ATI Med-Surg Hesi Concept Map Exam Study Guide

Pneumonia Pathophysiology - -Infection of the lungs. Problem in immunesuppressed patients. -Bacterial & Viral infections - hospital-acquired vs. community-acquired -Infection can spread throughout lungs. -Alveoli may collapse, resulting in a ventilation disorder. Risk Factors for Pneumonia - -age, immobility, malnutrition, smoking, URTI, chronic diseases, immunosuppressed Nursing Assessment Pneumonia - Tachypnea/ difficulty breathing Abrupt fever Productive cough Chest pain Bronchial and Crackles Consolidation and pleural effusion Elevated WBC Hypoxemia Nursing Interventions Pneumonia - -Increase fluids 3 L -Breathing exercises -Cough -Humidified o2 - Assess lung sounds -ABG monitroing -O2 sat -Temp -Abx -Vaccine education -rest and conserve energy Nursing Assessment: Acute Kidney Injury - -nephrotoxic drug hx -changes in urine output -edema and weight gain (waist bands tightened?) -Change in mental status -hematuria -dry mucus membranes -drowsiness, headache Lab information Kidney Damage - -azotemia - increased BUN and Cr -decreased calcium -elevated PO4, Mg, K, and Na -anemia Azotemia - (excessive) urea and nitrogenous substances in the blood Nursing Assessment UTI - - signs of infection, fever and chills -Urinary frequency, urgency or dysuria -Hematuria -*Pain at the costovertebral angle* -Elevated serum WBCs (10,000) UTI - E. coli, Staphylococcus saprophyticus (young women) Tx: Bactrim, Ciprofloxacin Nursing Interventions UTI - wipe front to back, wear cotton panties, discourage bubble baths and hot tubs -limit cath -good perineal care -increase fluid -monitor i/o -bathroom q 2-3 hours -abx and analgesics -no citrus Nursing Assessment Urinary Tract Obstruction - -Renal Colic pain -fever -chills -N/V/D -abdominal distension -dysuria -urgency, frequency, dribbling Nursing Interventions for Kidney Obstruction - -analgesics -moist heat for pain -increase fluid -abx -*strain all urine* -send stones for lab -I/O -lithotripsy teaching bengin prostatic hyperplasia - an enlargement of the prostate gland that most often occurs in men older than age 50 -proscar, tamsulosin, TURP tx Nursing Assessment BPH - -frequency, hesitancy -nocturia -dribbling -weak stream -bladder distension -urinary retention -UTIs Nursing Interventions BPH - -triple lumen catheter -teach about pain and bladder spasms post op -teach do NOT void around cath- irrigation will make it feel full bladder -observe output -vitals -monitor Hgb and HCT -Monitor frequency when cath is removed -get specimens -hematuria check- light pink is normal -first week: burning is normal -frank bleeding: report -increase fluids -ambulate first day if possible -impotent NOT common, sterility is possible Angina - a condition of episodes of severe chest pain due to inadequate blood flow to the myocardium Nursing Assessment of Chest Pain - - radiating pain -sudden onset, prolonged -dyspnea -N/V -fatigue -pallor -weakness -syncope Diagnostics for Angina - -ECG -stress test (look for ST depression) -cardiac cath -angiogram Nursing Interventions: Angina - -determine precipitating factors -teach risk factors -During attack: immediate rest, vitals, EKG, NO MORE than 3 nitro tablets 5 mins apart -seek emergency treatment if no relief after taking nitro -Teach no isometric exercises -implement exercise program -can climb two stairs= may continue sex; take prophylactic nitro -healthy diet mycardial infarction (MI) - heart attack - a blood clot forms in a narrowed coronary artery which blocks the blood flow to a section of the heart -ends in tissue necrosis -caused by thrombus, clotting, shock/hemorrhage Nursing Assessment MI - -Sudden Substernal Pain - unbearable -radiates shoulder and neck and jaw -Women may show SOB or fatigue -NOT relived by rest -N/V -Anxiety, doom -Nitro does not relieve pain -Persistent for hours or days is possible -thready pulse - decreased LOC -Cardiac Markers -narrowed pulse pressure -Diabetic Neuropathy patients may not have pain Nursing Interventions MI - -Morphine sulfate, ACE, Nitro, Beta Blockers, CCB, Aspirin, Antiplatelet -Vitals and ECG -02 2-6 L nasal cannula -patent IV -quiet environment -fluid balance -semi fowlers -bed rest 12 hours -gradual activity resuming -provide information peripheral vascular disease (PVD) - disease of blood vessels away from central region of body, most typically in legs; -Arterial: arteriosclerosis and advanced age, raynaud or bueger disease, diabetes, acute occlusion -Venous:DVT hx, valvular incompetence, varicose veins, thromb., venous stasis ulcers Arterial PVD - -Sharp, stabbing pain -Cool/cold; hairless, dry, shiny -Intermittent claudication -thickened nails -lowering feet may decrease pain (dangle from bed) -Absent or diminished pulse -distal ulcers -pallor on elevation -rubor -horizontal pain -absent pulse -Ulcers: painful, lateral and lower, small and deep, necrotic Venous PVD - -aching, cramping pain -elevating feet may relieve pain -Homan's sign -Brown pigment around ankles -full, dull sensation -cyanotic -normal pulse -warm extremities -Ulcers: slightly painful, medial, superficial but large, edema, exudative Nursing Interventions: PVD - -Monitor extremities at designated intervals (color, temp, sensation, pulse quality) -activity according to tolerance -rest at pain -position changes -no crossing legs or restrictive clothing -warm with clothing NO HEAT PADS -support hose -shoes and foot care -no smoking Abdominal Aortic Aneurysm (AAA) - -A condition in which the walls of the aorta in the abdomen weaken and blood leaks into the layers of the vessel, causing it to bulge. -Most common cause is arteriosclerosis -risk for those taking antihypertensives Nursing Assessment AAA - -bruit over abdominal aorta -pulsation in upper abdomen -Abdominal or lower back pain -heartbeat or mass in abdomen -Rupture: shock with sudden severe abdominal pain Nursing Interventions AAA - -Vitals and peripheral pulses regularly -Observe for occlusion after graft: change in pulses, severe pain, cool to cold extremities below graft, white or blue extremities -Check renal function post op -observe for post op ileus (NG suction 1-2 days post op to help prevent) frequent bowel sound check dysrhythmia - Abnormal heart rhythm -caused by electrical dysfunction of the heart -Cause by drugs, substances, AB imbalances, disease or trauma, thermal changes, stress Nursing Assessment: Dysrhytmias - -Change in pulse rate or rhythm -ECG Changes -Palpitations, syncope, pain, dyspnea -diapohoresis -hypotension -electrolyte imbalances AFIb - -Chaotic AV node -no true P waves are visible -irregular ventricular rhythm -anticoagulant therapy d/t stroke risk -drug therapy -cardioversion -cardiac cath ablation Atrial Flutter - -saw tooth wave form - fluttering in chest -ventricular rhythm stays regular -cardioversion -radiofrequency catheter ablation -drugs ventricular tachycardia - -wide , bizarre QRS -Assess pulse, Q -synchronized cardioversion IF PULSE PRESENT if not then treat like Vfib -drugs ventricular fibrillation - -cardiac emergency -irregular, undulations of varying amplitudes from coarse to fine -no Q or pulse -CPR -Defib ASAP -drugs Nursing Interventions Dysrhythmia - -Medication list -check serum drug levels; esp. digitalis -electrolyte levels, esp K and mg -ECG monitor -stay calm -monitor symptoms during activity -be prepared for cardioversion and defib -Pacemaker teaching: avoid high power generators, leaning on cars, MRIs Heart Failure - a chronic condition in which the heart is unable to pump out all of the blood that it receives and cannot meet the tissues o2 demands Nursing Assessment Heart Failure -Left and Right - -Left: pulmonary edema and congestion; cant pump blood to periphery S/S: Dyspnea, orthopnea, crackles, cough, fatigue, tachycardia, anxiety/restlessness, confusion -Right: peripheral edema S/S: edema, weight gain, distended neck veins, anorexia, nausea, nocturia, weakness, hepatmegaly, ascites both high BPN levels Nursing interventions Heart Failure - -vitals q 4 -apical HR for S3 S4 -Hypoxia (restless, tachycardic, angina) -Lung sounds for crackles -o2 as needed -elevate HOB -Edema (daily weights, i/o, observe fingers and ankles, measure abdominal girth -limit sodium -elevate lower extremities when sitting -hold digitalis if HR 60 bpm -morning diuretics -periods of rest with activity endocarditis - inflammation of the inner lining of the heart pericarditis - inflammation of the pericardium (outer membranous sac surrounding the heart) Endocarditis nursing assessment - -fever, chills -malaise, night sweats -fatigue -murmurs -symptoms of HF -artrial embolization Pericarditis Nursing Assessment - -Sudden, sharp pain in substernal radiating to back of arm; aggravated by coughing, inhalation or deep breaths; relieved by leaning forward -Friction rub heard over left lower sternal border -Fever Nursing Interventions Endo and Pericarditis - Endocarditis: -Monitor hemodynamic status (vitals, output and LOC) -IV abx for 4-6 weeks and before dental or GU procedures -good hygiene and medication therapy teaching -inform dentist and HCP of hx of endocarditis Pericarditis: -rest and comfort -analgesics and antiinflammatory Valvular Heart Disease (VHD) - -Heart valves that are unable to open fully (stenosis) or close fully (insufficiency and regurg) - Mitral most common -Rheumatic fever is common cause Nursing Assessment VHD - -pericardial effusion -fatigue -dyspnea and orthopnea -hemoptysis and pulmonary edema -murmurs -irregular heart rhythm -angina Nursing Intervention VHD - -monitor for DVT and afib -prophylactic abx before any invasive procedure -prepare client for surgical repair -teach about life long anticoagulant therapy with mechanical valve -vitals q 4 -apical HR for S3 S4 -Hypoxia (restless, tachycardic, angina) -Lung sounds for crackles -o2 as needed -elevate HOB -Edema (daily weights, i/o, observe fingers and ankles, measure abdominal girth -limit sodium -elevate lower extremities when sitting -hold digitalis if HR 60 bpm -morning diuretics -periods of rest with activity Hiatial Hernia & GERD - -herniation of a portion of the stomach into the chest through the esophageal hiatus of the diaphragm; sliding hernia is most common -GERD is the result of an incompetent lower esophageal sphincter that allows regurg. gastric contents into the esophagus Nursing Assessment GERD - -Heartburn after eating that radiates to arms and shoulders -Fullness or discomfort after eating -Positive dx determined by fluroscopy, barrium swallow or gastroscopy Nursing Interventions GERD - -Eating pattern that alleviates symptoms -small frequent meals -avoid aggravating foods (client specific but often strawberries, chocolate, caffeine) -sit up and remain up 1 hour after eating -no food 3 hours before bed -HOB 6-8 inch blocks -teach h2 antagonists and antacids Peptic Ulcer Disease (PUD) - -sore on the mucous membrane of the stomach, duodenum, or any other part of the gastrointestinal system exposed to gastric juices -commonly caused by infection with Helicobacter pylori bacteria Nursing Assessment Peptic Ulcer Disease - -belching, bloating, epigastric pain radiating to the back -determine how food intake affects pain -take history of antacid, h2 antagonist, or PPI -determine presence of melena -determine presence (EGD, Barium swallow) Complications: hemorrhage perforation obstruction Nursing Interventions Peptic Ulcer Disease - -determine symptom onset and relief -monitor color, quantity, consistency of stools and emesis -FOBT -meds 1-2 hours after meals and bedtime -Sucralfate 1 hour before meals -small meals -dumping syndrome -avoid salicyates, NSAIDs, anticoagulants and corticosteroids -teach smoking cessation and stress reduction -teach signs of abdominal bleeding Dumping syndrome - -Rapid emptying of gastric contents into small intestines. -5 to 30 minutes after eating -Client experience ab pain, nausea, vomiting, explosive diarrhea, weakness, dizziness, palpitations & tachycardia, syncope and hypotension -minimized by small frequent meals and low carbs -exacerbated by liquids with food. Chrons Disease - A chronic inflammatory bowel disease that affects the lining of the digestive tract. Chrons Disease Nursing Assessment - -RLQ abdominal pain not relieved by defecation -weight loss -steatorrhea -diarrhea -Constant fluid loss -low grade fever -perforation from inflammation: medical emergency -anorexia related to pain after eating -anemia -malnutrition Chron's Disease Nursing interventions - -Determine Bowel Pattern and control with diet and meds -LOW fiber, high protein and calorie, NO dairy or spicy -vitamin supplements and iron - avoid smoking, pepper, caffeine, ETOH -Complete bowel rest with IV TPN if necessary -I/O and Electrolytes -weigh 2x week -support group ulcerative colitis (UC) - -disease characterized by inflammation of the colon with the formation of ulcers - can cause bloody diarrhea -mainly lower intestine and rectum Nursing Assessment Ulcerative Colitis - -rectal bleeding -10-20 liquid stools with blood and mucus -Diarrhea -abdominal pain and cramping -intermittent tenesmus (anal cramping) -weakness and fatigue -anemia Nursing Interventions Ulcerative Colitis - -Determine Bowel Pattern and control with diet and meds -LOW fiber, high protein and calorie, NO dairy or spicy -vitamin supplements and iron - avoid smoking, pepper, caffeine, ETOH -Complete bowel rest with IV TPN if necessary -I/O and Electrolytes -weigh 2x week -support group Nursing Assessment Diverticulitis - -LLQ pain -increased flatus -rectal bleeding -Intestinal obstruction (constipation w diarrhea, abdominal distension, anorexia, low grade fever) Nursing Interventions: Diverticulitis / Diverticulosis - -high fiber BUT if inflamed or active disease: NPO followed by low residue, bland food -Metamucil (bulk forming laxative) -3L fluids/day -I/O -Observe for complications: obstruction peritonitis hemorrhage infection Nursing Assessment: Intestinal obstruction - -sudden onset abdominal pain, tenderness ad guarding -hx of abdominal surgeries or obstruction -distension -first increased peristalsis then decreased when paralytic ileus occurs -early high pitch sounds with mechanical obstruction and diminish with neurogenic or late mechanical obstruction Nursing Interventions Intestinal Obstruction - -NPO with IV fluids and electrolyte therapy -Monitor I/O (foley) -NG intubation (low suction, document q 8 hours, irrigate normal saline) -Assess Abdomen and bowel sounds regularly -medicine first; may need surgery Nursing Assessment: Colorectal Cancer - -rectal bleeding -change in bowel habits -CEA antigen -sense of incomplete evacuation, tenesmus -Abdominal pain -N/V -weight loss / cachexia -abdominal distension/ ascites -family hx -hx of chron's, polyps, UC Nursing Interventions Colorectal Cancer - -prepare for surgery -bowel prep with laxatives, gut lavage, poly. glycol -Stoma care -high cal, high protein, high fiber Pouch System Colostomy - -changed q 3-7 days -squirt bottle to remove effuence from sides of pouch -change when 1/3-1/5 full Ileostomy diet - Clients should chew food thoroughly; high fiber foods can cause severe diarrhea and may have to be eliminated Colostomy diet - Client should resume the regular diet gradually. Foods that were a problem preoperatively should be tried cautiously. Cirrhosis - chronic degenerative disease of the liver Nursing Assessment Cirrhosis - Hx of alcohol and street drugs, work history of exposure to toxic chemicals, medication history of long term use of hepatotoxic drugs; family history weakness malaise anorexia. wt loss palpable liver