N222 Finals Active Study Guide

Stephanie Talbot

Section 6.1 (2 questions)

Section 6.1
Management smallpox Respiratory isolation Comfort measures only
O2 IV fluids Pain meds Antibiotics for 2dary infection

Management exposure to radioactive dust

Put pt in shower

Section 7.1 (8 questions)

Care pt. w/ TPN

VS q15-30min for first hr, then q4hrs
Check insertion site for redness, extravation, etc

Check rate and volume q1hr

If TPN temporarily unavailable admin 20% dextrose

Accucheck q 6hrs
Administer sliding scale insulin if needed

Fluid & elytes q4hrs

Na, K+, Ca2+, BUN, urea Daily weight, I/O

Change IV tubing q24hrs, dressing q48-72hrs

Signs & Symptoms Peritonitis

1. 2. 3. 4. 5. Rigid, board-like abdominals Rebound tenderness Tachycardia Tachypnea w/ shallow bx N&V

Dumping Syndrome
Signs & symptoms 1. Diaphoresis 2. Palpitations, tachycardia 3. Dizziness 4. weakness 5. Borborygmi 6. Diarrhea All occur 15-30min after eating
Management dumping syndrome

Eat smaller meals Consume liquids between meals Increase protein & fat
Add pectin powder

Avoid concentrated sweets Lie down for 30min after eating

Risk factors PUD

1. 2. 3. 4. 5. NSAIDS H-pylori Alcohol Drugs Altered gastric acid secretion & levels

Caffeine & stress aggravate an ulcer, smoking delays healing of an ulcer

NSG Care pt w/ PUDconservative tx

Health promotion- avoid food cause pain, pepper, acidic, hot & spicy, caffeine, adequate rest, smoking cessation

1. 2. 3. 4.

Rest Diet modification Smoking cessation Drug therapy

Antacids: Maalox, Mylanta H2-histamine blockers- ranitidine (Zantac), Famotidine (Pepcid) PPIs= Omeprazole( Losec, Prilosec), Lansoprazole (Prevacid) AnticholinergicsMetoclopranamide (reglan) Cycloprotective- bismuth subsalicylate, Carafate(Sulcralfate) H-pylori eradicators- Flagyl, tetracycline, amoxicillin

5. Stress reduction 6. Surgery: Billroth I/II

NSG care PUD Exacerbations

Hemorrhage/perforation
NPO NG w/ cont aspiration & sxn Rest IV fluids, Increase/maintain rate Replace volume lost w/ ringers , PRBC Antibiotics for perforation (repair perforation) Stomach lavage

Obstruction NPO NG w/ sxn Rest IV fluids

Post-op Billroth I/II

1. Maintain patency NG tube
Notify if no drainage Anticipate frank, red bleeding 12-24hrs

2. 3. 4. 5. 6. 7. 8. 9. 10.

Mid-high fowlers, teach splint incision, coughing deep bx Fluid & e-lyte balance Assess acute gastric dilation Assess dumping Manage dumping Assess alkaline reflux gastritis Assess delayed gastric emptying Assess afferent loop syndrome Administer vitamin supps

Post-op EGD
1. S q30min till sedation wears off, side rails up 2. Check gag, NPO till returns 3. Vs q15-30check for perforation-pain, bleeding, fever 4. Warm saline gargle 5. No driving for 12hrs

Section 8.2 (23 questions)

Post-op Cerebral Angiography- 3D visualization w/ contrast media & x-rays

VS , neuro (q15-20 for 1st hr) & neurovasc check distal to site Remain bed rest several hours w/ affected extremity straight & immobilize Check extremities: colour, pulses, cap refill Check site bleeding Maintain P dressing & ice Oral & IV fluids to help expel contrast media

Risk Factors Stroke

Non-modifiable Age Race Gender Family hx Modifiable
Obesity High fat diet Sedentary lifestyle Smoking DM HTN migraines Heart dx: a-fib, MI. cardiac valve abnormalities, cardiomyopathy etc Alcohol consumption Hyperlipidemia Early forms of birth control

Stroke-destruction brain cells due to blockage cerebral blood flow

A. Types:
Hemorrhagic, ischemic (can be treated w/ tPA), embolytic, thrombolytic

A. Stages of development
TIA- mini, sm. Strokelasts < 24hrstreat w/tPA or cerebral endardectomy-WARNING SIGN hemiparesis, visual disturbance, slurred speech, aphasia, vertigo etc Stroke in evolutionstroke symptoms develop over hrs-days Completed stroke 23dys- permanent neurologic deficits

B. Key pathophysiology: cerebral edema (ICP), vasospasm & collateral circulation developmentdetermines the degree of brain damage

Stoke
Pre-disposing factors embolytic stroke S/S Hemorrhagic stroke- due to aneurisms, HTN

A-fib MI arterial Plaque Ischemic & rheumatic heart dx Prosthetic valves

Abrupt & occur during day Deepening stupor/coma Severe focal deficits Bloody CSF Seizures Permanent neurologic deficits

Stroke
Right sided -> unaware of deficits Visual & spatial deficits
No depth perception Leftsided-> aphasias, alexia (reading probs), agraphia (diff. writing)

Disorientation person, time & place, unable recognize faces Poor judgement- impulsive, safety issues Denial of illness Neglect left side
Hemiparesis

Aware of deficits Aphasia, alexia, agraphia Depression & anxiety Cautious & slow Hemiparesis Dysphagia Deficits right visual field

Cannot hear tonal variations dysphagia

LABS/ Diagnostics for stroke

Increased HbB & HCT---may have increased WBC if infection Blood in CSF if hemorrhagic in nature non-contrast CT scan gives differential diagnosis MRI shows edema & necrosis Angiography carotid arteries EEG- inverted T wave, ST depression, QT elevation Cardiac output should be 4-8L/min to maintain cerebral perfusion, PaO2 80-100mmHg, PaCo2 35-45mmHg, BP 80-100/60-80mmHg

Management TIA
-CT scan without contrast media initial diagnostic study t-PA given w/in 3hrs contraindicated in hemorrhagic stroke & head injury Aspirin w/in 48hrs Anticoag & platelet therapy for long term tx: aspirin, ticlopid, plavix, heparin, Warfarin, lovenox Surgery: carotid endardectomy to remove plaque

8.
Acute Interventions Stoke
1. 2.
3.

Administer drugs
Hyperosmotic agents: Mannitol & Lasix tx cerebral edema Thrombolytics to dissolve clots: tPA, streptokinaseonly w/in 3hrs of TIA contraindicated previous stroke, hemorrhagic stroke, head injured, recent MI & Anticoag tx, increased PTT, or pregnant Anticoagulants: aspirin, heparin, Warfarin(Coumadin)

Maintain patent airway Check VS, neurologic (GCS), & neurovasc q2hr
Maintain BP <220mmHg systolic

Bed rest

4.

Maintain fluid & e-lyte balance

IV fluids NG w/ sxn, TPN if cant swallow

5.

Maintain proper head & body alignment

HOB 30-45 Turn q2 ROM q4 Each joint positioned higher than joint proximal to it to prevent dependant edema

Check PT for oral Anticoag, PTT for heparin, INR for Warfarin PT & PTT goal 1.5-2xs normal, INR 2-3xs normal

6. 7.
8. 9.

Maintain skin Maintain elimination

Offer bedpan q2 Stool softeners

Anti-seizure meds: phenytoin, Neurontin (Gabapentin) Antihypertensives

9.

Quiet environment Establish means communication

Surgery- carotid endardectomyremoves the plaque

Communication w/ stroke pt
Receptive aphasia Demonstrate simple cues Gestures One command at a time Expressive aphasia Simple yes/no questions Give time & talk slowly Communication board

Management Post stroke

Manage Hemiplegia 1. Turn q2hrs 2. Proper positioning- HOB raised 3. Active & passive ROMq4hrs 4. Support paralyzed arm splint 5. Elevate extremities Consult physical therapy Provide for safety
1. Side rails up 2. Safety measures Manage dysphagia: 1. Check gag & swallow before feeding 2. Soft foods
1. Bent, wide grip & rocker utensils, plate guards, nonskid plates/bowls

3. Oral care before & after Consult speech therapy

Management Post stroke

Manage Homonymous Hemianopsia

1. Place items in field of vision 2. Approach from unaffected side 3. Teach scan to affected side

Emotional liability 1. Quiet environment 2. Explain family behaviour is not on purpose

Management Post stroke

Management aphasias Give time Speak slowly One command at a time Simple yes/no questions Demonstrate simple cues Communication board Consult speech therapist Sensory/perceptual deficits Assist w/ self-care Teach scan For apraxia- guide pt. through intended movementkeep repeating

PARKINSONS DISEASE: Characterized by slowness in initiating

and executing movement due to lack dopamine

Cardinal Sign & Symptom

1. Rigidity
Cogwheel

Other symptoms
1. 2. 3. 4. 5. Stooped posture-old man Drooling Akinesia Shuffling gait Mask like face-fixed starring eyes Monotone voice Micrographia Difficulty chewing & swallowing ASPIRATION!!!!!!

2.

Tremor more prominent at rest

Pill-rolling- parkinsonian Essential tremor- w/ voluntary movement

3.

bradyknesia

6. 7. 8.

PARKINSONS DISEASE Medications

Dopaminergics-precursers to dopamine increases DA levels
1. 2. Levodopa Levodopa /cardopaSinemet- monitor for, delirium, dyskinesia, involuntary movement face, eyes, extremities & HALLUCINATIONS Ropinirole (Requip) Bromocriptine (Parlodel) may start this first Amantidine (Symmetrel) Rotigotine (Neupro)

Antihistamines
1. Benadryl (Diphenhydramine) for tremors Benzotropine (Contingen) decrease activity ACH

Anticholinergics
1.

3. 4. 5. 6.

MAOI-reduce metabolic breakdown of DA by inhibiting MAO enzyme

1. Selegline (Eldepryl)

Seizure Medications- all prevent the spread of foci to other neurons

Tonic-clonic: Phenytoin (Dilantin), Phenobarbital, Tegretol, Divralproex (Depakote) Absence (Petite Mal)- Depakote, Klonopin (clonazepam), Zarontin Status elepticus- Diazepam (valium), lorazepam (ativan) Newer drugs: Gabapentin (Neurontin), topamax, Keppra, Zonegran MONITOR SERUM LEVELS

ALS- degeneration & destruction motor neurons

Key symptom weakness extremities, dysphagia, Dysarthriamuscle wasting & atrophydeath w/in 2-5yrs from resp. complications--infection Riluzole to slow progression of dx by inhibiting glutamate production Priority nsg dx=anticipatory grieving then respiratory 1. provide measures reduce risk aspiration 2. Vent support if needed 3. Provide for communication 4. Provide pain management 5. Diversional activities- still mentally intactreading, companionship 6. Assist w/ coping

Medications for Bells Palsy- paralysis of facial nerve (CNVII)

Corticosteroids-Prednisone during exacerbation Antivirals- acyclovir, Famciclovir, Valacyclovir

Myasthenia Gravis- autoimmune disorder attacks ATCH receptors

s/s Myasthenic crisis Ptosis Dysarthria Dysphagia Dyspnea Muscle Weakness Voice fades after a while Difficulty chewing Tensilon increases strength s/s cholinergic crisis All symptoms Myasthenic crisis plus
Abdominal cramps N&V Diarrhea Excessive salivation Diaphoresis Increased bronchial secretions

Tensilon decreases strength Keep atropine on hand

Teaching r/t care MG pt

1. Teach pt about dx course 2. Teach avoid heat, emotional stress, overeating, those w/respiratory infections, change sleep habits 3. Plan activities w/ periods rest 4. Take meds before activities like eating, engaging in work 5. Contact D.O if suspect Myasthenic/cholinergic crisis 6. Teach family resuscitation methods, keep Ambu bag, sxn equip & O2 avail 7. Wear medic alert bracelet 8. Support groups : MG foundation

Multiple Sclerosis
1. Fluctuating extremity weakness 2. Ptosis 3. Fatigue 4. Dysphagia 5. Dysarthria 6. Urinary/bowel retention or incontinence 7. Diplopia 8. Blurred vision 9. Scotomas-blind spots 10. Nystagmus 11. Tinnitus 12. Vertigo 13. Ataxias 14. Parasthesia, numbness, tingling, pain

Diagnostic test MS
1. 2. 3. 4. 5. Based on hx & s/s CT-scan visualize lesions MRI- visualize lesions Evoked potentials CFS analysis- see protein and IgG

s/s subdural hematoma

Slow, develops 2-14dys, venous in origin Symptoms similar ICP Decreased LOC, headache Ipsilateral pupil dilation

S/S IICP
1. 2. 3. 4. 5. 6. 7. 8. Change LOC Headache N&V Hemiparesis/Hemiplegia Abnormal posturing Vision disturbance: Diplopia, blurred vision Pupil changes: Ipsilateral/contralateral dilation Cushings triad: systemic hypertension s/ widened pulse pressure, bradycardia w/ strong bounding pulse, respiratory pattern disturbance

Prevention ICP
1. Raise HOB 30-45 2. Keep in mild respiratory alkalosis PaCO2=30-35mmHg, PaO2=80-100mmHg 3. Mild dehydration 4. Admin osmotics: Mannitol & Lasix 5. Admin corticosteroid: decadron if ICP not due to head injury 6. Admin phenytoin for seizures 7. Prevent increased ICP: no coughing, sneezing, straining, hiccups: admin meds to help 8. Limit sxn 9. Log roll pt

Medications spinal cord injury

IV Solu-Medrol w/in 8hrs
If on corticosteroids must take antacids to prevent ulcer: H2blockers, PPIs

Vassopressor: dopamine (intropin) tx hypotension Anticholinergic: atropine tx bradycardia Antispacicity (muscle relaxant)- baclofen, dantrolene (dantrium)

Section 8.3 (10 questions)

MENIERES DX
Dx of inner ear Accumulation endolymph labyrinth Assess for:
Vertigo, tinnitus, aural fullness, N&V Pallor, sweating, Nystagmus

Feeling of being pulled to ground, drop attack

MENIERES DX
1. Keep darkened quiet room
Avoid t.v, fluorescent & flickering lights

2. Side rails up, bed low position

Instruct call help getting out of bed Only essential carebath not essential

Discharge 1. Low sodium diet, fluid restriction 2. Avoid alcohol, nicotine, caffeine 3. Eliminate smoking

3. Emesis basin 4. IV fluids & medications

Strict I/O

5. Assist ambulation when attack over

MENIERES DX

Diagnostics based on hx & physical and ruling out other CNS problems Audiogramsensorineural lossglycerol--improvement hearing over 3hrs

Acute attackantihistamines (Benadryl), benzodiazepines (Valium/diazepam), & antiCholinergics (Atropine); bed rest for vertigo, sedation (Fentanyl )& anti-vertigo drugs or antiemetics (doperidol)antivert (Meclizine) Between attacks diuretics, antihistamines &low-sodium diet Surgery- destruction labyrinth
Labynrithotomy/ectomy

Restrict alcohol, nicotine,& caffeine

Cataract
Opacity of lens
Deceased vision, abnormal colour vision, night time glare

If not surgery, increase eyeglass script strength, stronger reading glasses or magnifiers, increase lighting

S/S Retinal Detachment

1. Flashing lights, floaters 2. Feeling veil pulled over eyes

Eye drop administration

1. Warm soln in hand 2. Cleans eyelid & lashes w/ gauze soaked in saline 3. Pull lower lid down 4. Instil drops into conjunctival sac 5. Occlude the puncta for systemic meds 6. Close eye for 1-2min

Glaucoma- increased intraocular pressure

Open angle- all structures inside normal, obstructed outflow s/s: progressive loss vision, tunnel vision Closed angle- medical emergency, results forward displacement of iris s/s: sudden, excruciating pain, around eye, N&V, coloured halos around lights, blurred vision, ocular redness

Glaucoma Medications
Eye drop meds
1. B-blockers- decrease aqu. Humour production.
Betopic, Timoptic,

Oral meds 1. Carbonic anhydrase inhibitors- decrease aqu. Humour production

Diamox Glycerin liquid (ophthalgan, Osmoglyn) Isosorbide soln (Ismotic) Mannitol soln

2.

A-agonsits- decrease aqu. Humour production.

Propine, epinephrine, brimodine

2. Hyperosmolar agents

3.

Cholinergics (miotics)constrict pupil

Pilocarpine OCCLUDE THE PUNCTA!!! Keep atropine onhand

Assess for pulmonary edema & HF before giving

Post-op stapedectomy
1. Change cotton ball when wet 2. Teach will have immediate improvement hearing, then decrease once swelling occurs, will last 1wk 3. Avoid sudden movements 4. Cough & sneeze w/ mouth open, avoid straining BMs 5. Avoid elevators 1yr 6. Avoid large crowds and those with upper respiratory infections

NSG Dx r/t visual impairment

Disturbed sensory perception Risk for injury Self-care deficit Fear r/t visual impairment Grieving r/t loss functional vision

Section 9.2 (5 questions)

Genital herpes
Medications 1. Antivirals- acyclovir, famiclovir, valcyclovir Teaching r/t herpes
Practice good perineal hygiene Wear loose cotton undergarments Warm sitz bath, drying agents, and urinating w/ pitcher water helpful for pain Avoid sexual contact when lesions present Condoms when not present

Chlaymidia
Most common infection, in women often asymptomatic In men penis discharge, pain & frequent urination In women w/ symptoms- vaginal discharge (yellowy), bleeding, urinary frequency abdominal discomfort

s/s tertiary syphilis

-occurs after 4-20 yrs 1. Begnin tumors of skin=GUMMAS 2. Aneurysms, heart valve insufficiency, heart failure 3. neurosyphillis

Transmission gonorrhea
Sexually transmitted, mother-fetus Often treated for chlamydia at same time

Section 9.1 (12 questions)

Predisposing factors
PID STDs Normal flora Cervical Ca Genital warts Multiple sexual partners Early sexual activity & pregnancy Sexual intercourse w/ men who had intercourse w/ cervical Ca pt Use oral contraceptives Smoking Vit A& C deficiencies

Pathophysiology endometriosis
Cause=unknown Endometrial implants travel outside of uterus & implant w/in abdominal cavity Still under endocrine cycle Cause scaring & adhesions as result of reabsorption of blood

Teaching r/t cystocele Use of pessary may help Kegals several times daily: tighten & relax perineal muscles, clench buttocks together and hold 5secs Stop flow of urine once started

Complications HPV Cervical CA Vulvar CA Anorectal CA & squamous cell carcinoma of penis in men

Predisposing factors Breast Ca

Menarche before age 12, menopause after 55yrs First degree relative Hormone therapy Nulliparty or Child birth after age 30 Obesity Exposure radiation Benign breast dx

Post Mastectomy
Precautions
No blood draws, BPs, injections operative arm, post sign over bed Semi fowlers w/ affected arm on pillow Extension/flexsion wrists & fingers, shoulder exercises done on D.O Teach never have arm dependant position Protect it from injury If trauma, clean it, antibiotic ointment notify D.O If lymphodema, compression stocking, massage, elevation, diuretics, isometric exercise

Home care
Explain importance follow up examinations Continue SBEcheck both sides even though one breast removed Teach report to D.O: inflammation @ site, Erythma, post-op constipation, & unusual swelling. Also report new back pain, weakness, SOB, & confusion Stress importance wearing prosthesis if did have reconstruction right away

TRAM flap procedure

Takes 2-8hrs Elevation of large portion of Rectus abdominus formed into breast Heals 4-6wks Implants can be used to get desired look Complications: bleeding, hernia, infection

Post-op Hysterectomy- abdominal bandage or perineal pad

Inspect site for bleedingmoderate amt serosanguineous drainage perineal pad expected Coughing, deep bx s/s infection Catheter carenotify D.O if decreased UOP & complaining of backache If nauseated- antiemetics or NG tube Rectal tube for flatus, ambulation & leg encouraged Frequent position changes--AVOID HIGH FOWLERS POSITION Inform surgical menopause HRT maybe Inform vaginal sensations will return in several months No heavy lifting 2mths No swift walking or exercise--swimming perfect Can wear girdle

Section 7.3(11 questions)

Miscl. info
Pt. teaching for fecal occult testing

Avoid red meats, horseradish & beets NSAIDS, vit C 48hrs before

Psych support pt colon Ca dx Fear, anxiety about pain, loss of life and family members (may be genetic--requires referral genetic councelling) Nsg dx: anticipatory grieving

Pre-op abdominal surgery

1. Re-enforce surgeons explanation and informed consent 2. Det. # incisions & drains 3. Consult enteral nurse about best place ostomy & care of ostomy 4. Bowel prep, laxatives & enemas 5. Liquid diet 1-2dys prior 6. Iv antibiotics 7. NPO and NG tube 8. IV lines

Section 7.3
Location stoma sites 1. Ileostomy- high up, water, loose stools, no control, avoid gas forming foods protect from odour, increased fluid requirements cause bypassing lg intestine 2. Colostomy-may not need an appliance s/s small bowel obstruction Severe abdominal pain , colicky, crampy relieved by vomiting Metabolic alkalosis Orange/brown vomitus foul odour