HESI RN Med-Surg Exam
VERSION 7
Teaching-AGN- diet instructions:
Acute Glomerulonephritis: Inflammatory injury in the glomerulus caused
by immunological reaction.Cause by streptococcal infection
Complications: kidney failure, pulmonary edema, HF
Assessment: periorbital and facial edema, decrease urinary output, hematuria,
hypertension, proteinuria (excessive foam in urine), increased BUN and creatinine Risk for fluid volume overload- measuring daily weight and assessing for changes is the most useful and effective measure for determining fluid balance DIET RESTRICTIONS: restrict sodium intakepotassium may be restricted during periods of oliguria Diuretics are usually administered with edema, antihypertension for hypertension and antibiotics for infection.
NP-Diabetes-Hypoglycemic shock:& altered LOC
Hypoglycemic shock signs and symptoms: headache, nausea, sweating, tremors,
lethargy, hunger, confusion, slurred speech, tingling around mouth, anxiety, nightmares, altered LOC Nursing Action: life threatening, check glucose- may seize if <40. Treat immediately with
complex carbohydrates (CHO):Tube of glucose, Fruit juice, Cola, Hard candy
Emergency kit of glucagon for patients with DM should be taught to use only when notice signs of severe hypoglycemia Check glucose levels, A1c levels if necessary
POLYURIA: THINK SHOCK
POLYURIA
liguria Anuria (too much too little can’t produce urine) O
Teaching-CVA-Visual perception:
Cerebral Vascular Accident (CVA): also known as a stroke/Brain attack. Sudden loss of brain function resulting from a disruption in the blood supply to a part of the brain; classified as thrombotic or hemorrhagic.
CNS involvement related to cause of stroke:
Hemorrhagic: caused by a slow or fast hemorrhage into the brain tissue; HTN
Embolic: caused by a clot that has broken away from a vessel and has lodged
in one of the arteries of the brain, blocking the blood supply. It is often related to atherosclerosis (may occur again) TROPONIN is the diagnostic test that is most sensitive to MI Risk factors: HTN; pervious ischemic attacks; smoking; diabetes; cardiac disease
Findings: Jugular vein distention, Palpable cervical lymph node, Carotid bruit,
Nuchal rigidity, decreased BP, crackles in lungs
Expressive aphasia:communicate with picture boards(visual perception)
Be consistent in using the same words each time a question is asked
Leadership-Rheumatoid Arthritis-pain diagnosis:
Rheumatoid Arthritis: Chronic systematic progressive deterioration of the connective tissue (SYNOVIUM) of the joints, characterized by inflammation 1 / 3
Assessment: fatigue, weakness, weight loss, anorexia, morning stiffness, joint pain Confirmed Lab results: confirmed by Elevated ESR, ASO; positive rheumatoid factor, presence of antinuclear antibody;abnormal synovial fluid; C-reactive protein
Diagnosis: Impaired peripheral mobility relate to join pain
Pain management: do not exercise painful swollen joints; do not exercise any joint to the point of pain, perform exercises slowly and smoothly; avoid jerky movements- therapeutic exercise daily.
Nutrition-Osteomalacia diet:
Osteomalacia: softening of the bones due to deficiency of VITAMIN D
Risk for injury
Increase diet of high calcium and high vitamin D:
Fortified milk and cereal
High in vitamin D: oily fish (salmon, mackerel, sardines) and egg yolks
NP-Urolithiasis-lithotripsy: (Nephrolithiasis)
Urolithiasis: refers to the formation of urinary calculi (kidney stones) form in the ureters May have pain and N/V and WBC in urine Anytime you suspect a kidney stone get a urine specimen ASAP & have it check for RBC If kidney stone are present client will get pain medication immediately
Lithotripsy: Removal of kidney stones
Ultrasonic wave is aimed at the stone to break into fragments (crushes)- stones are passed within urine in a few days Client is taught to watch for signs of urinary obstruction, bleeding, or hematoma formation Instruct client to increase fluid intake to flush out the stone fragments Avoid long periods of remaining in supine position Send stone for analysis Restrict physical action
WATCH FOR HEMATURIA
NP-Thick secretions:
Nursing intervention for liquefying or thinning of secretions would be to increase fluid intake to 3L/day if tolerated. The patient can get secretions out more easily.Tenacious sputum secretions- use bronchodilators
NP-Acute Kidney Injury: pyelonephritis (syllabus)
Acute Kidney Injury: a potentially reversible disorder, it is a rapid loss of kidney function accompanied by a rise in serum creatinine and or a reduction in urine output Total normal urine output 1500-2000ml
Pyelonephritis: inflammation of the renal pelvis and the parenchyma commonly
caused by bacterial invasion.
Nursing interventions:
Monitor vitals Encourage 3L of fluid uptake to reduce fever and prevent of dehydration Monitor weight Rest 2 / 3
High calorie, low protein Explain the relationship between chronic kidney infection renal failure and dialysis
Priority: administer IV antibiotics
NP-Guillain-Barre- Blink:
Guillain-Barre:Clinical syndrome of unknown origin involving peripheral&cranial nerves Usually preceded by a viral respiratory or GI infection 1-4weeks before onset
Assessment:
Paresthesia (tingling and numbness) Muscle weakness of legs progresses to upper extremity Paralysis of the ocular facial and oropharyngeal muscles causing marked difficulty in talking chewing and swallowing Due to respiratory nerves not working correctly watch for shallow/rapid breathing- if it occurs emergency incubation is necessary
Interventions:
If unable to blink administer lubricant Monitor respiration status closely Discharge teaching at home avoid exposure to respiratory infections Leadership-CKD- misses dialysis- Lab
Chronic Kidney Failure: irreversible, slow deterioration of kidney function
characterized by increasing BUN and creatinine. Eventually dialysis is required.If patient misses dialysis blood pressure will increase and fluid retention will worsen. Toxicity from retention can travel within the blood stream.
Missed labs: increased potassium, increased sodium
Apples are good source of dietary nutrition
Athlete’s foot-antifungal:
Athlete’s foot: also known as tinea pedis
Antifungal:ask patient if they are taking the prescription Tolfnate
encourage complete drying of the feet and wearing clean socks
Parkinson-ambulation:
Parkinson disease: chronic, progressive, debilitating neurologic disease of the basal ganglia and substantia nigra, affecting motor ability and characterized by tremor at rest, increased muscle tone (rigidity) slowness in the initiation and execution of movement (bradykinesia)and postural instability (difficulties with gait and balance).Ambulation: usually shuffling gait Reassure that stepping on walks’ is not harmful- CONFIRM that its effective- SAFTEY!!! Shoes should be flat
COPD-Signs & Symptoms:
COPD: emphysema and chronic bronchitis also termed chronic obstruction
pulmonary disorder are characterized by bronchospasm and dyspnea. The damage to the lung is not reversible and increases in severity.Respiratory acidosis
S&S:
Changes in breathing pattern Barrel chest
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