Exit HESI Version 2 Study guide.

Exit HESI Version 2 Study guide. Grave's disease signs and symptoms -Enlarged thyroid -Acceleration of body process: weight loss, increased appetite, diarrhea, heat intolerance, tachycardia, palpitations, increased BP, diaphoresis, nervousness, insomnia -Exopthalamos -Increased T3 and T4 levels -Low TSH levels Grave's disease test -Radioactive Iodine Uptake to detect how the thyroid is working -Ultrasound -Bloodwork -Imaging tests Grave's disease treatment -Goal: inhibit production of thyroid hormones and block effect on the body -Radioactive iodine therapy: destroys overactive thyroid cells over time -Propylthiouracil, methimazole -Betablockers -Subtotal or full thyroidectomy (risk of damaging vocal cords and parathyroid glands) Nursing interventions for a pt with COPD -Sit upright (positioning) -Pursed lip breathing -Diaphragmatic breathing -HOB up -Not too much O2: decreases stimulus to breathe -O2 is not first choice! Considerations when choosing an IV site -Avoid restricted extremities (fistula, breast CA (mastectomy/lymphedema), cellulitis) -If no upper extremities available, can use legs -Infiltration is a problem, dont reinstill IV access; keep IV in but start a new line Pheochromocytoma -Tumor on the adrenals that causes release of catecholamines (epi and norepi) -Can cause hypertensive crisis (above 240) -Monitor BP frequently -Mosly cardio sx: increased HR and BP General teaching points for pt taking meds -Take the full dose of antibiotics (can build resistance) -Pay attention to timing and whether you take with food or on an empty stomach Describe post-surgical nursing assessment -VITALS!! -Take VS first to give you "the lay of the land" and plan further treatment -Watch for shock and hemorrhaging -Make sure BP is above 90 -Give O2 if decreased sat -Look/ask about pain if HR increased Describe Lupus and pt education -*Autoimmune disorder -Could have a decreased WBC count; increased risk for infection -Avoid crowds, avoid sick people, avoid sunlight (trigger) Explain safe insulin administration practice and how to teach another nurse -Give in SubQ fat, rotate spots -Sliding scale dose is based on most recent glucose level -Check orders in the computer if forget dose/med -Clean area with alcohol -Make sure you have the right pt Assessment points for pt with constipation -Assess current medications -Check measures that they're currently taking (daily enemas, laxatives, etc) -Assessment: no bowel sounds, abd distention -Make a doctors appointment -Assess current nutrition, diet, and exercise -Drink more water Osteomalacia and implications for pt teaching -Focus on nutritional support -Sunlight is a good source of vitamin D -Vitamin D is important to absorb calcium and phosphorous -Check vitamin D levels Osteomyelitis -Bone infection -Treat with antibiotics -Poor healing, injury entered the bone UTI -Pt doesn't always report sx! -Urine sample is foul smelling and cloudy -Send sample to lab for urinalysis -Order a secondary test (culture and sensitivity) to choose the correct tx Assessment and nursing interventions for hip fx -Assess for pain -Hip fracture sometimes shortens the leg/rotates it -Treat like its a hip fracture even if no testing done yet -Assess circulation (pulse, cap refill, feeling, movement, wiggle toes, color) -Don't elevate the leg -No extra motion until hip is stabilized -Assess skin and circulation if in traction Care and assessment for adrenalectomy -Pt at risk for electrolyte abnormalities -Put on telemetry -Daily serum electrolytes -Monitor VS -Watch for dysrhythmias Tracheostomy pt teaching -Maintain airway: suctioning -Communicate with white boards -Cough and suction on the way out -No more than 10 seconds Steps of the chain of infection -Causative agent -Reservoir -Portal of exit: ex: wound, dressing change -Mode of transmission: nurse could be mode if they wear a gown in the hallway -Portal of entry -Susceptible host: decreased immune system, also have wounds (entry site) *Ways to block transmission: precautions, wash hands Aseptic handwashing -Wash clean to dirty -Point arms down so dirty water runs from clean to dirty Chrones Diet -Low fat -High-calorie: dried fruit increases calories and nutrients -High nutrient foods -Ex: eggs w/o yolk, lean meat, fish, seafood, chicken Heart Failure Diet -No canned/processed food -No cheese or salami -Limit sodium (fluid retention) -Vegetables and fruits Mormon Diet -No alcohol -No caffeine -Give milk, juice, or water -If diabetic, no juice -Church = latter day saints Muslim Diet -Ramadan: fast for one month each year from dawn till after dark -Respect this -No alcohol Enema administration and nursing considerations -Monitor pt for cramping and abd pain -Coach and support pt through this pain -Need to get procedure done, take break, deep breaths, then continue Trapeze bar and considerations -Need upper body strength/upper extremities -Get history from pt: make sure they don't have any problems with dislocated shoulder -Allows more independence and participation with repositioning Education for splenomegaly -Avoid heavy lifting/straining -Avoid contact sports -Cant go right back to the norm, unless they just sit at a desk all day -Wear a seatbelt in the car Manual bladder irrigation and CBI -CBI: 3 way catheter -Check for kinks if not flowing properly -Manually irrigate CBI if there's a clot -If a clot is blocking, the pressure in the bladder could cause leakage around the catheter site Assessment for hypocalcemia -8.5 -Chvostek's sign: stroke face and face twitches -Trousseau's sign: pump up BP cuff, hand/wrist flexes -Possibly from thyroid surgery TB Precautions -Airborne isolation -N-95 masks -Negative pressure, single room MRSA Precautions -Precautions if they've already had MRSA -Contact isolation -Single rm or cohorted Pertussis (whooping cough) Precautions -Droplet isolation and contact precautions -Facemask AKI assessment -Decreased kidney function because of secondary condition and output decreases -Oliguria: less than 400 cc in 24 hrs -Kidneys aren't producing urine -Possibly can't produce urine sample AKI Interventions -Follow up and look at what drugs they're on -Monitor electrolytes -Monitor weight and edema -Monitor VS: HTN/HypoTN, increased HR -Aggressive fluids: watch for fluid overload, check lung sounds and vitals -Lasix or Mannitol IM Injections -If you stick yourself, fill out appropriate paper work and get pts blood sample -If you think you're in the wrong space, get a larger needle -If you aspirate and get blood return, take out and throw everything away Catheter Insertion -Always ask for allergies: could be allergic to the Iodine/Bedadine used to sterilize -Document time, size of foley, fluid in the balloon -Landmark = meatus inbetween clitoris and vaginal opening Safety concerns with Parkinson's -Early: falls, decreased mobility, risk for aspiration -Late: wheelchair bound, ulcers, decreased muscle, decreased mobility Distracting Injury -Ex: traumatic amputation, so focused on treating that you don't realize the pt isn't breathing -ABCs -C: know the cause and how to control it 3 Middle ear bones Incus, Maleus (hammer), Stapes Hearing -Maleus (hammer) is first small bone hit from the eardrum vibrations -Sound waves go to tiny hair cells in cochlea and communicate with the brain to perceive sound Stapedectomy -Performed for otosclerosis -Incision behind inner ear, stapes removed and implant inserted -Allows sound and vibrations to pass from eardrum to inner ear fluids Stapedectomy pt teaching -Improvement of hearing isn't immediate, can initially be worse -Hearing improves in 3 weeks, maximum hearing takes 6 months -Dressing on the ear Fat embolism symptoms -SOB -Confusion -Anxious/restless Fat embolism risk factors -Breaking a long bone (usually femur) Polycystic Kidney Disease treatments -Need pain relievers -NO NSAIDS (advil, naproxin sodium, motrin) -Can have tylenol Neurogenic Diabetes Insipidus assessment -Very high urine output, very dilute -Monitor sodium *Monitor osmolarity and osmolality: abnormal means its dilute urine -Mostly from trauma to hypothalamus DVT assessment -Pain -Warmth -Increased size in leg: sometimes they measure the calf DVT plan of care -Maintain on bed rest -No SCDs -Concern after surgery -Tx: heparin; d/c daily dose of aspirin Pt receiving blood -Nurse takes vitals for first 15-30 min, then can delegate to UAP -Nurse documents final vitals -VS: watch for significant changes -No specific diet Symptoms of transfusion reaction -Sx: fever, chills, flank pain, change in VS, nausea, headache, urticaria, dyspnea, bronchospasm -Stop infusion immediately Korotkoff sounds -Heard over brachial artery Emphysema treatment -Sit pt up in bed -Pursed lip breathing doesn't make the pt work less -Need to rest...might need bipap Emphysema classic presentation Barrel chest Stages of CKD -1,2,and 3: pt still functioning well, living faily normal life, may never progress or advance -Stage 5: dialysis 3x/week -Can't go on a week long vacation without dialysis; will end up back in the hospital -Fistula = restricted extremity (no BP or IV) Trouble shooting for pulse ox -Warm up the extremity -Change site: nose, toes, earlobes Trouble shooting for BP machine -Get a different machine! Herpes Zoster -Rash along the nerves of the side of the body (usually one side) -Very painful Herpes Zoster treatment -Try to stop the replication of the virus; can still have symptoms -Pain meds throughout: narcotics