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