HESI MEDICAL SURGICAL STUDY GUIDE 2023 - HEMATEMESIS INFORMATION NURSING PROCESSES

HESI MEDICAL SURGICAL STUDY GUIDE 2023 - HEMATEMESIS INFORMATION NURSING PROCESSES Please use this guide as such, a guide however remember to utilize the basics, the nursingprocess, ABC’s and prioritize accordingly. • Hematemesis (vomiting blood) – typically upper GI bleed a. What to assess? i. Remember ABC’s (pt having diff breathing?), check vital signs first* ii. Assess stool (blood present? – if so, what color. Dark red = upper GIbleed, usually more serious) iii. Check if they are on iron supplements iv. Worried about hypovolemic shock 1. S/S: restlessness, agitation, inc HR and RR, cool, pale, sweaty • Open vs Close angle glaucoma b. Def: condition characterized by inc intraocular pressure (IOP > 22 mmHg) r/t aqueous fluid being inadequately drained from eye à gradual painless visionloss. Generally asymptomatic in early stages (seen in reg eye exam) i. Nocure,canbetreatedpharmacologicallyandsurgically c. Patientteaching i. Develop a teaching plan that includes the following: (p. 131) 1. Careful adherence to eye-drop regimen can prevent blindness 2. Vision already lost cannot be restored 3. Eyes drops are needed for rest of life a. Eye drops used to cause pupillary constriction – mvmt 4. ***Proper eye-drop instillation technique. Obtain a return demonstration. a. Wash hands and external eye b. Tilt head back slightly c. Instill drop into lower lid, s touching the lid c the tip ofthe dropper d. Release lid, and sponge excess fluid from lid and cheek e. Close eye gentle, and leave closed for 3-5 min f. Apply gentle pressure on inner canthus to decrease systemic absorption g. (Caution: Vision may be blurred for 1-2 hrs post adminand adaption to dark environments difficult r/t pupillary constriction (FALL RISK)) i. Blurring tends to dec c inc use of meds