it appropriate for the nurse to mark the operative site on the patient? -right or left distinctions -multiple structures: fingers/toes -levels: spinal procedures what assessments are made immediately of the patient arrival in the PACU? -vitals -level of consciousness -skin color & condition -dressing location & condition -IV fluids -drainage tubes -position -o2 sat levels when is a client moved from the PACU to the floor/unit? when the client is stabilized what should be monitored in the immediate post-operative period? monitor for signs of shock & hemorrhage -hypotension -narrow pulse pressure -rapid weak pulse -cold moist skin -increased capillary filling time what are some post-operative nursing interventions? -position client on side to prevent aspiration -keep warm - heated blanket -anti-emetics & NG suctioning for N/V -analgesics for pain post-op complications: urinary retention -occurs 8-12 hrs post op -monitor hydration status -encourage oral intake -offer bedpan or assist to commode post-op complications: pulmonary probs -atelectasis, pneumonia, embolus -occurs 1-2 days post op -assist pt to TCDB -keep hydrated -enable early ambulation -provide incentive spirometer post-op complications: wound healing probs -occurs 5-6 days post op -splint incision when coughing -monitor for s/s of infection, malnutrition, dehydration -provide high protein diet wound dehiscence the separation of the wound edges that is more likely to occur with vertical incisions wound evisceration the protrusion of intestinal contents more likely to occur in older, diabetic, obese, malnourished, or prolonged paralytic ileus pts post-op complications: UTI's -occurs 5-8 days post op -oral fluid intake -empty bladder q 4-6 hrs -monitor I & O's -avoid catheterization if possible post-op complications: thrombophlebitis -occurs 5-8 days post op -leg exercises q 8 hrs while in bed -early ambuation -TED hose or sequential compression devices -DO NOT raise knee gatch on bed -DO NOT place pillows beneath knees -no crossing legs at knees -low-dose heparin post-op complications: decreased GI peristalsis -constipation & paralytic ileus -occurs 2-4 days post op -NG tube: decompression -limit use of narcotic analgesics (dec peristalsis) -early ambulation why do we prep the bowels before a surgery involving the intestinal tract? -to decrease the bacterial count w/in the intestinal tract -to empty the intestine of stool -ultimately: to help reduce the risk of infection in the postoperative period roles of the circulating nurse -pt advocate -obtains necessary supplies for the procedure -ensures diagnostic studies & bld products are available -prepares OR table -positions the pt (pads bony prominences prn) -cleanses skin in operative area before positioning surgical drapes -assists other team members into gowns & gloves roles of the scrub nurse -sets up the sterile field -assists w/ draping the pt -hands sterile supplies into the operative field & takes used instruments from the surgeon roles of holding area nurse -cares for/manages the pts who have been brought into the OR suite but are not yet ready to go into the actual OR -helps transport & transfer pts how must a patient be positioned after a procedure that used spinal anesthesia? the pt must remain FLAT to avoid leakage of CSF from the puncture site describe priority of assessments in the PACU -initial: ABC's (airway, breathing, circulation); watch for stridor from edema or bronchospasms -next: CV status -vitals q 15 min until stable -neuro: level of consciousness -GI: n/v -labs what are some major CV post-op complications? -MI: elevated troponin levels, ST elevation or T wave inversion for ischemia -arrhythmias -hypotension (orthostatic) -DVT: clots on ultasound what are some major respiratory post-op complications? -atelectasis (CXR shows collapsed area) -pneumonia (CXR shows area of infiltration) -pulmonary embolism (CXR shows wedge infiltrate) what are some major GI post-op complications? -N/V -constipation (x-ray shows stool; slow/dec bowel sounds) -paralytic ileus (x-ray shows gas in intestines; absent bowel sounds) what are the s/s of malignant hyperthermia? -tachycardia, tachypnea -cyanosis -fever -muscle rigidity -diaphoresis -mottled skin -hypotension -dec UOP -cardiac arrest what is the earliest sign of malignant hyperthermia? tachycardia when should the nurse expect malignant hyperthermia to occur in the peri-operative period? -10-20 after anesthesia started -first 24 hrs post-op what are the s/s of hypovolemic shock? -pallor -rapid weak thready pulse -low BP -rapid breathing how far in advance should a patient stop taking aspirin before surgery? 7-10 days why is NPO status so important prior to surgery? to avoid aspiration s/s of IV infiltration -edema, discomfort/pain, redness, coolness at site, leakage s/s of extravasation of IV -inflammation, blistering, & necrosis at site s/s of IV phlebitis -redness, tender/pain, swelling (inflammation of the vessel) when should a patient stop smoking prior to a scheduled surgery? why? 4-8 wks to reduce pulmonary and wound healing complications what are some indications to postpone a schedule surgery? -uncontrolled HTN -pt intoxicated -current infection first intention wound healing granulation not visible & scar formation minimal; cover w/ dry sterile dressing second intention wound healing granulation occurs in infected wounds or wounds w/ edges not approximated; pack w/ moist sterile dressing & cover w/ dry sterile dressing third intention wound healing deep wounds not sutured early or break down & re-suture later; pack w/ moist gauze & cover w/ dry sterile dressing anemia a low hemoglobin or RBC count that results in dec oxygenation carrying capability of the blood s/s of anemia -pallor -tachycardia -fatigue -s/s bleeding - hematuria, melena, menorrhagia -dyspnea -spoon nails what diagnostics indicate anemia? Hgb 10 Hct 30 RBC 4 x 10^12 how does the body compensate for a Hgb that drops below 7? increase in cardiac output food sources w/ iron -meats, spinach, carrots food sources w/ folic acid -green leafies, liver, & citrus fruits food sources w/ vitamin B12 meats, green leafies, milk, & cheese administration of iron? -give with meals to dec gastric irritation administration B12 & folic acid? -administer orally when should B12 be given parenterally? if the patient has pernicious anemia -- use the Z track method to avoid skin staining; d/n use the deltoid & d/n massage the injection site leukemia a malignant neoplasm of the blood-forming organs characterized by an abnormal over-production of immature forms of any leukocytes & an interference w/ normal blood production resulting in dec # of erythrocytes & platelets complications of leukemia -anemia: dec RBC & bld loss -immunosuppression: immature WBCs & neutropenia -hemorrhage: thrombocytopenia types of leukemia: acute myelogenous leukemia -inability of leukocytes to mature -poor prognosis -death by infection types of leukemia: chronic myelogenous leukemia -abnormal production of granulocytic cells -poor prognosis types of leukemia: acute lymphocytic leukemia -abnormal leukocytes are found in blood-forming tx -most common childhood cancer -favorable prognosis types of leukemia: chronic lymphocytic leukemia -inc production of leukocytes & lymphocytes & proliferation of cells w/in the bone marrow, spleen & liver nursing assessment findings of leukemia -bleeding: petechiae, nosebleeds, bleeding gums -anemia: pale, fatigue, HA, bone/joint pain -infection: fever, tachycardia, lymphadenopathy -GI distress: anorexia, abd pain, diarrhea, thrush what should a nurse do before she administers antibiotics for leukemia? -take trough & peak blood levels of the antibiotic to ensure a therapeutic dose range -trough taken before admin -peak taken 30 min - 1 hr after admin hodgkin disease a malignancy of the lymphoid system characterized by a generalized painless lymphadenopathy what is the characteristic cell of hodgkin dx? the Reed-Sternberg cell s/s of hodgkin dx -enlarged lymph nodes -anemia, thrombocytopenia, elevated WBCs, dec platelets -fever -anorexia/weight loss -malaise, bone pain -night sweats neoplasm a new formation of cancer cells carcinoma a malignant tumor arising from epithelial tx sarcoma a malignant tumor arising form non-epithelial tx differentiation degree to which neoplastic tx is different from parent tx adjuvant therapy therapy supplemental to the primary therapy what are the 7 warning signs of cancer? 1. change in usual bowel/bladder fx 2. a sore that d/n heal 3. unusual bleeding or discharge, hematuria, tarry stools, ecchymosis, bleeding mole 4. thickening or a lump in the breast or other 5. indigestion or dysphagia 6. obvious changes in a wart or mole 7. nagging cough or hoarseness what are the functions of the spleen? -filter whole blood -remove old & imperfect WBC, lymphocytes, macrophages, & RBCs -breaks down Hgb & stores of RBCs/platelets how does the liver contribute to hematology? -produces clotting factors aplastic anemia (pancytopenia) a type of anemia when the bone marrow stops producing a sufficient amount of RBC, WBC, & platelets, increasing the risk of infection & hemorrhage iron deficiency anemia a type of anemia w/ lower than normal amt of iron in the blood resulting in dec formation of Hgb & dec ability for the blood to carry O2; low ferritin levels pernicious anemia a type of anemia where the ability of Vitamin B12 (needed to make RBC) to bind w/ intrinsic factor is lost, decreasing the amt that is absorbed resulting in a dec in RBC count s/s of pernicious anemia -premature graying of hair -neurologic probs: diminished senses, dementia -beefy red tongue -typical anemia symptoms Disseminated Intravascular Coagulation (DIC) blood coagulates throughout the vascular system depleting platelets & the body's ability to coagulate resulting in an increased risk of hemorrhage s/s of DIC -unexpected bleeding, hemorrhage -petechiae, purpura -tx hypoxia -hemolytic anemia nursing goals for DIC -decrease coagulation abilities -replace clotting factors multiple myeloma a malignancy of the plasma cells causes an excessive amt of plasma cells in the bone marrow causing destructive lesions and reducing normal bone marrow function complications of multiple myeloma -diminished immune fx -anemia -hypercalcemia s/s of multiple myeloma -severe bone pain -anemia -skeletal fractures (osteoporosis) -inc risk of infection -spinal cord compression -renal failure what two major signs should indicate that an elderly patient should be evaluated for multiple myeloma? -complaints of back pain + high protein polycythemia vera a myeloproliferative disorder that results in an overproduction of blood cells & a thickening of blood (specifically RBCs, WBCs, & platelets) complications of polycythemia vera -HTN -vision blurred & tinnitus -thrombosis & tx hypoxia -organ damage goal of treatment for polycythemia vera maintain bloodflow to the smaller vessels & diminish the amt of excess blood cells being made sickle cell anemia an autosomal recessive disorder in which an abnormal Hgb S "sickles" and obstructs the blood vessels due to dehydration, hypoxemia, & acidosis s/s of sickle cell anemia -acute pain of back, chest, & long bones -fever -painful swollen joints -fatigue (chronic anemia) -stroke, hepatomegaly, cardiomegaly neutropenia a neutrophil count 2,000 increasing the risk for infection thrombocytopenia VS thrombocythemia -thrombocytopenia = low platelets -thrombocythemia = inc platelets normal platelet levels 150,000 - 450,000 hyperthyroidism -graves dx, goiter -excessive activity of the thyroid gland resulting in elevated T4 and low TSH assessment findings of hyperthyroidism -goiter: enlarged thyroid -acceleration of body processes: weight loss, appetite, diarrhea, heat intolerance, tachycardia/palpitations, inc BP, diaphoresis, nervousness, insomnia -exophthalmos what is thyroid storm, what do you look for, & what is your primary nursing intervention? -a life-threatening event that occurs w/ uncontrolled hyperthyroidism -fever, tachycardia, agitation, anxiety, HTN -maintain airway & aeration hyperthyroidism diet -high calorie, protein -low caffeine, fiber what is the major post-thyroidectomy complication? -laryngeal edema -watch for hoarseness or inability to speak clearly -tracheostomy set, O2 & suction equipment at bedside -calcium gluconate