HESI MILESTONE EXAM 2 MEDSURG
2/OB/PEDS
24 hour jaundice: - ANS-manufacturing and elimination of bilirubin, threat elements consist
of :polycythemia, shortened erythrocyte lifestyles, immature hepatic uptake and conjugation
strategies. Management: nurse eight-12 times an afternoon, phototherapy.
Acute pancreatitis assessment: - ANS-success of ⅔, records of upper belly ache,
biochemical modifications with serum amylase or lipase stage greater than 3 times the
everyday limit, or typical locating on ct. Elevated serum amylase and lipase tiers
Acute renal failure priorities: - ANS-monitor fluid and electrolyte imbalance inclusive of
hyperkalemia, promoting pulmonary feature (turning patient deep respiratory), metabolic rate
(treat fever right away), save you infection (aseptic method), skin care,
Acute respiratory distress findings: - ANS-fast onset of excessive dyspnea, arterial hypoxia
that doesn't respond to supplemental oxygen
Addison's crisis hypoglycemia: - ANS-sweating and headache. Five% dextrose and ordinary
saline (zero.Nine%) The loss of glucocorticoids consequences in hypoglycemia with lawsuits
of muscle weak point, lethargy, and GI symptoms such as anorexia, weight loss, nausea and
vomiting.Must take medications dailY
Alc hepatitis teaching: - ANS-sodium restrict, avoid uncooked shellfish,
Ards abg - ANS-:screen client for symptoms of o2 toxicity and hypoxia. PH high manner
alkalosis, low manner acidosis,
Cancer intractable ache - ANS-: pioid remedy (morphine, fentanyl, codeine, oxycodone,
hydromorphone). IV and oral. Most common plan of care is palliative sedation
Chemo side results: - ANS-nausea and vomiting, myelosuppression (reduced wbc),
accelerated serum creatine and serum electrolytes, cardiac issues, infertility, peripheral
neuropathy, temper changes, hair loss, ulcers,
Cirrhosis ascites: - ANS-spironolactone is utilized in cirrhosis, the healing reaction would be
decreased ascites, A. Paracentesis and peritoneovenous shunts (LeVeen and Denver
shunts) may be indicated. (hesi e-book)
CKD metabolic acidosis - ANS-: kidneys are unable to excrete expanded loads of acid,
reduced acid secretion outcomes from the kidneys no longer being capable of excrete
ammonia, and to reabsorbed sodium bicarb.
, Compartment syndrome: - ANS-compromises blood flow, there can be potential for
irreversible damage. You ought to hold hand increased to preserve arterial perfusion
Cushing's syndrome: - ANS-surgical removal of the tumor, submit op adrenal disaster is
dealt with with hydrocortisone. Monitor blood glucose Clients with Cushing syndrome
frequently increase diabetes mellitus.
Cystic fibrosis headaches - ANS-: Lung insufficiency (maximum critical problem). ALWAYS
MONITOR RESP. Hemoptysis, pneumothorax, bacterial colonization, cor pulmonale,
volvulus, intussusception, intestinal obstruction, rectal prolapse, gastroesophageal reflux
disorder, diabetes, portal high blood pressure, liver failure, gallstones, and reduced fertility.
Avoid lung infections, wash palms,
Diabetes insipidus: - ANS-patient may additionally experience very thirsty due to loss of ADH
hormone, do now not try to restrict water consumption due to the fact it can purpose
excessive dehydration and hypernatremia, the drug of choice for DI is desmopressin, use
with warning with human beings who've CAD.
Dialysis HTN edema: - ANS-dialysis may be used for hypertension and edema that doesn't
respond to different remedies. Swelling, SOB, weight advantage, HTN, reveal na and K.
End of lifestyles care plan: - ANS-palliative care is quit of existence making them relaxed
Engorgement: - ANS-postnatal physiologic painful circumstance wherein distention and
swelling of the breast tissue happens because of an boom in blood and lymph deliver as a
precursor to lactation. Usually peaks inside four-5 days postpartum. Apply heat or bloodless
compress, breast rub down, milk expression, ultrasound, breast pumping, and
antiinflammatory retailers
Fetal charge tachycardia: - ANS-more than 160 for 10 minutes or longer. -Caused by way of
decreased fetal oxygen supply, Turn patron onto left side Discontinue oxytocin (Pitocin) if
infused. Administer O2 at 10 L by means of a tight facemask. Bolus IV fluids Notify fitness
care provide
FHR decels: - ANS-early decels do now not require intervention, No nursing interventions
are required besides to screen the development of exertions. Document the tactics of labor.
Past due decels are normally as a result of uteroplacental insufficiency. Heart price slowly
and smoothly decelerates at beginning of contraction and returns to baseline at stop of
contraction
Fractured femur assessment: - ANS-investigate for pores and skin breakdown, alignment of
the frame and leg, verify the color, temperature, capillary replenish, edema, pulses, potential
to transport, and sensations to the unaffected extremities each hour for the primary 24
hours, encourage patient to do extension and flexion sports 10x each hour,
Glaucoma s/s: - ANS-they enjoy blurred vision or 'halos', visual adjustments and loss.
Aching, slight soreness, headache.
2/OB/PEDS
24 hour jaundice: - ANS-manufacturing and elimination of bilirubin, threat elements consist
of :polycythemia, shortened erythrocyte lifestyles, immature hepatic uptake and conjugation
strategies. Management: nurse eight-12 times an afternoon, phototherapy.
Acute pancreatitis assessment: - ANS-success of ⅔, records of upper belly ache,
biochemical modifications with serum amylase or lipase stage greater than 3 times the
everyday limit, or typical locating on ct. Elevated serum amylase and lipase tiers
Acute renal failure priorities: - ANS-monitor fluid and electrolyte imbalance inclusive of
hyperkalemia, promoting pulmonary feature (turning patient deep respiratory), metabolic rate
(treat fever right away), save you infection (aseptic method), skin care,
Acute respiratory distress findings: - ANS-fast onset of excessive dyspnea, arterial hypoxia
that doesn't respond to supplemental oxygen
Addison's crisis hypoglycemia: - ANS-sweating and headache. Five% dextrose and ordinary
saline (zero.Nine%) The loss of glucocorticoids consequences in hypoglycemia with lawsuits
of muscle weak point, lethargy, and GI symptoms such as anorexia, weight loss, nausea and
vomiting.Must take medications dailY
Alc hepatitis teaching: - ANS-sodium restrict, avoid uncooked shellfish,
Ards abg - ANS-:screen client for symptoms of o2 toxicity and hypoxia. PH high manner
alkalosis, low manner acidosis,
Cancer intractable ache - ANS-: pioid remedy (morphine, fentanyl, codeine, oxycodone,
hydromorphone). IV and oral. Most common plan of care is palliative sedation
Chemo side results: - ANS-nausea and vomiting, myelosuppression (reduced wbc),
accelerated serum creatine and serum electrolytes, cardiac issues, infertility, peripheral
neuropathy, temper changes, hair loss, ulcers,
Cirrhosis ascites: - ANS-spironolactone is utilized in cirrhosis, the healing reaction would be
decreased ascites, A. Paracentesis and peritoneovenous shunts (LeVeen and Denver
shunts) may be indicated. (hesi e-book)
CKD metabolic acidosis - ANS-: kidneys are unable to excrete expanded loads of acid,
reduced acid secretion outcomes from the kidneys no longer being capable of excrete
ammonia, and to reabsorbed sodium bicarb.
, Compartment syndrome: - ANS-compromises blood flow, there can be potential for
irreversible damage. You ought to hold hand increased to preserve arterial perfusion
Cushing's syndrome: - ANS-surgical removal of the tumor, submit op adrenal disaster is
dealt with with hydrocortisone. Monitor blood glucose Clients with Cushing syndrome
frequently increase diabetes mellitus.
Cystic fibrosis headaches - ANS-: Lung insufficiency (maximum critical problem). ALWAYS
MONITOR RESP. Hemoptysis, pneumothorax, bacterial colonization, cor pulmonale,
volvulus, intussusception, intestinal obstruction, rectal prolapse, gastroesophageal reflux
disorder, diabetes, portal high blood pressure, liver failure, gallstones, and reduced fertility.
Avoid lung infections, wash palms,
Diabetes insipidus: - ANS-patient may additionally experience very thirsty due to loss of ADH
hormone, do now not try to restrict water consumption due to the fact it can purpose
excessive dehydration and hypernatremia, the drug of choice for DI is desmopressin, use
with warning with human beings who've CAD.
Dialysis HTN edema: - ANS-dialysis may be used for hypertension and edema that doesn't
respond to different remedies. Swelling, SOB, weight advantage, HTN, reveal na and K.
End of lifestyles care plan: - ANS-palliative care is quit of existence making them relaxed
Engorgement: - ANS-postnatal physiologic painful circumstance wherein distention and
swelling of the breast tissue happens because of an boom in blood and lymph deliver as a
precursor to lactation. Usually peaks inside four-5 days postpartum. Apply heat or bloodless
compress, breast rub down, milk expression, ultrasound, breast pumping, and
antiinflammatory retailers
Fetal charge tachycardia: - ANS-more than 160 for 10 minutes or longer. -Caused by way of
decreased fetal oxygen supply, Turn patron onto left side Discontinue oxytocin (Pitocin) if
infused. Administer O2 at 10 L by means of a tight facemask. Bolus IV fluids Notify fitness
care provide
FHR decels: - ANS-early decels do now not require intervention, No nursing interventions
are required besides to screen the development of exertions. Document the tactics of labor.
Past due decels are normally as a result of uteroplacental insufficiency. Heart price slowly
and smoothly decelerates at beginning of contraction and returns to baseline at stop of
contraction
Fractured femur assessment: - ANS-investigate for pores and skin breakdown, alignment of
the frame and leg, verify the color, temperature, capillary replenish, edema, pulses, potential
to transport, and sensations to the unaffected extremities each hour for the primary 24
hours, encourage patient to do extension and flexion sports 10x each hour,
Glaucoma s/s: - ANS-they enjoy blurred vision or 'halos', visual adjustments and loss.
Aching, slight soreness, headache.
