ADVANCED MED SURG UPDATED FINAL PAPER
QUESTIONS AND SOLUTIONS GUARANTEE A+
✔✔AIDS and nutrition-labs to evaluate, assessment of - ✔✔**Nutritional Status - BUN
will give you an idea of what nutritional status is like - r/t PROTEIN**
-Skin Integrity
-Respiratory Status
-Neurologic Status
-Fluid and Electrolyte Balance
-Knowledge Level of Patient
-Treatment of opportunistic infections
✔✔Brachytherapy-what is it? Pt teaching regarding it - ✔✔**RADIATION THERAPY**
Option for low-risk cases
Implantation of 80-100 seeds
Teaching
**Internal- aka Brachytherapy** needles, seeds, beads, or catheters. Can be temporary
or permanent.
**Intraluminal**- insertions of catheters into lumens of organs- bronchus, esophagus or
bile duct
**Intracavitary**- gynecologic cancers
**Interstitial implants**- prostate pancreatic, breast cancer
**Systemic Brachytherapy**- IV administration - bone and ovarian
Patient teaching:
**Straining their urine**
**Avoid pregnant women and infants for 2 months**
For the first 2 weeks, seeds may be present in urine and semen
Wear condom
✔✔Blood Transfusion Administration - ✔✔-19 gauge catheter at the minimum (not 20 or
22)
**Signed consent**
**Assess for previous transfusion reaction**
Use Y tubing
Follow facility protocol regarding identification
**Pre-transfusion responsibilities:**
-Usually takes 2 nurses to verify blood once brought to the unit
-Verify prescription, test donor and recipient blood for compatibility
-Examine blood bag for identification
-Check expiration date
-**Inspect blood for discoloration, gas bubbles, cloudiness**
(Most hospitals use a blood loc device now)
✔✔Blood Transfusion Administration - ✔✔**Obtain baseline VS**
, Inform client of reaction symptoms
**Initial infusion rate maximum is 120 mL/hr (2 l/min.)**
Record VS per facility protocol
After the first 15 minutes, increase the infusion rate
Most clients can tolerate one unit of PRBC over 2 hours (250 - 500 mL); others cannot
**PRBC transfusion must be complete within 4 hours of product leaving blood bank**
✔✔Transfusion reactions and nursing steps to take when it occurs (pg 971) -
✔✔**Signs and Symptoms**
-fever, chills, low back pain, nausea, chest tightness, dyspnea, anxiety
**Nursing Actions**
1. **Immediately stop transfusion**
2. Maintain the IV line with NS through **NEW** IV tubing @ a slow rate.
3. Assess the patient carefully. Compare vitals to baseline. Note the presence of
adventitious breath sounds.
4. Notify the Doctor of assessment findings. Continue to monitor vitals, respiratory,
cardiovascular, and renal status.
5. Notify blood bank of suspected transfusion reaction
6. Send blood container and tubing to the blood bank for repeat typing and culture.
7. Obtain appropriate blood specimens
8. Collect a urine sample
9. Document the reaction according to institution's policy
✔✔Complications of fluid overload - ✔✔**When administering large volumes of
crystalloid solutions, monitor the lungs for adventitious sounds and s/s of interstitial
edema
(Abdominal Compartment syndrome)
**Shortness of Breath
**Pulmonary Edema**
Anaphylactic reactions- (Colloid solutions)
Hypothermia
**Nursing concerns**
Monitor for effect
VS, UO, skin, LOC/mental status
week 1 slide 54
✔✔Nutrition and anemia-nursing considerations and pt teaching - ✔✔Iron
take on empty stomach - food (especially dairy) interferes with absorption
-**reverse taper**
allows body to adjust
-**increase intake of vitamin C**
contributes to absorption
-**high fiber intake, stool softeners**
prevents constipation
QUESTIONS AND SOLUTIONS GUARANTEE A+
✔✔AIDS and nutrition-labs to evaluate, assessment of - ✔✔**Nutritional Status - BUN
will give you an idea of what nutritional status is like - r/t PROTEIN**
-Skin Integrity
-Respiratory Status
-Neurologic Status
-Fluid and Electrolyte Balance
-Knowledge Level of Patient
-Treatment of opportunistic infections
✔✔Brachytherapy-what is it? Pt teaching regarding it - ✔✔**RADIATION THERAPY**
Option for low-risk cases
Implantation of 80-100 seeds
Teaching
**Internal- aka Brachytherapy** needles, seeds, beads, or catheters. Can be temporary
or permanent.
**Intraluminal**- insertions of catheters into lumens of organs- bronchus, esophagus or
bile duct
**Intracavitary**- gynecologic cancers
**Interstitial implants**- prostate pancreatic, breast cancer
**Systemic Brachytherapy**- IV administration - bone and ovarian
Patient teaching:
**Straining their urine**
**Avoid pregnant women and infants for 2 months**
For the first 2 weeks, seeds may be present in urine and semen
Wear condom
✔✔Blood Transfusion Administration - ✔✔-19 gauge catheter at the minimum (not 20 or
22)
**Signed consent**
**Assess for previous transfusion reaction**
Use Y tubing
Follow facility protocol regarding identification
**Pre-transfusion responsibilities:**
-Usually takes 2 nurses to verify blood once brought to the unit
-Verify prescription, test donor and recipient blood for compatibility
-Examine blood bag for identification
-Check expiration date
-**Inspect blood for discoloration, gas bubbles, cloudiness**
(Most hospitals use a blood loc device now)
✔✔Blood Transfusion Administration - ✔✔**Obtain baseline VS**
, Inform client of reaction symptoms
**Initial infusion rate maximum is 120 mL/hr (2 l/min.)**
Record VS per facility protocol
After the first 15 minutes, increase the infusion rate
Most clients can tolerate one unit of PRBC over 2 hours (250 - 500 mL); others cannot
**PRBC transfusion must be complete within 4 hours of product leaving blood bank**
✔✔Transfusion reactions and nursing steps to take when it occurs (pg 971) -
✔✔**Signs and Symptoms**
-fever, chills, low back pain, nausea, chest tightness, dyspnea, anxiety
**Nursing Actions**
1. **Immediately stop transfusion**
2. Maintain the IV line with NS through **NEW** IV tubing @ a slow rate.
3. Assess the patient carefully. Compare vitals to baseline. Note the presence of
adventitious breath sounds.
4. Notify the Doctor of assessment findings. Continue to monitor vitals, respiratory,
cardiovascular, and renal status.
5. Notify blood bank of suspected transfusion reaction
6. Send blood container and tubing to the blood bank for repeat typing and culture.
7. Obtain appropriate blood specimens
8. Collect a urine sample
9. Document the reaction according to institution's policy
✔✔Complications of fluid overload - ✔✔**When administering large volumes of
crystalloid solutions, monitor the lungs for adventitious sounds and s/s of interstitial
edema
(Abdominal Compartment syndrome)
**Shortness of Breath
**Pulmonary Edema**
Anaphylactic reactions- (Colloid solutions)
Hypothermia
**Nursing concerns**
Monitor for effect
VS, UO, skin, LOC/mental status
week 1 slide 54
✔✔Nutrition and anemia-nursing considerations and pt teaching - ✔✔Iron
take on empty stomach - food (especially dairy) interferes with absorption
-**reverse taper**
allows body to adjust
-**increase intake of vitamin C**
contributes to absorption
-**high fiber intake, stool softeners**
prevents constipation
