HESI Milestone #2
-Chemo Side Effects - ANSo Nausea/vomiting (24-48 hr, can be delayed up to 1 week)
Meningitis first step - ANSo Antibiotics - penicillin (ampicillin) AND cephalosporin
o Corticosteroids
Multiple sclerosis and urinary retention - ANSo Sensation of void heeded immediately (bed
pan/urinal @ bedside)
o Voiding schedule (start 1/5-2hr then extend)
o Drink specific amt every 2 hour; urinate 30 min after w/ timer
o Self-catherization
Acute renal failure priority - ANSo Maintain fluids
o Avoid fluid excess
o Renal replacement therapy
o Reduce metabolic rate
o Promote pulmonary function
Acute Respiratory distress priority findings - ANSo Hypoxia
o Intercostal retractions
o Crackles
o BNP levels
(alveoli collapse because small airways are narrowed due to interstitial fluid and bronchial
obstruction)
End of life plan of care - ANSo Signs and symptoms of impending death are recognized and
communicated in developmentally appropriate language for children and patients with cognitive
disabilities with respect to family preference. Care appropriate to this phase of illness is proved
to the patient and the family
Cushing Syndrome - ANSo Can result from corticosteroids
***Attempt to reduce/taper medication while still treating underlying disease
o Alternate day therapy decrease symptoms and allows adrenal glands to recover
Valve replacement teaching - ANSo Anticoagulant therapy (frequent follow-up/lab tests)
§ Pt on warfarin has specific normal ratios
o Prevent infection
o ANTIBIOTIC PROPHYALXIS FOR DETAL PROCEDURES!!!
, Cancer intractable pain plan of care - ANSo Pain, other symptoms and side effects are
managed based on the best available evidence, with attention to disease-specific pain and
symptoms, which are skillfully and systematically applied. ??????
Schizophrenia nursing diagnoses and interventions - ANS- Dx: 2 or more S&S for over 6 mo
(Positive= delusions, hallucinations, disorganized speech or Negative= 6 A's Anhedonia, Flat
Affect, Apathy, Anergia, Algogia, Avolition)
-Establish rapport and trust, ask about hallucinations, distract, lower environmental stimuli,
monitor suicidal ideation, 1st or 2nd generation antipsych
Grief process therapeutic response - ANSAllow the 5 steps of grieving (DABDA), active listening
and offer a supportive presence
Dementia action refusing ADLs - ANSEncourage finger foods, distraction, speak therapeutically
Alcohol withdrawal - ANS- Needs to be done under medical supervision b/c can be deadly
- VS Q4, onset of symptoms 4-6 hours after last drink, give lorazepam, reduce temp.
- Tremors, nausea, vomiting
Methadone overdose - ANSS&S= constricted pupils, resp. depression, circul. depression, LOC
decreased
Give naloxone
Domestic violence screening tool - ANS- Don't probe, write evidence down verbatim, provide a
safe environment
- Increase in violence during pregnancy
- Cycle of violence= tension building, violent, honeymoon
Aggression response - ANS5-phase cycle= Triggering (event), Escalation (movement toward a
loss of control), Crisis (loss of control), Recovery (regain control), Postcrisis (reconciliation)
***Hx = likely to occur again
Violence handling - ANS- Engage in dialogue to prevent escalation, intervene early in the cycle
- Approach as non threatening, calm manner and convey empathy
- Encourage the client to express their anger, build trust, anticipate need for meds, be consistent
Medication adverse reactions care (schizophrenia) - ANSConstipation is a common side effect
of antipsych meds, polydipsia occurs after years of treatment
Nurse can help minimize effects of delusions with distraction techniques, music, tv, writing and
talking to friends, positive self-talk and positive thinking
-Chemo Side Effects - ANSo Nausea/vomiting (24-48 hr, can be delayed up to 1 week)
Meningitis first step - ANSo Antibiotics - penicillin (ampicillin) AND cephalosporin
o Corticosteroids
Multiple sclerosis and urinary retention - ANSo Sensation of void heeded immediately (bed
pan/urinal @ bedside)
o Voiding schedule (start 1/5-2hr then extend)
o Drink specific amt every 2 hour; urinate 30 min after w/ timer
o Self-catherization
Acute renal failure priority - ANSo Maintain fluids
o Avoid fluid excess
o Renal replacement therapy
o Reduce metabolic rate
o Promote pulmonary function
Acute Respiratory distress priority findings - ANSo Hypoxia
o Intercostal retractions
o Crackles
o BNP levels
(alveoli collapse because small airways are narrowed due to interstitial fluid and bronchial
obstruction)
End of life plan of care - ANSo Signs and symptoms of impending death are recognized and
communicated in developmentally appropriate language for children and patients with cognitive
disabilities with respect to family preference. Care appropriate to this phase of illness is proved
to the patient and the family
Cushing Syndrome - ANSo Can result from corticosteroids
***Attempt to reduce/taper medication while still treating underlying disease
o Alternate day therapy decrease symptoms and allows adrenal glands to recover
Valve replacement teaching - ANSo Anticoagulant therapy (frequent follow-up/lab tests)
§ Pt on warfarin has specific normal ratios
o Prevent infection
o ANTIBIOTIC PROPHYALXIS FOR DETAL PROCEDURES!!!
, Cancer intractable pain plan of care - ANSo Pain, other symptoms and side effects are
managed based on the best available evidence, with attention to disease-specific pain and
symptoms, which are skillfully and systematically applied. ??????
Schizophrenia nursing diagnoses and interventions - ANS- Dx: 2 or more S&S for over 6 mo
(Positive= delusions, hallucinations, disorganized speech or Negative= 6 A's Anhedonia, Flat
Affect, Apathy, Anergia, Algogia, Avolition)
-Establish rapport and trust, ask about hallucinations, distract, lower environmental stimuli,
monitor suicidal ideation, 1st or 2nd generation antipsych
Grief process therapeutic response - ANSAllow the 5 steps of grieving (DABDA), active listening
and offer a supportive presence
Dementia action refusing ADLs - ANSEncourage finger foods, distraction, speak therapeutically
Alcohol withdrawal - ANS- Needs to be done under medical supervision b/c can be deadly
- VS Q4, onset of symptoms 4-6 hours after last drink, give lorazepam, reduce temp.
- Tremors, nausea, vomiting
Methadone overdose - ANSS&S= constricted pupils, resp. depression, circul. depression, LOC
decreased
Give naloxone
Domestic violence screening tool - ANS- Don't probe, write evidence down verbatim, provide a
safe environment
- Increase in violence during pregnancy
- Cycle of violence= tension building, violent, honeymoon
Aggression response - ANS5-phase cycle= Triggering (event), Escalation (movement toward a
loss of control), Crisis (loss of control), Recovery (regain control), Postcrisis (reconciliation)
***Hx = likely to occur again
Violence handling - ANS- Engage in dialogue to prevent escalation, intervene early in the cycle
- Approach as non threatening, calm manner and convey empathy
- Encourage the client to express their anger, build trust, anticipate need for meds, be consistent
Medication adverse reactions care (schizophrenia) - ANSConstipation is a common side effect
of antipsych meds, polydipsia occurs after years of treatment
Nurse can help minimize effects of delusions with distraction techniques, music, tv, writing and
talking to friends, positive self-talk and positive thinking
