Study Guide for N120 HESI Cardiovascular Coronary Artery Bypass Graft (CABG): the construction of new conduits

s (vessels to transport blood) between the aorta, or other major arteries. o Requires use of Sternotomy (opening of the chest cavity) & the use of cardiopulmonary bypass (CPB). o Internal mammary artery (IMA); most common artery for graft o Palliative treatment for those with CAD, not a cure Stent: an expandable meshlike structure designed to maintain vessel patency by compressing the arterial wall & resisting vasoconstriction Peripheral Vascular Disease (PVD) o Most common disease of the artery caused by build-up of fatty material w/in the vessels (atherosclerosis). o A gradual process where the artery gradually becomes blocked, narrowed, or weakened. o Causes: ischemia, gangrene, stroke, blood clot o Risk factors: positive family Hx, > 50 yrs old, overweight/obese, inactive lifestyle, Diabetes, BP/cholesterol/or LDL (bad cholesterol), plus high triglycerides & low HDL Congestive Heart Failure (CHF) o an abnormal clinical condition involving impaired cardiac pumping. o Results in characteristic pathophysiologic changes of vasoconstriction & fluid retention. o Classified as: Systolic failure (inability to pump blood) Diastolic failure (inability of ventricles to relax & fill during diastole). o Left sided Heart Failure is related to respiratory conditions => ex) Pulmonary edema Dyspnea, wet lung sounds, confusion, cough, tachycardia o Right sided Heart Failure is related to peripheral conditions => ex) Peripheral edema Peripheral edema, distended neck veins, nocturia, weakness, weight gain o Collaborative management: decrease intravascular volume, decrease venous return, decrease afterload, improve gas exchange/oxygenation, reduce anxiety, B-blockers, ARBs, Ace Inhibitors, Diuretics, Nitrates Dysrhythmia: Cardiac dysrhythmia occurs when the average adult HR falls below or rises above the normal range of 60 to 100 beats per minute (see page 849 for various types) o can be seen using and electrocardiogram (ECG) o determine serum drug levels (especially K & Mg), determine drug levels Deep Vein Thrombosis: a disorder involving a thrombus in a deep vein (most commonly the iliac & femoral veins)

o the treatment options are anticoagulation, thrombolysis, embolectomy, surgical revascularization, or amputation Anticoagulants are administered immediately to prevent further enlargement of a thrombus and inhibit embolization. (Administer heparin!!!!!) Prior to administering Heparin, check PTT or APPT values!!! 1.5-2.5 times the normal control When using heparin, dont massage area or aspirate Respiratory Trauma Acute Respiratory Distress Syndrome (ARDS): Serious reaction to numerous injuries to the lung. o Characterized by inflammation of the lung, parenchyma leading to impaired gas exchange with concomitant systemic release of inflammatory mediators causing inflammation, hypoxemia and frequently resulting in multiple organ failure. This condition is often fatal, usually requiring mechanical ventilation and admission to an ICU. A less severe form is called acute lung injury. o S/s: SOB, tachypnea, & confusion Emphysema: Increase size of air spaces w/ loss of elastic recoil of lung due to hyperinflation of distal airways causing airway obstruction. Emphysema & bronchitis are known as COPD o Destruction of alveolar walls & diffuse airway narrowing causes resistance to airflow because the loss of supporting structure & bronchospasm further impeded airflow. o Clinical manifestations: cyanosis, barrel chest, crackles, dyspnea, clubbing Superior Vena Cava (SVC) syndrome: results from obstruction of the superior vena cava by a tumor or thrombosis. Most common causes are lung cancer, non Hodgkins lymphoma, & metastatic breast cancer. o Clinical Manifestations: Facial edema, periorbital edema, distention of the veins of the head/neck/chest, headaches, & seizures. o Treatment: radiation therapy to site of obstruction (chemotherapy may also be used) Laryngospasm: a brief spasm of the vocal cords that temporarily makes it difficult to speak or breathe. o Clinical Manifestations: Inspiratory stridor, sternal retraction, acute respiratory distress o Treatment: O2, pos. pressure ventilation, IV muscle relaxant, Lidocaine, Corticosteroids Breathing Exercises: may assist the patient during rest and activity by decreasing dyspnea, improving oxygenation, and slowing the respiratory use. o Typically performed by Respiratory or Physical Therapists o Main types are:

Pursed Lip Breathing: purpose is to prolong exhalation and thus prevent bronchiolar collapse and air trapping. (slows RR) Patient taught to inhale slowly through nose and exhale slowly through purse lips (as if whistling) Recommended for severe COPD (diaphragmatic breathing may cause hyperinflation, thus is not recommended in this case) Diaphragmatic Breathing: focuses on using the diaphragm rather than accessory muscles of the chest to 1) achieve maximum inhalation 2) slow the RR Fingernail Clubbing o a thickening of the flesh under the toenails and fingernails. The nail curves downward, similar to the shape of the round part of an upside-down spoon. o Seen in those suffering from chronic hypoxemia, cystic fibrosis, lung cancer, and bronchiectasis (also may be seen in COPD) Pneumonia: an acute inflammation of the lung parenchyma caused by a microbial organism. o Acquired via aspiration, inhalation, or hematogenous spread o Clinical Manifestations: fever, chills, SOB, cough (productive purulent sputum), chest pain, confusion (elderly), hypoxia o Treatment: antibiotics (penicillin), antipyretics, analgesics, bronchodilator, flu/pneumonia vaccine, increase fluids, breathing/coughing exercises, O2 therapy Crush Injury: occurs when a body part is subjected to a high degree of force or pressure, usually after being squeezed between two heavy objects. o May result in: bleeding, bruising, compartment syndrome, fracture, laceration Chronic Obstructive Pulmonary Disorder (COPD): a preventable & treatable disease state characterized by airflow limitation that is not truly reversible. o Encompasses chronic bronchitis and Emphysema o Cigarette smoking is a major risk factor toward COPD o Characterized by chronic inflammation found in the airways, lung parenchyma, and pulmonary vasculature. o S/s: barrel chest, decreased abd. breathing, relying on intercostals/accessory muscles for breathing, non productive cough, purse lips breathing, hypoxemia, cyanosis o ABGs: usually assessed in the severe stages and monitored in those hospitalized with acute exacerbations. pH PCO2 HCO3 values 7.35-7.45 35-45 mmHq 21-27 mEq/L X Sample Ranges X

Respiratory Metabolic Respiratory Metabolic Acidosis Alkalosis Alkalosis Acidosis

Endocrine Chvosteks sign (tetany???) o Chvosteks sign is a contraction of facial muscles in response to a light tap over the facial nerve n the front of the ear. o Also indicates hypocalcemia with latent tetany. o Tetany is the increased nerve excitability and sustained muscle contraction. Troussseaus sign: refers to carpal spasm induces by inflating a blood pressure cuff on the arm. Cushings Syndrome: A spectrum of clinical abnormalities caused by an excess of corticosteroids (glucocorticoids in particular). o Clinical Manifestations: weight gain, hyperglycemia, protein wasting, loss of collagen, HTN, mood disturbances, moon face o Primary Goal: to normalize hormone secretion Goal of Drug Therapy: inhibition of adrenal function. o Tx: surgical (laparoscopic adrenalectomy) or meds (Mitotane, Metyrapone, aminoglutethimide, ketoconazole) Diabetes o Diabetes mellitus is a chronic multisystem disease related to abnormal insulin production, impaired insulin utilization, or both. o Type I Diabetes Mellitus: formerly known as juvenile onset or insulin dependant diabetes, type I diabetes most often occurs in those under 30 yrs of age. This condition is the end result of a long standing process in which the bodys own T cells attack and destroy pancreatic B cells, which are the source of the bodys insulin. Classic symptoms of type I diabetes include Polydipsia, Polyphagia, and Polyurea (the 3 Ps) o Type II Dia betes Mellitus is formerly known as adult onset diabetes usually occurring in those over 35 yrs (kids at high risk today), & involves the pancreas being able to make endogenous insulin which is either insufficient for the needs of the body, &/or is poorly utilized by the tissues. Clinical manifestations are often nonspecific but often include: fatigue, recurrent infections, prolonged wound healing, visual changes Hyperparathyroidism: a condition involving an secretion of parathyroid hormone (PTH) o Associated with increased serum Calcium levels Excessively high levels of circulating PTH usually lead to hypercalcemia and hypophosphatemia o Clinical Manifestations: weakness, loss of appetite, constipation, incr. need for sleep, emotional disorders, kidney stone, and shortened attention span. May result in calcium loss from bone (decrease bone density) May cause renal caliculi

o Tx: moderate Ca intake and increase fluid intake, Biphosphonates, Calcimimetic agents (incr sensitivity of Ca receptor on parathyroid gland) Propanolol (thyroid???) o Beta blockers such as propanolol can help to control the heart rate, and intravenous steroids may be used to help support circulation o Reduces HR, myocardial irritability, and force of contractions. Parathyroid: The parathyroid glands secrete parathyroid hormone (PTH) also known as parathormone. Its role is to regulate the blood level of calcium by acting on bone, kidneys, and GI tract (indirectly). o PTH stimulates renal conversion of Vitamin D which enhances the intestinal absorption of Calcium. o When Ca serum is low, PTH secretion rises; when Ca serum is high, PTH secretion falls. o Low Ca levels allow Na to move into excitable cells, decreasing the threshold of action potentials with subsequent depolarization of the cells. Results in Tetany (increased nerve excitability & sustained muscle contractions) Adrenalectomy: the surgical removal of one or both adrenal glands o may be performed through laparoscopic or open surgery o an open surgical adrenalectomy is used to treat adrenal cancer. Diabetes A1C: a test useful in determining glycemic levels over time. o Used by diabetic patients and health care providers to monitor success of treatment and to implement changes in treatment modalities o Indicates the overall glucose control for the previous 90-120 days. o For people with diabetes, the ideal A1C goal is 7.0% or less according to the ADA. The American College of Endocrinology recommends an A1C of less than 6.5%. Normal HbA1C levels decrease the incidence of neuropathy, nephropathy, and retinopathy. Diabetic Neuropathy: nerve damage that occurs because of the metabolic derangements associated with Diabetes Mellitus. o the most common type is sensory neuropathy, which may lead to the loss of protective sensation in the lower extremities, and coupled with other factors, this significantly increases the risk for complications that result in a lower limb amputation. o Autonomic Neuropathy can affect nearly all body systems and lead to hypoglycemic unawareness, bowel incontinence/diarrhea, and urinary retention. A diabetic w/ postural hypotension should change from a lying or sitting position slowly. Myxedema coma: mental sluggishness, drowsiness, and lethargy of hypothyroidism may progress gradually or suddenly to this notable impairment of consciousness or coma.

o S/s: subnormal temperature, hypotension, hypoventilation Propylthiouracil (PTU): a first line antithyroid drug which inhibits the synthesis of thyroid hormones. Also blocks peripheral conversion of T4 to T3. (not curative) o There is a high rate of recurrence of hyperthyroidism if this drug is discontinued. o Lowers hormone levels more quickly but must be taken three times a day. Tracheostomy: a stoma that results from the tracheotomy (surgical incision into the trachea for the purpose of establishing an airway). Indications for a tracheotomy are to: o Bypass an upper airway obstruction o Facilitate removal of secretions o Permit long term mechanical ventilation o Permit oral intake & speech in a patient who requires long term mechanical ventilation. Parathyroidectomy: partial or complete surgical removal of the parathyroid glands. o Leads to a rapid reduction of chronically high Ca levels What is the only kind of insulin that can be given via an IV? => Regular Insulin

GI/Hepatic/Renal Appendicitis: an inflammation of the appendix (a narrow blind tube extending from the inferior part of the cecum). o Most common causes are obstruction of the lumen by accumulated feces (fecalith), foreign bodies, tumor of the cecum or appendix, or intramural thickening caused by excessive growth of lymphoid tissue. o S/s: periumbilical pain, anorexia, n/v (pain located around McBurneys point) o Preop: Until physician sees patient, the patient remains NPO Place ice bag to right lower quadrant to decrease flow of blood to the area and impede the inflammatory process. (heat may cause appendix to rupture) Surgery performed as soon as a Diagnosis is made. o Postop: Patient observed for evidence of peritonitis Ambulation begins day of surgery or the first postop day Diet advanced as tolerated by patient D/c on first or second post op day Diverticulitis: results from retention of stool and bacteria in the diverticulum, forming a hardened mass called fecalith. This causes inflammation and usually small perforations. o Inflammation spreads to the surrounding area in the intestines causing the tissue to become edematous (abnormal accumulation of fluid in the body tissues or in the body cavities causing swelling or distention of the affected parts) o Diet: high fiber diet (mainly from fruits and vegetables), intake of fat/red meat,

Guaiac Test: finds hidden (occult) blood in the stool (bowel movement) o ***Vitamin K should be administered if blood is evident in the stools, as vitamin K may help in clotting the source of the bleed. N/G Tube: a silicone tube that is inserted through the nose down into the stomach, and is used for short term feeding problems. (use x-ray to determine placement prior to initiating feeding) o Coughing, cyanosis or choking may indicate that the NG tube has passed through the larynx. If this occurs, retract tubing so it is out of the larynx & reinsert into the stomach. Perforated Ulcer: perforation of a peptic ulcer occurs when the ulcer penetrates the serosal surface, with spillage of either gastric or duodenal contents into the peritoneal cavity. o Larger perforation = longer duration that the patient had the ulcer o Bacterial peritonitis may occur within 6-12 hours o Treatment: H2 Receptor Blockers, PPIs, antibiotics, antacids Ulcerative Colitis: part of the group (along with Crohns Disease) called Inflammatory Bowel Disease (IBD). Characterized by chronic inflammation of the intestine with periods of remission interspersed with periods of exacerbation. o Ulcerative Colitis usually begins in the Rectum and advances to the cecum spreading in a continuous pattern (unlike Crohns disease). o S/s: bloody diarrhea and abdominal pain o Goals of Treatment: Res the bowels Alleviate stress Provide symptomatic relief Control inflammation Improve quality of life Combat infection Correct malnutrition Reflux (cancer risk): in GERD, there is a risk of Barrets Syndrome, which is a precancerous lesion that increases the risk for esophageal cancer Systemic Lupus Erythematosus (SLE): a multisystem inflammatory disease of autoimmune origin. A complex disorder of multifactorial origin resulting from interactions among genetic, hormonal, environmental, and immunologic factors. o **Skin care is extremely important; wear protective clothing and sunscreens when outdoors, however try to minimize outdoor exposure to the sun if at all possible. Dilutional hyponatremia: metabolic condition in which there is not enough sodium (salt) in the body fluids outside the cells. Causes hypoosmolality with a shift of water into the cells. o S/s: n/v, confusion, lethargy, muscle weakness, spasms, seizures, LOC, restlessness o Nursing Interventions: fluid restriction, IV hypertonic saline solution, fluid replacement with sodium containing solutions. Hypermagnesemia: an electrolyte (magnesium) imbalance caused by an increase in magnesium intake accompanied by renal insufficiency or failure.

o Depresses neuromuscular and CNS functions o S/s: lethargy, drowsiness, n/v, deep tendon reflexes, somnolence, resp./cardiac arrest Kayexalate (ARF??): hyperkalemia is one of the most serious complications in Acute Renal Failure (ARF) as it can cause life threatening cardiac dysrhythmias. Sodium polysterene (Kayaxalate) and dialysis remove potassium from the body. o Causes diarrhea Peritoneal dialysis (CAPD); used to treat Chronic Kidney Disease (CKD) o Continuous Ambulatory Peritoneal Dialysis (CAPD): carried out manually by exchanging 1.5-3 L of peritoneal dialysate at least 4 times daily, with dwell times of 4 to 10 hours. Potassium Hypokalemia Indicators: o Clinical Manifestations: Cardiac changes; impaired repolarization, flattened T wave, emergence of a U wave, increased (possible peak) P wave, Lethal Ventricular Dysrhythmias, bradycardi Decreased GI motility Paresthesias (decreased reflexes) Polyuria Hyperglycemia Muscle weakness (soft flabby muscles) Urolithiasis: calculi in the urinary tract, bladder, ureters, and kidneys o predisposed by immobility, hypercalcemia, UTI, urine stasis, high urine specific gravity o S/s: acute sharp pain, dull tender ache in flank, n/v, hematuria, abd distension GERD (Bed Blocks???): the nurse should ensure that the head of the bed is elevated to approximately 30 (usually on 4-6 inch blocks) & that the patient does not lie down after eating. T-tube: a narrow flexible tube in the form of a T that is used for drainage; especially of the common bile duct Paralytic ileus: a lack of intestinal peristalsis and presence of no bowel sounds o (intervention): Patient placed on NPO status Insertion of NG tube (decompress bowel) Insertion of IV (NS or Lactated Ringers + Potassium) No improvement in 24-48 hours? => surgery to remove obstruction o Goals: 1) relief of the obstruction 2) Correction & maintenance of fluid/electrolytes Acute Renal Failure: a clinical syndrome characterized by a rapid loss of renal function with progressive azotemia (accumulation f nitrogenous waste products like urea nitrogen and creatinine in the blood). o (renal cause):

Prerenal causes: due to factors external to the kidneys that reduce renal blood flow and lead to decreased glomerular perfusion & filtration. Hypovolemia, dehydration, hemorrahage, GI losses, diuresis, hypoalbuminemia, burns Decreased CO, dysrhythmias, cardiogenic shock, HF, MI Decreased peripheral vascular resistance, anaphylaxis, neurologic injury, septic shock Decreased renovascular blood flow, bilateral renal vein thrombosis, embolism, hepatorenal syndrome, renal artery thrombosis Intrarenal causes: conditions that cause direct damage to the renal tissue (parenchyma), resulting in impaired nephron function. Prolonged prerenal ischemia Nephrotoxic injury , drugs, radiocontrast agents, hemolytic blood transfusion reaction, severe crush injury, chemical exposures Interstitial nephritis, allergies (meds/antibiotics), infections Acute glomerulonephritis Thrombotic disorders Toxemia of pregnancy Malignant HTN SLE Postrenal causes: involve mechanical obstruction of urinary outflow, thus impairing kidney function. Benign prostatic hyperplasia Prostate cancer Spinal cord disease Bladder cancer Strictures Calculi formation Trauma (back, pelvis, perineum) Neuromuscular disorders Hyponatremia (what is the best IV): 5% Dextrose in water, hypotonic saline Fluid Volume: o Fluid Volume Excess: results from excessive intake of fluids, abnormal retention of fluids, or interstitial to plasma fluid shift. removal of fluid w/o producing abnormal changes in the electrolyte composition or osmolality of ECF Diuretics & fluid restriction are primary forms of therapy o Fluid Volume Deficit: can occur with abnormal loss of body fluids inadequate intake, or a plasma to interstitial fluid shift Correct underlying cause and replace both water and any needed electrolytes. Parecentesis (bleeding?): needle puncture of the abdominal cavity o may be performed to remove ascetic fluid (tends to accumulate thus this is temporary) o Liver disease, one of the main causes of abd fluid build-up, can also cause susceptibility to clotting problems. After the needle is removed from the

abdomen, bleeding may continue to occur from the vessels providing blood flow to the inner abdominal wall.

PET -Oncology o A diagnostic examination used to detect cancer, determine the stage of cancer, & evaluate effectiveness of cancer tx, such as chemotherapy or radiation therapy. o Permits a physician to accurately image many organs of the body w/ a single scan in order to detect malignancy. Laxative abuse: overuse of laxatives may lead to chronic constipation o People who continue to use laxatives & enemas eventually become unable to have a bowel movement w/o them. (many abuse laxatives to lose weight) o At risk for dehydration as well as electrolyte imbalance UTI (Clean catch specimen): in order to test for a UTI, the patient will need to provide a clean catch specimen. o Instruct the patient to fill the urine cup midstream (urinate a little, stop, then fill specimen cup w/ as much with the remaining urine). Crohns disease: inflammation involves the all layers of the bowel wall o S/s: diarrhea, colicky abdominal pain, weight loss (due to malabsorption), fever, rectal bleed (not as common as in Ulcerative Colitis) Esophageal varices o Teach: Avoid ingesting alcohol, aspirin, and irritating foods, o Goal: avoidance of bleeding and hemorrhage Hepatitis C: infection caused by a virus that attacks the liver and leads to inflammation o Transmission usually due to percutaneous needle exposure or other blood exposure and undetected parenteral transmission o Generally asymptomatic (early) later on, s/s may be: Fatigue Muscle & joint pains Fever Tenderness in the area of your liver Nausea or poor appetite o Although positive for Hepatitis C, one may not need Tx (severe cases need Tx) Teaching-Ileostomy care-stoma o Explain that an ostomy is a surgical opening in the body for discharge of body wastes o Describe underlying conditions that result in the need for an ostomy o Perform activities like: Remove old skin barrier, cleans skin, and apply new skin barriers Apply, empty, clean, and remove old pouch Empty pouch before it is 1/3 full to prevent leakage Irrigate colostomy to regulate bowel elimination o Explain how to contact the enterostomal therapy nurse w/ questions o Explain dietary & fluid management

Id a well balanced diet and dietary supplements to prevent nutritional deficiencies Id foods to avoid to reduce diarrhea, gas, or obstruction (w/ illiostomy) Drink at least 3000 ml/day of fluid to prevent dehydration Explain how to contact RD w/ questions Explain how to recognize problems & how to contact the appropriate HCP. o Describe community resources to assist w/ emotional/psych. adjustment to the ostomy o Explain the importance of follow up care o Describe the ostomys potential effects of sexual activity, social life, work, and recreation and strategies to manage these influences. Immune/Hematology/Fluid and Electrolytes Hemolyzed specimen: Platelets (thrombocytes): function in initiating the clotting process by producing a plug at the site of the injury. o Normal platelet count: 150,000-450,000/mm3 o Increased platelet count signifies the possibility of a clot o Decreased platelet count signifies bleeding Decreased neutrophil is a condition known as neutropenia, and is identified as a neutrophil count less than 1000 to 1500 /ul. o Normal levels: 4000-11000/ul o Predisposed to infections of normal flora Minor infections lead rapidly to sepsis (immediate treatment necessary) o Collaborative care: Determine case of neutropenia Id offending organisms if an infection has developed Institute prophylactic, empiric, or therapeutic antibiotic therapy Administer hematopoietic growth factors Institute protective environmental practices, like strict hand washing, visitor restrictions, and a private room if hospitalized. Risk factors for skin cancer o Having a fair skin type o History of chronic sun exposure o Family history of skin cancer o Environmental factors (living near equator, outdoor occupations, frequent outdoor activities) o Indoor and outdoor tanning o Smoking HIV CD4 count: below 200 cells/ul + opportunistic infection + wasting + ADC = AIDS Dx o Pathology:

RNA virus binds to specific CD4 and chemokine receptors to enter cell. Reverse transcriptase assists to make viral DNA Viral DNA enters cell nucleus and splices itself into genome permanently. Consequence of integration into genetic structure All daughter cells are infected Viral DNA will direct cell to make HIV Cells w/ CD4 receptor sites infected T helper cells, lymphocytes, monocytes/macrophages, astrocytes, oligodendrocytes Immune dysfunction results mostly from destruction of CD4 T cells which are key from immune recognition and defense against pathogens. Viral activity destroys 1 billion T cells daily Immune problems begin when CD4 T cells ddrop below 500 cells/ul Normal range is 800-1200 cells/ul Well differentiated cells

Integumentary/Oncology Flu-like syndrome: Tumor lysis syndrome (TLS)-hyperkalemia: a metabolic complication characterized by rapid release of intracellular components in response to chemotherapy. o 4 hallmark signs of TLS are: Hyperuricemia Hyperphosphatemia ***Hyperkalemia*** Hypocalcemia o Goal: preventing renal failure and severe electrolyte imbalances Prophylactic mastectomy (post op) o Patient stays in the hospital for 1 to 3 days (depending on the type of surgery) simple mastectomy = patient may go home on the same day. Most go home after 1 to 2 days. may stay longer if you have breast reconstruction. o Many women go home with drains still in their chest. The doctor then removes them later during an office visit. o Patient may have pain around the site of your incision after surgery. o Fluid may collect in armpit called seroma (relatively common). It usually goes away on its own, but it may need to be drained. Allopurinol (prior to chemotherapy) o This medication, also known as (Zyloprim), is used for the treatment and prevention of gout attacks and certain types of kidney stones. It is also used to treat elevated uric acid levels in the blood and urine, which may occur in patients receiving chemotherapy for treatment of leukemia, lymphoma, and other types

of cancer. If left untreated, high uric acid levels in those receiving cancer chemo may cause kidney stones and kidney failure. IV site care Stomatitis (antineoplastics) Agranulocytosis: failure of the bone marrow to make enough white blood cells (neutrophils) AIDS dementia: Decline in mental processes is a common complication of HIV infection (and many other conditions. The AIDS dementia complex affects behavior, memory, thinking, and movement o symptoms include decline in thinking, or "cognitive," functions such as memory, reasoning, judgment, concentration, and problem solving. o Furthermore, changes in personality and behavior, speech problems, and motor (movement) problems such as clumsiness and poor balance occur. Radiation therapy (tender skin): the skin contains rapidly proliferating cells, thus is affected by radiation therapy. o The skin changes induced by radiation may be acute or chronic based on the area, dosage, and technique. o Skin care to manage most desquamation includes keeping tissues clean w/ normal saline compresses or modified Burows solution soaks and protected from further damage with moisture vapor- permeable dressings or Vaseline.

Musculoskeletal/Neuro Cast care tightness: Cast Syndrome may occur if the body cast is applied too tightly and the cast compresses the superior mesenteric artery against the duodenum. o Results in patient complaining of abdominal pain, n/v, & abdominal pressure. o Tx: gastric decompression w/ NG tube, remove or split cast. Compartment syndrome: a condition in which the elevated intracompartmental pressure w/in a confined myofascial compartment compromises the neurovascular function of the tissues w/in that space. o Causes capillary perfusion to be reduced below a level necessary for tissue viability and is classified as acute, chronic/exertional, or crush syndrome. o Characteristics of an impending Compartment Syndrome: Paresthesia (numbness & tingling) Pain (distal to injury & unrelieved by opioid analgesics in addition to pain on passive stretch of muscle traveling through compartment) Pressure (increases in compartment) Pallor (coolness, & loss of normal color of the extremity) Paralysis (loss of function) Pulselessness (diminished/absent peripheral pulses) o Assess urine output (watch for myoglobinurea; red/brown urine & s/s of ARF) Hip replacement (dislocation) (Athroplasty) o Athroplasty performed in order to relieve pain, improve or maintain ROM, and correct the deformity.

o Foam pillow placed between joints in order to prevent dislocation o Physical therapy initiated first postop day & weight bearing exercises w/ a walker begin o Monitor for infection, and prevention of DVT are key concepts for home care. Rheumatoid arthritis (use of heat): the use of heat for Rheumatoid Arthritis is an excellent non-pharmacological remedy. Hip replacement o post op activity Emboli prevention pain management Ambulation CPT Wound care Management of catheter Patient teaching (home care) Management of Hemovac Bed rest w/ legs abducted o chest pain-report findings activity Osteoporosis (goal): o Reduce bone loss o Prevent fracture o Control pain o Prevent diability Fractured ribs: a condition known as Flail Chest may result from multiple rib fractures, causing an unstable chest wall. o Dx is made on the basis of fracture of two or more ribs, in tow or more separate locations, causing an unstable segment. Laminectomy (reposition): this procedure involves the surgical excision of part of the posterior arch of the vertebra to gain access to part of or the entire protruding disk to remove it. Brachytherapy (precautions) o A form of radiotherapy where a radiation source is placed inside or next to the area requiring treatment. Commonly used as an effective treatment for cervical, prostate, breast, and skin cancer, and can also be used to treat tumors in many other body sites. Can be used alone or in combination with other therapies such as surgery, External Beam radiotherapy, and chemotherapy. o If temporary barchytherapy is used, there is no risk to friends or family from being in close proximity with the patient. o In permanent brachytherapy, low dose radioactive seeds are left in the body following treatment, and devrease over time. However, as a precaution, those receiving permanent brachytherapy may be advised to not hold any small children or be close to pregnant women for a short time following treatment. Cranial radiation: intracranial metastasis occurs in up to 39% of patients with Small Cell Lung Cancer (SCLC). This procedure is effective in preventing metastasis (20%), although it is not known if it increases survival. Toxicities of this therapy may include scalp erythema, fatigue, and alopecia.

o Most chemotherapy drugs do not penetrate the blood brain barrier, thus this procedure is used. Operative Ambulation (postop): usually patients ambulated day of operation or 1st day postop. OR surgical scrub: The scrub nurse follows the designated scrub procedure & remains in the sterile field. Postop risk o Airway Obstruction o Hypoxemia o Hypoventilation o Hypotension/HTN, dysryhthmias, Deep Vein Thrombosus o Emergence delirium, delayed emergence o Pain/discomfort o Hypothermia o Acute urinary retention o n/v o wound dehiscence Preop teach assess (checklist, allergy, NPO) Op permit (legal for RN): nurse can witness the patient sign the consent form ensuring that the patient was fully informed, understood everything, and signed the consent voluntarily. PACU assessment o General info: name, age, ACP, Surgeon, surgical procedure o Patient Hx: indication for surgery, medical hx, meds, allergies o Intraoperative management Anesthetic medications Other meds received preoperatively or intraoperatively blood loss fluid replacement totals (blood transfusions???) urine output o Intraoperative Course Unexpected anesthetic events or rxns Unexpected surgical events Vitals and monitoring trends Results of intraoperative lab tests Malignant hyperthermia: a rare metabolic disease characterized by hyperthermia w/ rigidity of skeletal muscles that can result in death. o Occurs in affected people exposed to certain anesthetic agents. Suctioning needed: this procedure is done especially for patients who have a tracheostomy and are breathing through a trach. o Be sure to use aseptic/sterile technique throughout the procedure

o Apply suction only when w/drawing catheter (gently rotate) Never suction from more than 10-15 seconds (pass 3 or fewer times) o Suction when: Adventitious breath sounds are hear Secretions are present Gurgling sounds are noted

Laboratory Values Check PT/INR prior to administering Coumadin PT: 10-13 seconds Check aPPT prior to administering Heparin INR: <2 aPPT: 25-39 seconds Hgb: 13.2-17.3 g/dl (men)/11.7-15.5 g/dl (female) Hct: 43%-49% (male)/38%-44% (female) WBCs: 4500-10000 mm3 Potassium: 3.5-5.0 mEq/L Sodium: 135-145 mEq/L Magnesium: 1.6-2.6 mg/dL Conversion Factors

1 L = 100 ml 1 ml = 1 cc 1 dram = 4 ml 1 tbs = 15 ml 2.2 lbs

1kg = 1000 g 1mg = 1000 mcg 1 oz = 30 ml 1 unit = 1000 milliunits

1g = 1000 mg 1 g = 15 gr 1 tsp = 5 ml 1 kg =

Pounds (lbs)-Kilograms (kg): divide by 2.2 Kilograms (kg)-Pounds (lbs): multiply by 2.2 Ounces (oz)-Pounds (lbs): divide by 16 Essential Calculations Desire x supply = Amount Have IV Piggy Back: mL x TF = gtt/min as there are many) min for microdrip TF= 60 gtt (macrodrip is given

Finding the amount of a drug in a solution: Amount of Drug mL Amout of Fluid (mL)

= amount of drug in

How long an IV will run:

number of mL = hrs number of mL/hr

mg/min-Rule and Calculation: Reduce numbers in standard solution to mg/mL Change mg-mcg Divide by 60 to get mcg/min Solve for mL/hr

HESI Review 1 1. Respiratory COPD a. S/S: Increased RR, Easily fatigued, frequent respiratory infections, use of accessory muscles to breath, orthopneic, Cor Pulmonale(late in disease) Thin in appearance, wheezing, pursed lip breathing, chronic cough, barrel chest, dyspnea, prolonged expiratory time, Bronchitis-increased sputum, digital clubbing fingernail-chronic b. ABGs: Normal PH 7.35-7.45 PaC02 35-45 mm Hg, Pa02 80-95 mm Hg, O2 Sat 96-100% Serum HCO3 22-26 mEq/L in respiratory conditions, clients can experience acidosis (when PH is lower than 7.35) or alkalosis (when PH is greater than 7.45) 2. Outcome evaluation a. Nursing process: Identifies expected outcomes and establishes goals and timeframes for achieving them. 3. Rheumatoid Arthritis a. Autoimmune disorder/ Connective tissue disorder: Chronic systemic autoimmune disease that affects all areas of the body; inflammatory responses occur in all connective tissue. Higher incidence in women. Symmetrical joint involvement, systemic effects are vasculitis, pulmonary fibrosis, pericarditis, sjogrens. Goal is to relieve pain and preserve joint mobility and muscle strength, *use warm compresses to promote relaxation and to decrease stiffness, use cold to decrease inflammation. b. Resources (leadership): Teaching about modification of daily functions, grasping, lifting, use of special devices (utensils) 4. Elimination

a. Vagal response (geriatrics): If performing a digital removal of impacted feces, nursing priority is to monitor clients heart rate during and after; a vagal response can precipitate bradycardia. b. Straining of bowel movements: Teach client to avoid straining. High fiber diets/ stool softeners/exercise. 5. Mobility/ Ambulation a. Type of shoes: Velcro shoes or non skid socks 6. Safety restraints a. Mittens who wears them and why? Protection to avoid self harm: when clients are high risk for removing IV lines (non compliant or decrease in LOC) or to avoid scratching 7. IV a. Gtts/min reference med math book from skills 8. IV a. mL/hour reference med math book from skills 9. PO a. How many oz in a mL? 1 oz = 30 ml 10. Pressure ulcer a. Digital imaging photographs taken of wound to watch progression or healing of wound. b. Consent? Clients face should not be in photo. 11. Fluid volume overload conditions a. CHF: Congestive heart failure due to left sided heart failure cause fluid accumulation in lungs, Right sided heart failure causes peripheral edema. b. Renal failure: The kidneys are not able to filter through and excrete waste and byproducts of metabolism, causing peripheral and pulmonary c. Monitor VS, weight, electrolytes, Intake and Output. Monitor lung sounds periodically for signs of pulmonary edema, monitor for cardiac dysrhythmias, maintain fluid restrictions as ordered, and administer drugs, including diuretics as ordered. Monitor for complications. 12. Fluid loss (Hypovolemia; volume loss) a. Monitor VS for hypotension or tachycardia (indicates increasing hypovolemia) monitor for electrolytes for hypokalemia and other lab abnormalities, assess mucous membrane and moisten as needed, monitor strict intake and output, administer IV fluids as ordered

and oral fluids to maintain hydration, institute fall precautions from orthostatic hypotension, weakness, dizziness. Monitor for complications. 13. UTI a. Clean catch i. Patients must first wash their hands thoroughly, and then wash the penis or vulva and surrounding area four times, with front-to-back strokes, using a new soapy sponge each time. ii. The patient must then begin urinating into the toilet and stop after a few drops. iii. The patient then positions the container to catch the middle portion of the stream. Ideally, this urine will contain only the bacteria and other evidence of the urinary tract infection. iv. The patient then urinates the remainder into the toilet. v. The patient securely screws the container cap in place without touching the inside of the rim. 14. Crutch a. 3 point gait i. Move BOTH crutches and the WEAKER LEG forward ii. Move the STRONGER leg forward ** How to go up stairs 1. Tuck both crutches under your strong side arm and use the handrail to support your weight on your injured side. 2. Lean forward slightly and swing your good leg up to the next step. Then lift your body weight by straightening the hip and knee of your good leg as you do in normal stair climbing. ** How to go down stairs With the crutches on your good leg side and your opposite hand on the railing: 1. Stand on your good leg leaving your injured leg behind on step above. 2. Bend forwards slightly and move your crutches down a step. 3. Support your body weight with the crutches on your good side and the handrail on your injured side and swing your good leg down. Keep your head and shoulders back to prevent your center of balance from pitching forward. 15. Hip replacement a. Abduction pillow

i. A foam abduction pillow is placed to prevent dislocation of the new joint b. Ambulation i. PT is initiated the first post op day, with ambulation and weight bearing with a walker. c. 90 flexion of the hip must be avoided for 4-6wks post op d. Elevated toilet seats and chair alterations at home are necessary e. Do not cross your legs. 16. Walker a. Strength of upper extremity and unaffected leg are assessed and improved with exercises, if necessary, so that that upper body is strong enough to use walker. b. Client lifts and advances the walker and steps forward. 17. Cyanosis a. Bluish discoloration of skin and mucous membranes. Caused by cardio respiratory problems, vasoconstriction, asphyxiation, anemia, leukemia, and malignancies. b. Safety: Make sure client is getting adequate O2 18. Korotkoff sounds a. Korotkoff sounds are distinctive sounds that can be distinguished when a blood pressure cuff is applied and adjusted. Five Kortokoffs signs: o The first Korotkoff sound is the snapping sound first heard at the systolic pressure. A clear tapping sound; onset of the sound for two consecutive beats is considered systolic. o The second sounds are the murmurs heard for most of the area between the systolic and diastolic pressures. o o The third = A loud, crisp tapping sound. The fourth sound, at pressures within 10 mmHg above the diastolic blood pressure, were described as "thumping" and "muting". o The fifth Korotkoff sound is silence as the cuff pressure drops below the diastolic blood pressure. The disappearance of sound is considered diastolic blood pressuretwo points below the last sound heard. 19. Hypokalemia

a. Cardiac changes: Impaired repolarization resulting in a flattening of the t wave and eventually in emergences of a u wave. b. Cardiac monitoring to detect cardiac changes related to potassium imbalance. c. Decrease GI motility, fatigue, muscle weakness, leg cramping, nausea vomiting, paralytic ileus, weak, irregular pulse, polyuria, hyperglycemia. 20. Inhaled corticosteroids (first line of therapy for patients with Asthma). a. Must be administered 1 to 2 weeks before maximum therapeutic effects can be seen. b. At the highest dosage level, have been associated with easy bruising, accelerated bone loss, candidiasis, hoarseness, dry cough. c. Using spacers and gargling with water or mouthwash after each use and reduce side effects. 21. Peripheral vision confrontation a. How do you talk to the patient? Where do you stand? Approach them from the side that the patient can see. 22. Nursing process a. Compare data to normal values to figure what to do next in the nursing process. 23. Hypertension (High BP) a. DASH diet: The diet involves eating several servings of fish each week, eating plenty of fruits and vegetables, increasing fiber intake and drinking a lot of water. Decrease cholesterol, sodium and saturated fats. Limit alcohol consumption 24. Choking geriatrics a. Not sure on this one but I know that the elderly have decrease liver function. Soft foods are recommended to prevent choking or aspiration. To prevent chocking for geriatric patients before a meal, chop food into small pieces. Ensure the set of denture is in its fixed position and not loose. (sry guys couldnt find a lot on this related to hepatic) 25. Endocrine (*micro- retinal neuropathy, nephropathy, peripheral neuropathy; macro- CAD*) a. DM: complications of long term DM can cause nephropathy, retinal neuropathy, and peripheral neuropathy if not taken care of can lead to CAD which can then lead to stroke. 26. Diabetes a. Type I: Inability of the pancreas to produce any insulin in response to elevated blood sugar levels. Usually juvenile onset. Assess polyuria, polydipsea, polyphagia, blood sugar

levels, dietary plan, irritability, fatigue, poor wound healing, weight changes, presence of glucose or ketones in urine, Hgb A1C. Complications are stroke, hyperlipidemia, coronary artery disease, HTN Kidney disease, blindness, poor wound healing, hyperglycemia (DKA); hypoglycemia. b. Type II: Inability of the pancreas to produce enough insulin in response to elevated blood sugar levels. Usually adult onset, linked to obesity, sedentary lifestyles. Leads to other chronic diseases including hyperlipidemia, CAD, kidney disease, poor wound healing, blindness, and peripheral neuropathy. Assess history of infection, polyuria, polydipsea, polyphagia, blood sugar levels, dietary plan, irritability, fatigue, poor wound healing, weight gain, obesity, presence of glucose, or ketones in urine, Hgb A1C, history of cardiovascular disease or co-morbities including hypertension, high cholesterol, CAD. Complications stroke, hyperlipidemia, coronary artery disease, HTN Kidney disease, blindness, poor wound healing, hyperglycemia (DKA, HHNS); hypoglycemia 27. Pneumonia prevention a. Identify high risk clients, encourage pneumococcal vaccine every 5 years, encourage mobility and ambulation. Good respiratory hygiene, turn, cough and deep breath. b. Stop smoking, stay away from sick people, hand washing important, and pneumovac. 28. DVT a. Bed rest, elevate limb, warm moist packs, support stockings if edema is present (only after client is ambulatory), treatment with Heparin. b. Heparin (apTT) activated partial thromboplastin time, used to determine adequacy of anticoagulation with heparin, do not draw sample from extremity with a hep lock or infusion. Normal 30-45 seconds. 29. Cardiac sounds a. S1: Closure of the mitral and tricuspid valves - normal b. S2: Closure of the pulmonic and aortic valves-normal c. S3: Represents rapid ventricular filling, in adults it may be an indication of volume overload, ventricular dysfunction secondary to hypertension. Abnormal d. S4: Extra sounds during atrial contraction are abnormal 30. HbA1c a. A test to monitor the average glucose attached to hemoglobin for the past 3-4 months.

b. Normal range is 2-6% for non diabetics, 2-6.4% for diabetics with good control (for diabetics 7% is the goal) over 8% is poor control. 31. GERD/ reflux a. Teaching: Avoid drinking beverages during meals, including alcohol and carbonated beverages. Avoid temperature extremes in food, avoid drinking fluids 3 hours before bedtime, and elevate the head of the bed on 6-8 inch blocks. If overweight, lose weight to decrease abdominal pressure gradient. Avoid tobacco, NSAIDS, and salicilytes. Decrease intake of highly seasoned foods and tomato products, eat small frequent meals (up to 5 per day at 3 hour intervals) to prevent gastric dilation. Avoid any food that precipitates discomfort; do not lie down for 2-3hours after eating. 32. AIDS a. Dementia: The most frequently documented neurologic manifestation in human immunodeficiency virus (HIV) seropositive patients is known as acquired immunodeficiency syndrome (AIDS) dementia complex. Three stages of dementia progression have been identified with impairment noted in cognitive, behavioral and motor function (cannot write). Specific diagnostic findings include diffuse cortical atrophy on computed tomography (CT) scan and magnetic resonance imaging (MRI) and alterations in cerebrospinal fluid (CSF) findings. Current research hypothesizes that AIDS dementia is the result of direct HIV infiltration of the central nervous system (CNS) and autopsy studies have addressed this theory. Nursing's role in the care of the patient with AIDS dementia focuses on neurologic assessment, counseling of patient and family, supportive care and prevention of complications. Recognition of disease progression and the maintenance of the patient's self-worth are essential. Nursing diagnoses with respect to this patient population have been provided. 33. Braden scale a. Risk assessment: Scores six subscales, sensory perception, moisture, activity-mobility, nutrition, friction, and shear, total score range is 6-23; a lower score indicates a higher risk for pressure ulcer development, most reliable and most often used assessment scale for pressure ulcer risk; score of 18 is cut-off for adults. 34. Cast care tightness a. Check for neurological sensations: Cap refill, pulses, color tone of skin and temperature, edema, sensations to touch.

35. Compartment syndrome a. When muscles, nerves and vessels are restricted to a confined space within an extremity can be caused by a cast, splints, tight bandages, and tight surgical closure. If there is a cast it can be bivalved or split in half and then wrapped with ace bandage to keep cast in place. b. Pain: Clients complain of intractable pain unrelieved by analgesics, immediate attention is necessary to avoid permanent damage (get the doctor). 36. Compound fracture a. Is an open wound with bone protruding b. Increase WBC can indicate infection, especially in clients with compound fractures. * A high WBC is a normal stress response for open fractures. It is the bodys normal reaction as a protective mechanism. 37. Degenerative joint disease a. Progressive non systemic, no inflammatory, disease that causes progressive degeneration of synovial joints of weight bearing long bones, primarily associated with aging, but can be caused by injury or repetitive damage to joints. Radiological findings degenerative cause of joint space narrowing is characterized by osteophytes; bone sclerosis; subchondral cysts, or geodes; asymmetric joint space narrowing. b. Pain occurs on motion and with weight bearing. Pain increases in severity with activity. 38. CVA - Spatial perception a. Due to right brain strokes minimize danger. Put sharp objects and dangerous chemicals out of reach to minimize the chance of accidental injury. Pad edges. Cover corners and edges of furniture and doorways to avoid bumps and bruises. You can buy childproofing products at the hardware store, or you can improvise your own using foam rubber or towels. Emphasize the right side. If a stroke survivor has lost her entire left visual field, place most items she uses frequently on her right side. One exception: Have her put her watch on her affected side. Whenever she checks the time, she'll be reminded of her left arm. Encourage a wider visual field. Periodically remind her to move her head from side to side to scan a wider area. Keep it calm. Keep the environment as calm and quiet as possible so she can focus on whatever she's doing. Minimize clutter. Minimize clutter so she can find what she needs and avoid tripping. 39. Seizures

a. Complications: Aspiration is important to watch for; maintain airway during seizure: turn client on side to aid ventilation. Do not restrain client. Protect the client from injury during seizure and support head (avoid neck flexion). Document seizure, noting all data in assessment. Maintain seizure precautions: reduce environmental stimuli as much as possible, pad sire rails or cribs, have suction equipment and oxygen quickly accessible, tape oral airway to head of the bed. Do NOT use a tongue blade, padded or not, during a seizure. It can cause traumatic damage to oral cavity. Administer anticonvulsant medications as prescribed. Monitor therapeutic drug levels. Teach family about drug administration: dosage, action, and side effects.

40. Pre-op assessment a. Data to obtain when taking a preoperative nursing history: i. Age ii. Allergies to medications, foods, and topical antiseptics (Patient should wear an identification band that includes all allergies. Patient with a history of any allergy responsiveness has a greater potential for demonstrating hypersensitivity reactions to drugs administered during anesthesia). iii. Current medications, prescriptions, over the counter, and herbal preparations iv. History of medical and surgical problems v. Previous surgical experiences vi. Previous experience with anesthesia vii. Tobacco, alcohol, and drug use viii. Understanding of surgical procedure ix. Coping resources b. Cultural and ethnic factors that may affect surgery 41. Pre-op a. Teaching: i. Regulations concerning valuables, jewelry, and dentures ii. Food and fluid restrictions such as NPO after midnight iii. Invasive procedures such as urinary catheters, IVs, NG tubes, enemas, douche iv. Preoperative medications v. Operating room, transportation, skin preparation, post anesthesia vi. Postoperative procedures vii. Respiratory care, such as ventilator, incentive spirometer, deep breather, splinting viii. Activity such as ROM, leg exercises, early ambulation, turning ix. Pain control, such as IM medications, patient controlled analgesia x. Dietary restrictions xi. Intensive care unit or post anesthesia care unit orientation 42. Sterile specimen a. Should be in a sterile container, and refrigerate if not in use.

43. Gonorrhea a. Most common veneral disease, an infection of the GU tract, however, gonorrhea may also affect the rectum, pharynx, and eyes, caused by the bacteria Neisseria gonorrhoeae. b. MEN: Urethritis w/ dysuria & profuse, purulent urethral drainage 2-5d after infxn; painful/swollen testicles; symptoms are more obvious & distressing so they usually seek treatment early on; unusual for men to be asymptomatic. i. Complications are uncommon but may be prostatitis, urethral strictures & sterility. c. WOMEN: Initial urethritis or cervicitits that is often mild enough to remain undetected. Vulvovaginitis, vaginal discharge, dysuria. i. Complications PID, Bartholins abcess, ectopic pregnancy & infertility. 44. Pneumonia a. Tachypnea: shallow respirations, often with use of accessory muscles b. Abrupt onset of fever with shaking and chills (not reliable in elderly) c. In elderly, symptoms include confusion lethargy, anorexia, rapid respiratory rate d. Pain and dullness to percussion over the affected lung area e. Bronchial breath sounds, crackles f. Chest radiograph indication of infiltrates with consolidation or pleural effusion

g. Elevated white blood cell h. Arterial blood gas indication of hypoxemia i. On pulse oximetry, a drop in o2 sat. ( should be >90, ideally >95)

45. Dilutional hyponatremia a. Common causes: water deprecation, hypertonic tube feeding, diabetes insipidus, heatstroke, hyperventilation, watery diarrhea, renal failure, Cushing syndrome. b. S/S: thirst, hyperpyrexia, sticky mucous membranes, dry mouth, hallucinations, lethargy, irritability, seizures, Na above 145 mEq/l. Confusion, loss of appetite, delusional, vomiting. Restrict fluids! 46. COPD a. Postural drainage: is an airway clearance technique that uses gravity to assist in the removal of secretions from the airways. i. Teach client to sit upright and bend slightly forward to promote breathing

ii. In bed, teach client to sit with arms resting on over bed table iii. In chair, teach client to lean forward with elbows resting on knees iv. Teach diaphragmatic and pursed-lip breathing 47. Finger-nail clubbing a. Clubbing is seen in individuals who have coexistent pulmonary hypertension (high pressure inside lung blood vessels), a condition that can result from chronically low oxygen levels in COPD patients, but the majority of COPD patients do not have suffer from clubbing. 48. Cataracts a. Post-op teaching: F.Y.I. After surgery there should be no pain! i. Warn patient not to rub or put pressure on eye ii. Teaching that glasses or shaded lens should be worn during waking hours. An eye shield should be worn during sleeping hours iii. Teaching to avoid lifting objects over 15 pounds, bending, straining, coughing, or any other activity that can increase intraocular pressure iv. Teaching to use a stool softener to prevent straining at stool v. Teaching to avoid laying on operative side vi. Teaching the need to keep water from getting into eye while showering or washing hair vii. Teaching to observe and report signs 49. Trabeculectomy a. The last treatment used for wither type of glaucoma (used only after medications and laser treatments such as a trabeculoplasty have failed to reduce IOP). b. It is a surgical procedure that removes part of the trabeculum in the eye to relieve pressure which is caused by glaucoma. c. This outpatient procedure is most commonly performed under monitored anesthesia care using a retrobulbar block or peribulbar block or a combination of topical and subtenon (Tenon's capsule) anesthesia. Occasionally sedation or general anesthesia will be used. 50. Diabetic retinopathy a. Many people with early diabetic retinopathy have no symptoms before major bleeding occurs in the eye. This is why everyone with diabetes should have regular eye exams.

b. Most often, diabetic retinopathy has no symptoms until the damage to your eyes is severe. c. Symptoms of diabetic retinopathy include: i. Blurred vision and gradual vision loss ii. Floaters iii. Shadows or missing areas of vision iv. Difficulty seeing at nighttime 51. PAD (Raynouds disease) a. Raynouds disease is a disorder in which the vessels that supply blood to the fingers and toes contract, causing the fingers and toes to turn white, feel numb, tingle, or burn. 52. Osteoarthritis a. Pathology: Osteoarthritis (commonly referred to as degenerative joint disease), the most common form of arthritis, is a chronic condition causing the deterioration of joint cartilage and the formation of reactive new bone at the margins and subchondral areas of the joints. It usually affects weight bearing joints (knees, feet, hips, lumbar vertebrae). The major defect in primary and secondary osteoarthritis is loss of articular cartilage. It occurs in synovial joints; the joint cartilage deteriorates, and reactive new bone forms at the margins and subchondral areas of the joints. Cartilage particles within the joint irritate the synovial lining. b. S/S: Deep, aching joint pain due to degradation of cartilage, inflammation, and bone stress particularly after exercise or weight bearing. Stiffness in the morning and after exercise (relieved by rest). Herberdens nodules (bony enlargements of the distal interphalangeal joints), and Bouchards nodes (bony enlargements of the proximal interphalangeal joints), altered gait, decrease ROM. c. Goal of tx: Is to relieve pain, maintain or improve mobility, and minimize disability. d. Special considerations: Promote adequate rest, particularity after activity, plan rest periods during the day, and provide for adequate sleep. Moderation is the keyteach pt to pace daily activities. Assist with physical therapy and encourage pt to perform gentle isometric ROM exercises. 53. Documentation a. Pre-op preparation: The nurse caring for the patient must have basic knowledge. First the nurse must have the knowledge of the nature of the disorder requiring surgery and

any coexisting disease processes. Secondly, the nurse must identify the individual patients response to the stress of surgery. Third, the nurse must assess the results of appropriate preoperative diagnostic tests. Lastly the nurse must consider the bodily alterations and potential risks and complications associated with the surgical procedure and any coexisting medical problems. The nurse caring for the patient preoperatively is likely different from the nurse in the OR and PACU, thus communication and documentation of important preoperative assessment findings are essential to the continuity of care. b. All finding of the medication history should be documented and communicated to the intraoperative and postoperative personnel. c. The nurse should document and report to the perioperative team if the patient has problems voiding d. If the patient has a history of a compromised immune system or takes immunosuppressive drugs, it must be documented. e. Caffeine withdrawal headaches could be confused with spinal headaches if the preoperative data are not documented. f. JACHO requires that all patients admitted to the operating room have a documented physical examination (PE) in the chart. g. The nurse should review the documentation already present on the patients chart including the review of systems and the physicians PE report, to better proceed with the examination. All findings must be documented, with any relevant findings immediately communicated to the surgeon or ACP. h. All teaching should be documented. i. The site and side of the anticipated surgery may be marked with an indelible marker by the patient and documented to indicate agreement with the patient. 54. Grief following CVA a. Communication: The mental and emotional sequelae of brain trauma are often the most incapacitating problems. Most patients who have been comatose for more than 6 hours undergo some personality changes. In all cases the family must be given special consideration. They need to understand what is happening and be taught appropriate interaction patterns. The nurse must give guidance and referrals for financial aid, child care, and other personal needs and must assist the family in involving the patient in

family activities whenever possible. The family often has unrealistic expectations of the patient. In reality the patient experiences reduced awareness and ability to interpret environmental stimuli. Assisting the patient and family in developing hope and keeping communication open are strategies perceived as supportive by families. The grieving process takes time, energy and work. Goals for the grieving process include resolving emotions, reflecting on the injured/dying person, expressing feelings of loss and sadness, and valuing what has been shared.

HESI Review 2 55. Diabetes (self-management) a. Dos: Monitor your blood glucose at home and record results in a log, take your insulin as prescribed, obtain hemoglobin H1C blood test ever 3-6 months as an indicator, carry some form of glucose at all times so you can treat hypoglycemia quickly, Instruct family members in the use of glucagon admin in the case of emergencies, learn how to exercise and how food affects your blood glucose levels, begin a medically supervised exercise program, have an individualized meal plan created by a dietician, follow your diet eating regular meals at regular times, eat slowly and chew food thoroughly, choose foods in low saturated fat, limit the amount of alcohol you consume, learn your cholesterol level, obtain an annual eye examination, obtain annual urine testing for protein, examine your feet at home, wear comfortable well fitting shoes to help prevent foot injury, break in new shoes gradually, always carry identification that says you have diabetes, have other medical problems treated especially high blood pressure and high cholesterol, know the symptoms of hypoglycemia and hyperglycemia, quit smoking. b. DONTS: Dont skip doses of you insulin especially when you are sick, dont run out of insulin, dont enroll in a fad diet, dont rub the area where insulin was administered, dont forget exercise will lower your blood glucose level, dont exercise if your blood glucose levels are very elevated- this may lead to a temporary worsening of your blood glucose level, dont drink excessive amounts of alcohol bc this may lead to unpredictable low blood glucose reactions, dont eat fried food, dont drink soda or lots of fruit juices, dont smoke, dont apply hot or cold directly to your feet, dont go barefoot, dont ignore symptoms of hypoglycemia and hyperglycemia, dont put oil or lotion between your toes.

56. GERD a. S/S: Heartburn- burning, tight sensation, dyspepsia- pain or discomfort centered in the upper abd, episodes of hypersalivation, noncardiac chest pain. Burning pain in the epigastric area possibly radiating to the arms and chest. Pain usually after a meal or when lying down. Feeling of fluid accumulation in the throat without a sour or bitter taste due to hypersalivation. 57. Catheriterization a. Insertion procedure: i. Preparation: Bring equipment, check lighting, identify client, provide privacy, cover patient ii. Procedure: Open STERILE catheter kit, place draper to expose perineum, open white outer wrap away from sterile package with last turn toward client, remove sterile absorbent pad and position under pt buttocks- pad creates a sterile field. Put on sterile gloves, remover sterile articles from tray, pour antiseptic solution over cotton balls, lubricant- lube catheter tip, if specimen required open cap, move catheter tray close to pt prep meatus- cleanse, once you commit non sterile hand dont move, use sterile hand and grab catheter, insert about 2 inches (female)/ male 10-12 inches or until urine flow, push extra inch, inflate balloon, check for resistance. Page 733 potter and perry. 58. Ambulation a. Gait belt: Ambulation should be done 2-3 times a day for 10 to 15 min. A transfer belt should be placed around the patients waist to provide stability during learning stages. The nurse should discourage the patient from reaching for furniture or relying on another person. 59. Fall assessment a. Check muscle strength on right and left side, ROM, steady gait, coordination etc, assistive devices. Patients usually begin slow; first dangle feet over bed, second as strength increases move to sit on commode, then standing and eventually graduating to walking. 60. IM injections a. (Information from Smith) 1-5 mL syringe with needle gauge appropriate for muscle site and fat thickness; deltoid muscle site and fat thickness; deltoid muscle requires 23-25

gauge 1 inch needle; needle size for the vastus lateralis and gluteus muscles vary from 18-23 gauge needle lengths, 1-1.5 inches. Clinical alert: Change needle before administering intramuscular medication that is irritating to the tissue (e.g. Vistaril) b. Purpose: to promote rapid absorption of the drug, to provide an alternate route when drug is irritating to subcutaneous tissue. c. Injection sites i. Ventrogluteal injection site (preferred) ii. Dorsogluteal injection site (least desired) iii. Vastus lateralis iv. Deltoid d. Remember to inject to inject at 90 degree angle and aspirate. If client is obese use a 2-3 inch needle. The Z-track method prevents tracking and is used for admin meds that are irritating to subcu and nervous tissue (e.g. imferon, Vistaril) e. Time, name of med, dosage, route, injection site, initials, signature 61. IV (pg. 206 in med math) a. Gtts/min b. Keep vein open 62. IVPB (pg. 215 in med math) a. mL/hr 63. Constipation a. Geriatrics: A detailed acct of the patients bowel elimination should be elicited. Frequency, time of day, and usual consistency should be noted. The use of laxatives and enemas, and recent change in bowel movement should be noted. The amount and type of fluid and fiber intake should be determined because they have an important effect on the frequency and consistency of stool. Causes of constipation include insufficient dietary fiber, inadequate fluid intake, decreased physical activity, opioids, ignoring defecation urge and diseases that slow the GI such as diabetes, Parkinsons and multiple sclerosis. b. Overall goals: Increase dietary fiber and fluids, increase physical activity, have the passage of soft formed stools, not have any complications such as hemorrhoids.

64. Pedal pulse a. Palpate both dorsalis pedal pulse and posterior tibial pulse. i. The dorsalis pedis pulse may be felt on the medial side of the doesum of the foot. Palpate the pulse lateral to the extensor tendon of the great toe, use light pressure, and repeat the procedure on the other foot, note rate, rhythm, amplitude and symmetry. Grade the amplitude on a 4 point scale (4 is strongest). ii. The absence of a dorsalis pedis pulse may not be indicative of occlusion because another artery may be supplying blood to this area of the foot. Edema in the foot will make palpation difficult. iii. The posterior tibial pulses may be palpated behind and slightly inferior to the medial malleolus of the ankle, in the groove between the malleolus and the Achilles tendon (see pic pg 497 assessment book). Palpate the pulse by curving your fingers around the medial malleolus. Note rate, rhythm, amplitude and symmetry. Grade the amplitude on a 4 point scale (4 is strongest). iv. If the artery is difficult to palpate the artery may be occluded 65. Laxative abuse a. Some patients believe they are constipated if they do not have a daily bowel movement. This can result in chronic laxative use and subsequent cathartic colon syndrome- the colon becomes dilated and atonic (lacking muscle tone) and person cannot defecate without a laxative. 66. Fluid volume deficit (hypovolemia) a. Hypervolemia causes skin turgor to diminish, there is a lag in the pinching skinfolds return to its original state (tenting). The skin may be cool and moist if there is vasoconstriction to compensate for the decreased fluid volume. Mild hypovolemia usually doesnt stimulate this compensatory response; consequently, the skin will be warm and dry. Volume deficit may also cause the skin to appear dry and wrinkled. These signs may be difficult to evaluate in the older adults because the pts skin may be normally dry, wrinkled, and non-elastic. 67. Osteoporosis a. Prevention and treatment of osteoporosis focuses on an adequate diet high in calcium intake (1000 mg/day in premenopausal women and 1500mg/day in postmenopausal

women who arent receiving estrogen). If dietary intake of Ca+ is inadequate, supplemental Ca+ may be recommended. Foods high in Ca+ are skim milk, yogurt, turnip greens, cottage cheese, ice cream, sardines, and spinach. Vitamin D is important in the Ca+ absorption and function and may have a role in bone formation. Increase intake of protein as well. 68. Bandage extremity a. When bandaging the extremities the thing to be caution of is circulation, make sure that the bandages arent too tight. 69. Leukotriene modifiers (Singulair) a. Drugs used to reduce inflammation and ease bronchoconstrication. These drugs are used as an alternative drug in the management of asthma symptoms. Ex: Singulair is a PO med and should be taken at night. Singular is ineffective in acute asthma. The current role of leukotriene modifiers in the management of asthma is for persistent asthma that cannot be controlled with inhaled corticosteroids or short-acting beta agonist. 70. Osteoporosis goal a. To prevent fractures. b. To decrease pain and promote activities to diminish progression of disease. 71. Osteoporosis a. Clinical manifestations: Spinal deformity and dowagers hump. i. Results from repeated pathologic, spinal vertebral fractures. ii. Gradual loss of height (due to bone loss). iii. Increase in spinal curvature (kyphosis). 72. Cataracts a. Cataract is an opacity within the lens. Pts complain of decreased visual acuity or other complaints of visual dysfunction. Most cataracts is age related, but it can also be associated with other factors including: blunt, or penetrating trauma, congenital factors such as maternal rubella, radiation or UV light exposure, certain drugs such as systemic corticosteroids or long-term topical corticosteroids, and ocular inflammation. Pts with diabetes mellitus tends to develop cataracts at a younger age then it does with pts without diabetes.

b. The only way to cure cataracts is surgery; if the cataract is not removed the pts vision will continue to deteriorate. Post-op meds usually include antibiotic drops to prevent infection and corticosteroid drops to prevent inflammation. Pt need to avoid activities that increase IOP; such as bending, stooping, coughing, or lifting. 73. Renal dehydration a. Urine specific gravity is a laboratory test that measures the concentration of all chemical particles in the urine. Specific gravity should be between 1.020 to 1.028 and when renal dehydration occurs the specific gravity increases (specific gravity > 1.028). 74. PVD a. Peripheral vascular disease is when the veins arent pumping the blood back as much as they should be, so the circulation is the problem. To increase blood flow back to the heart the pt should keep legs elevated, wear compression stocking, and ambulate for short distances. 75. HbA1c a. HbA1c is a test that measures the amount of glycated hemoglobin in your blood. The doctor may order this test for pts that have diabetes. This test is used to see how the blood sugar has been over the last 3 months. For diabetes pts they want to keep their level below 7%, non-diabetic pts below 6.5%. 76. Gastroendoscopy post-care a. Gastroendoscopy is a test that is usually done on pts with GERD and its a camera that goes into the mouth and down to the stomach. This procedure is done under local anesthesia so when the pt gets back for the procedure the pts gag reflex has to be checked before the pt in able to eat or drink anything. 77. NG tube a. If a pt has an NG tube and is cyanosis chances are the tube is in the wrong spot and cutting off the pts airway. If cyanosis occurs the NG tube should be removed immediately. 78. Reflux cancer disease: a. Barretts esophagitis results from long-term erosion of the esophagus as a result of reflux of stomach contents 2nd to GERD; this is a precursor to esophageal cancer.

79. AIDS (CD4 < 200) a. viral disease caused by human immunodeficiency virus (HIV) which destroys T cells increasing susceptibility to infxn & malignancy; manifested by opportunistic infxns & neoplasms that may not appear until late in the infxn; malaise, fever, anorexia, night sweats, weight loss, flu-like symptoms, fatigue, diarrhea, leukopenia, protozoal infxns (PCP: major source of mortality), fungal/viral/bacterial infxns. b. Kaposi Sarcoma: Skin lesions that occur in individuals w/ a compromised immune system; Neoplasm; slow-growing tumor that appears as raised, oblong, purplish, reddish-brown lesions; tender/non-tender; organ involvement inc: lymph nodes, airways/lungs, any part of GI from mouth to anus c. Interventions for Kaposi: Standard precautions, protective isolations if immune system depressed, prep client for radiation therapy/chemotherapy as prescribed, admin immunotherapy as prescribed to stabilize immune system 80. Pressure Ulcer a. Area of tissue damage that occurs as a result of skin & underlying tissue compression from pressure between a surface & a bony prominence; restricts blood flow to skin = tissue ischemia, inflammation, necrosis. Can occur anywhere on the body & once it forms its difficult to heal. i. Stage I: Intact, red & blanch w/ external pressure, may be painful/firm/soft/warmer or cooler than adjacent tissue ii. Stage II: Skin not intact, partial thickness loss of dermis, shallow open ulcer w/ red-pink wound bed or as intact or opened/ruptured serum-filled blister iii. Stage III: Full-thickness loss, extends into dermis & SQ, & slough may be present, SQ may be visible, undermining & tunneling may/may not be present iv. Stage IV: Full-thickness loss, present w/ exposed bone/tendon/muscle, undermining & tunneling may develop 81. Compartment syndrome a. Pressure increases in a confined anatomical space, leading to decreased blood flow, ischemia, & dysfunction of these tissues; initial ischemia w/ pain, pallor, paresthesia, muscle weakness, & loss of pulses may progress to necrosis & permanent muscle cell dysfunction. b. Assessment- unrelieved or increased pain in the limb, distal tissue to involved area =

pale/dusky/edematous, pain w/ passive movement, paresthesia, pulselessness (late symptoms). Call physician if compartment syndrome occurs. 82. Hip replacement a. Big problem is infection, predisposition to anemia so Hct q3-4d, monitor function of extremity, neurovascular status, I&O every shift, skin integrity. b. Discharge: Rehab planning, encourage fluid intake of @least 3L/d, self-care activities at max level, get out of bed asap & stay out of bed as much as possible, elevated toilet seat, chairs w/ high seats, dont lift leg upward from a lying position or elevate the knee when sitting as this can pop the prosthesis out of the socket. c. Dislocation: Abduction pillow, avoid extreme hip flexion (>90), maintain hip & leg in proper alignment & prevent internal or external rotation, avoid chairs, avoid crossing legs & bending over. d. Turn client to the unaffected side & only to affected side as prescribed by physician, Elevate HOB 30-45 for meals ONLY. e. Avoid weight bearing on affected leg as prescribed, always refer to prescriptions. 83. Nuero assessment of fracture site a. Pain/tenderness, decreased or loss of muscular strength or function, obvious deformity, crepitation, erythema, edema, bruising, muscle spasm, neurovascular impairment. b. Check movement, strength, sensation, reflexes, cap refill, edema 84. Osteoarthritis a. Degenerative joint disease; progressive deterioration of the articular cartilage, causes bone build-up & loss of articular cartilage in peripheral & axial joints, fx weight-bearing joints & joints that receive the greatest stress (i.e., hips/knees/lower vertebral column, hands), cause is unknown, risk factors (trauma, aging, obesity, smoking, genetic changes) b. naproxen (Naprosyn)- NSAID; reduces inflammation & pain, antipyretic c. Adverse reactions: Na+ & water retention = peripheral edema, GI bleeding & ulceration, anaphylaxis or hypersensitivity d. SDFx: Nausea, vomiting, GI discomfort, bruise easily, peripheral edema, dizziness. e. Assessments S/S of bleeding (i.e., black tarry stools, bruising, hematemesis, bleeding gums), drug allergies, C/I conditions (active bleed, renal/liver problems), drug interactions (dilantin, warfarin).

f.

Nursing Implications: May cause GI discomfort which can be decreased by admin w/ food, NSAID induced ulcers may occur (stop!), increases risk for bleeding, esp. during menses.

g. Teaching: About drug, dosing schedule, C/I, teach to take w/ food to minimize GI discomfort, encourage to report any Sxs of increased bleeding/bruising while taking this, avoid taking ASA & Tylenol & Alcohol 85. Pre-op teaching: a. Inform about what to expect post-op b. Notify nurse if any pain is experienced postoperatively & the pain meds prescribed will be given as needed c. Inform client to use noninvasive pain relief techniques (guided imagery, relaxation, distraction) before the pain occurs as soon as pain is noticed d. Demo use of PCA as prescribed e. Inform client that requesting an opioid after surgery make them a drug addict f. Importance of deep breathing & coughing techniques, use of incentive spirometry, & importance of performing the techniques post-op to prevent development of pneumonia & atelectasis g. Do not smoke for @least 24h b4 surgery h. Leg & foot exercises to prevent venous stasis of blood & to facilitate venous blood return i. j. How to splint an incision, turn, and reposition Inform of any invasive instruments that may needed post-op (NG tube, foley, epidural catheter, IV, subclavian lines) k. Instruct not to pull on any invasive devices & they will be removed asap 86. Toradol effects: SEE NAPROSYN 87. Renal pre-op checklist a. Renal System i. Acute Renal Failure- abrupt deterioration of the renal system, reversible; when metabolites accumulate in the body & urinary output changes, 3 major types, assess history of taking nephrotoxic drugs (i.e., NSAIDs, salicyclates, antibiotics), alterations in urinary output, edema/weight gain, change in mental status, assess Na+/K+/Phos/Chloride levels, BUN, creatine, pH, urine specific gravity

ii. Chronic Renal Failure: End Stage Renal Disease- progressive irreversible damage to nephrons & glomeruli = uremia, as renal function decreased dialysis becomes necessary; assess family Hx, increased BP, high med use, edema/pulmonary edema, neurological impairment (weakness/drowsiness), decreasing urinary function (hematuria, oliguric, proteinuria, cloudy urine, anuric), yellow skin, GI upset, metallic taste in mouth, ammonia breath, dialysis, previous kidney transplant, azotemia, increased creatine/BUN, decreased Ca+, elevated phos/Mg+ b. Assessment: Allergies to latex, HH & physical exam done & document, prescribed labs documented and in chart. c. Checklist: Height/weight, ensure client is wear ID bracelet, informed consent forms signed for procedure/blood trans/disposal of limb/ sterilization procedures, blood type/screen/cross-match are done, remove jewelry/makeup/hairpins/nail polish/glasses/prostheses & document valuables (given to family/locked in hospital safe), document last time client ate/drank/voided, document meds given, (M) vital signs. 88. Fluid volume: Renal System a. Maintain acid-base balance b. Excrete end products of body metabolism c. Control fluid & electrolyte balance d. Excrete bacterial toxins, water-soluble drugs, & drug metabolites e. As fluid flows through the tubules, water, electrolytes & solutes are reabsorbed & other solutes such as creatine, hydrogen ions, & K+ become urine f. Water & solutes that are not reabsorbed become urine

g. Process of selective reabsorption determines the amount of water & solutes to be secreted h. Homeostasis of Water: ADH primarily responsible for reabsorption of water by the kidneys, produced by hypothalamus & secreted by posterior pituitary gland (stimulated by dehydration or high Na+ intake & by a decrease in blood voL); when ADH is lacking = Diabetes Insipidus & they produce large amounts of dilute urine; treatment is necessary b/c the client drink sufficient water to survive i. (M) I&O, labs (serum & urine) especially K+ for Hyperkalemia (ECG changes), LOC,

Weight daily, Kayexalate may be admin for >K+, j. Assess for sxs of fluid voL alterations: Excess (dyspnea, tachycardia, JVD, peripheral/pulmonary edema); Deficit (decreased urine output, reduction in body weight, decreased skin tugor, dry mucous membranes, HypoTN, tachycardia k. Assess for Sxs of Hyperkalemia: dizziness, weakness, cardiac irregularities, muscle cramps, nausea, diarrhea 89. Hyponatremia a. Common causes: Diuretics, GI fluid loss, hypotonic tube feeding, D5W or Hypotonic IV fluids, diaphoresis b. S/S: Anorexia, nausea, vomiting, weakness, lethargy, confusion, muscle cramps/twitching, seizures, <135 Na+ c. Treatment: (3% saline or NS) - Hypertonic solution, restrict fluids, if saline solution is prescribed then administer very slowly (use when fluid restriction not useful). 90. Reproductive a. Hormone Replacement Therapy (HRT) i. Osteoporosis: Estrogen replacement therapy to prevent osteoporosis (inhibits osteoclasts leading to decreased bone reabsorption) and most effective when combined w/ Ca+ supplements; Salmon calcitonin (Calcimar) inhibits osteoclastic one resportion by directly interacting w/ active osteoclasts; Biophosphates like alendronate (Fosamax) inhibit osteoclast-mediated bone resorption = increasing BMD & must take w/ full glass of water 30min b4 food/other meds & remain upright for @least 30min after taking. ii. Perimenopause & Postmenopause: Estrogen for women w/o ovaries or estrogen & progesterone for women w/ a uterus, studies now show that women who take thee have an increased risk for developing stroke, breast cancer, heart disease, DVT, pulmonary emboli. But, they have fewer hip fracture and lower risk of developing colorectal cancer; the lowest dose should be used. 91. Pneumonia a. Listen to lungs for crackles before doing sputum culture b. essential components of nursing care for patients with pneumonia include monitoring physical assessment parameters, facilitating laboratory and diagnostic tests, providing

treatment, and monitoring the patients response to treatment (p.569, MedicalSurgical Nursing 7th ed.) 92. Pursed lip breathing (PLB) a. COPD patients develop increased respiratory rate w/ prolonged expiration to compensate for obstruction to airflow resulting in dyspnea. PLB decreases dyspnea, improves oxygenation, and slows respiratory rate by prolonging expiration and thereby preventing bronchiolar collapse and air trapping. b. Teach to use PLB before, during, and after any activity causing dyspnea or tachypnea (sex, alcohol, drugs, exercise). Teach to inhale slowly through the nose and exhale slowly through pursed lips. Exhalation should be 3x as long as inhalation. Nurse should demonstrate so patient can imitate. c. The following techniques may be used to teach PLB i. Blow through straw in glass of water to form small bubbles ii. Blow at a lit candle to bend flame w/o blowing it out iii. Steadily blow a ping pong ball across a table iv. Blow a tissue held in hand until it gently flaps 93. Theophylline a. Methlyxanthine bronchodilator that alleviates early phase of asthma attacks and the bronchoconstrictive component of the late phase asthmatic response. Not as effective as beta-adrenergic agonists. Long-acting theophylline administered at bedtime used to treat pt w/ nocturnal asthma. b. Serum blood levels should be monitored regularly to determine if drug is w/in therapeutic range (10 20 mcg/mL). c. Common side effects: vomiting, headaches, nausea, irritability, flushing and palpitations. Insomnia, GI distress, tachycardia, dysrhythmias, and seizures. Restlessness of caffeine like jitters. 94. Thick secretions a. Hydrate, humidified oxygen, chest physiotherapy b. Chest physiotherapy i. Perform an hour before meals or 1-3 hr after meals ii. Admin bronchodilator 15min prior to therapy

iii. Assume pt in correct position for postural drainage for 5-15 min (see 648 of med-surg textbook for positions) iv. Observe pt breathing pattern and color changes to face to determine tolerance v. Have pt take several deep abdominal breaths vi. Percuss appropriate area for 1-2 min keeping pts face in view vii. Vibrate same area while pt exhales 4-5 deep breaths viii. Assist pt to cough. Suction if necessary ix. Repeat same procedure for all necessary positions x. Monitor hypoxemia and chart effectiveness of treatment by amount of sputum produced and results of lung auscultation 95. Retinal detachment a. S/S: Photopsia (light flashes), floaters, and cobweb or ring in the field of vision. Once the retina has detached, there is a painless loss of peripheral/central vision like a curtain coming across field of vision. Area of visual loss corresponds to area of detachment 96. HTN a. Complications: Coronary artery disease, left ventricular hypertrophy, heart failure, cerebrovascular disease (stroke), PVD, aortic aneurysm, speeds up atherosclerosis, kidney disease (nephrosclerosis), and retinal damage. 97. PAD and PVD a. Arterial s/s: i. Aortic aneurysms: Deep chest pain that may extend to interscapular area, angina, dysphagia, distended neck veins, edema of head/arms, pulsatile mass in periumbilical area, bruits, back pain, epigastric discomfort, altered bowel elimination ii. Aortic dissection: Chest pain, ALOC, dizziness, weak/absent carotid/temporal pulse, angina, MI, new high-pitched diastolic cardiac murmur, dyspnea, orthopnea, different BP readings in left/right arms iii. PAD of lower extremities: Intermittent claudication (ischemic muscle pain caused by activity and relieved w/ rest), paresthesia of toes/feet, loss of hair on lower legs, weak/absent pedal pulse, pallor/blanching of foot in response to leg elevation, redness of foot (reactive hyperemia) when limb is hung

b. Venous s/s: i. DVT: Unilateral leg edema, extremity pain, warm skin, erythema, systemic temp greater than 100.4F, tender calf upon palpation, positive homans sign, and edematous/cyanotic lower extremities. ii. Varicose veins: Ache/pain after prolonged standing (relieved by walking or elevating legs), nocturnal calf cramps, and swelling of legs. 98. Gingival hyperplasia b. May be drug induced with drugs such as dilantin (anticonvulsant), nifedipine (calcium channel blocker), and ciclosporin (immunosuppressant) a. Stop medication and notify HCP b. Thorough oral hygiene after each meal, gum massage, daily flossing, and regular dental care are essential to prevent or control gingival hyperplasia. 99. Documentation 100. 101. 102. Establish goals Legal OP HIV/AIDS (complications) a. Pneumocystis jiroveci pneumonia (PCP) i. Clinical manifestations: Pneumonia, nonproductive cough, hypoxemia, progressive SOB, fever, night sweats, fatigue. 103. HIPPA a. Young adult: A client under the age of 18 is not legally able to give permission for surgery unless the adolescent is given an emancipated status by the judge. b. Once a child reaches the age of majority (typically 18 - 21 years of age), a parent is no longer entitled to see or amend the child's medical records. If the parent continues to pay for the child's care, some information may be disclosed so the parent can obtain payment from the insurer. The physician is allowed to exercise some professional judgment about when to disclose PHI to the parents without the young adult's authorization. When in doubt, ask the young adult patient to sign a written authorization.