MEDSURG 1 FINAL-KAPLAN – Flashcards
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acute renal failure
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sudden interruption of kidney function o Signs/Symptoms: oliguria, anorexia, nausea, diarrhea o Treatment: reestablish effective renal functioning, diet low in protein, Na, K, & vitamins o Nursing care: intake and output, vital signs, nutritional status, electrolyte balance, dialysis assistance
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Extracorporeal Shock Wave Lithotripsy
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noninvasive, high energy dry shockwaves pass through skin the fragment the kidney stone o Nursing care: encourage fluid intake, strain all urine for calculi, slight hematuria is expected
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Urolithiasis:
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urinary calculi composed of substances in the urine o Signs/Symptoms: pain, nausea, committing, abdominal distention. Hematuria. Fever o Treatment: analgesics, antibiotics, vigorous hydration o Nursing care: strain all urine, encourage fluids
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• Nephrectomy
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removal of a kidney because of a tumor, infection, or anomalies o Nursing care: well hydrated, one healthy kidney is needed for proper functioning, prepare patient that postop pain may happen
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• AV Fistula:
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created by surgical anastomosis of an artery and vein, used for a patient receiving dialysis o Cannot be used for 4-6 weeks after creation, cannot have BP or blood drawn from the arm with the access o Nursing care: assess vascular access for patency, check for bruit every 8 hours to prevent clotting or blockage, monitor blood pressure
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• Chronic Renal Failure
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progressive reduction of functional kidney tissue resulting in inability of kidneys to excrete wastes, concentrate urine, and conserve electrolytes, irreversible o Signs/Symptoms: decreased urine output, hypertension, metallic taste in mouth, skin complications, muscle cramping o Treatment: preserve kidney function, dialysis, transplantation o Nursing care: monitor K levels, hydration status, education on dialysis
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• Cystoscopy:
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direct visualization of the bladder, inserted into the urethra o Nursing care: explain situation, monitor for urinary retention, teach patient to avoid caffeine and understand that slight hematuria may happen
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• Urinary Tract Infection (UTI):
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infection that begins in the urethra, bladder, ureters, or bladder o Signs/Symptoms: frequent urination, urgency, pain/burning, cloudy urine o Treatment: antibiotics, Pyridium, increased fluid, cranberry juice
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• Cerebrovascular Accident (CVA):
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sudden disruption in blood supply to brain resulting in sudden loss of brain function that may be temporary or permanent o Signs: loss of movement, thought, memory, speech, sensation in one side o Nursing care: promote maximum independence, stimulate senses, speak clearly
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• Electroencephalogram (EEG):
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records electrical activity of brain o Can help identify seizure disorders, head injuries, intracranial lesions, stroke or brain death o Nursing care: withhold patients seizure medications night before, explain procedure,
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Coma
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sustained unconsciousness, indications include no response to verbal stimuli, no voluntary movement o Signs/Symptoms: unresponsiveness, absence of motor/verbal responses, fixed pupils o Treatment: maintain a patent airway (most important) o Nursing care: maintain the airway, protect patient, fluid balance, mouth care, skin integrity, temperature regulation, urinary/bowel function
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• Epilepsy:
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chronic disorder characterized by recurrent seizure disorder, symptom of brain or central nervous system irritation o Treatment: prescribed drugs, phenytoin, carbamazepine phenobarbital, surgery may be necessary if drug therapy fails
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• Meningitis:
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infection or inflammation of membranes covering brain and spinal cord, bacterial, viral, or fungal in origin o Signs/Symptoms: high fever, headache, nuchal rigidity, positive Kernig's sign positive Brudzinski's sign, photophobia, disorientation, seizures o Treatment: immediate treatment with antibiotics, supportive care, analgesics to relieve pain o Nursing Care: assess patient's neurologic status, fluid balance, turn patient often, adequate nutrition, support for family, teach prevention
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• Parkinson's Disease:
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chronic disease of the nervous system characterized by fine, slowly spreading tremor, muscular rigidity and altered gait o Signs/Symptoms: gradual onset, tremor, bradykinesia, altered gait, dysphagia, depression o Treatment: mainly palliative and not curative o Nursing care: encourage independence, scheduled voiding, nutrition, fatigue can exacerbate symptoms
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• Spinal Cord Injury:
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indications include loss of motor and sensory function below level of injury, spinal shock symptoms, postural hypotension, edema, temperature control abnormality o Signs/Symptoms: acute pain, respiratory dysfunction, sensory/motor paralysis, loss of bladder/bowel control. Hypotension, spinal shock o Treatment: immediate immobilization of neck in neutral position, high dose corticosteroids, oxygen, surgery o Nursing care: skeletal tractions, steroid therapy, move client by log-rolling, skin care, emotional support, nutrition, bladder/bowel training, catheterization, prevent complication of autonomic dysreflexia
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• Angina Pectoris
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quick or slow onset of chest pain caused by myocardial ischemia often related to CAD o Signs/Symptoms: burning/crushing tightness in substernal chest, pain may radiate to left arm, nausea, weakness, diaphoresis, women may have atypical chest pain o Treatment: nitrates, beta-adrenergic blockers, antiplatelet drugs o Nursing care: monitor blood pressure, heart rate, ECG, duration of pain
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• Tension Headache:
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most common headache, usually less severe than migraines o Signs/Symptoms: steady pressure around the forehead, band-like pain o Treatment: heat application, massage, exercise, analgesics, Imatrex o Nursing care: general history, medication history, sleep patterns, prevention strategies
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• Increased Intracranial Pressure (ICP):
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increase in the pressure within the skull causes shifting of the brain o Signs/Symptoms: changes in LOC, slow pulse, respiratory irregularities, confusion, drowsiness, stupor, slowing speech o Treatment: osmotic diuretics, corticosteroids, restriction of fluids, draining of CSF, regulation of fever, blood pressure, oxygenation o Nursing care: maintain airway, proper positioning, administer fluids reduce infection risk, monitor for complications
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• Heart Murmur:
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abnormal sound hear on auscultation of heart or adjacent large blood vessels o Nursing care: auscultate heart in quiet relaxed setting, identify loudest location, describe pitch, quality, intensity, radiation
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• Autonomic Dysreflexia
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reaction of the autonomic nervous system to over-stimulation, occurs in patients with spinal cord lesions o Signs/Symptoms: pounding headache, profuse sweating, nasal congestion, piloerection, hypertension o Nursing care: placing patient in sitting position, catheterizing patient, checking rectum for fecal mass, administering IV antihypertensive agent slowly
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• Heart Failure:
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failure of the heart to pump enough blood to meet metabolic demand of tissues, left or right o Signs/Symptoms: LEFT- dyspnea, cough, orthopnea, fatigue, bibasilar crackles, RIGHT- dependent edema, jugular vein distention, hepatomegaly o Treatment: diuretics, ACE inhibitors, digoxin, beta-adrenergic blockers, sodium restricted diet o Nursing care: administer medications, monitor labs, daily weight, prevent DVT
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• Asthma
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inflammatory disease of the airways caused by increased responsiveness of tracheobronchial trees to various stimuli o Signs/symptoms: sudden dyspnea, wheezing, cough, increased mucus secretion, tachypnea o Treatment: bronchodilators and corticosteroids o Nursing care: oxygen, IV fluids if needed, administer medications
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• Infective Endocarditis:
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infection of the heart lining and valves, bacterial or fungal o Signs/Symptoms: weakness, fatigue, night sweats, murmur, petechiae, fever, anorexia o Treatment: IV antibiotics, bed rest, antipyretics, sufficient fluid intake o Nursing care: administer antibiotics, watch for
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• Glasgow Coma Scale:
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tests a patient's level of consciousness after a head injury or trauma, including neurologic trauma o Nursing care: determine extent of injury, maintain patent airway, administer oxygen, vital signs o High score: 15, patient is alert o Low score: 8 or less- indicates severe neurological damage, 3 or less- patient is unresponsive
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• Peripheral Arterial Disease:
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: indications include rubor, cool, shiny skin, cyanosis, gangrene, impaired sensation, intermittent claudication, decreased peripheral pulses. o Predisposing factors: smoking, exposure to cold, emotional stress, diabetes mellitus, high-fat diet, hypertension, obesity o Nursing care: monitor peripheral pulses, good foot care, do not cross legs, regular exercise, stop smoking
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• Chronic Obstructive Pulmonary Disease (COPD):
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group of conditions associated with obstruction of airflow entering or leaving the lungs, asthma, emphysema, chronic bronchitis, and cystic fibrosis o Signs/Symptoms: asymptomatic until middle age usually, reduced ability to exercise, productive cough, dyspnea with minimal exertion o Treatment: aims to relieve symptoms, receive beta-agonist bronchodilators (Albuterol) and other medications o Nursing care: administer antibiotics, low concentrations of oxygen, check ABG levels, evaluate
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• Pneumonia
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inflammatory process that results in edema of lung tissues and extravasation of fluid in alveoli causing hypoxia o Signs/Symptoms: fever, chills, nonproductive cough, pleuritic chest pain, shortness of breath, crackles o Treatment: antibiotics, antimicrobials, hydration, supportive care, oxygen therapy o Nursing care: assess for complications, coughing, deep breathing, incentive spirometer, oxygen, increase fluid intake, vaccines
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• Bell's Palsy:
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: unilateral facial paralysis involving the seventh cranial nerve, usually temporary o Signs/Symptoms: unilateral facial weakness, aching at the jaw angle, drooping mouth, distorted tastes, impaired ability to close eye on weak side o Treatment: prednisone, reduces facial nerve edema o Nursing care: moist heat to affected side, massage face, frequent mouth care, cover eye at night to prevent corneal scratch
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• Oxygen Delivery Systems
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low-flow or high-flow systems o Types: nasal cannula, rebreather, Venturi mask
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• Trigeminal Neuralgia (Tic Douloureux):
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involves one or more branches of the 5th cranial nerve, causes involuntary contraction of facial muscles and episodes of extreme facial pain o Signs/Symptoms: unilateral shooting or stabbing sensation in the face, paroxysm triggered by touching o Treatment: antiseizure medications, alcohol injection o Nursing care: recognize triggers, assess eye of affected side, do not rub eye, monitor difficulty swallowing
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• Hypertension
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persistent elevation of systolic blood pressure above 140 mm and diastolic blood pressure above 90 mm o Signs/Symptoms: retinal changes, headache, dizziness, noctuira, shortness of breath o Treatment: diuretics, ACE inhibitors, calcium channel blockers, vasodilators o Nursing care: monitor blood pressure regularly, compliance, lifestyle changes, limit alcohol
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• Guillain-Barre Syndrome (GBS):
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progressive inflammatory autoimmune response occurring in peripheral nervous system, results in compression of nerve roots and peripheral nerves o Signs/Symptoms: symmetrical muscle weakness, facial diplopia, dysphagia, hypotonia o Treatment: hospitalization, monitor respiratory function, plasmapheresis, high-dose immune globulins o Nursing care: watch for ascending motor loss, vital signs, respiratory function, skin care, ROM, gag reflex, hypotension, signs of thrombophlebitis, urine retention, PT
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• Pulmonary Embolism
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obstruction of the pulmonary artery, usually caused by embolus from lower extremity thrombosis o Signs/Symptoms: dyspnea, anginal chest pain, tachycardia, productive cough, fever o Treatment: adequate cardio and pulmonary function as the obstruction resolves, oxygen, anticoagulation o Nursing care: oxygen, ABGs, intubation if necessary, prevention, do not cross legs, IV heparin
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• Neurogenic Bladder:
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bladder dysfunction related to abnormal or absent bladder innervation, failure to store urine or empty bladder o Signs/Symptoms: incontinence, changes in initiation or interruption of voiding, inability to completely empty bladder o Treatment: anticholinergics, muscle relaxants, diet low in calcium to avoid stone formation o Nursing care: monitor for signs of infection, drink fluids, intake/output, stay mobile
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• CPR
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process of externally supporting circulation and respiration, failure to institute ventilation within 4-6 minutes results in brain damage o Sequence is CAB-compression, airway, breathing
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• Myasthenia Gravis:
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systemic disturbance of nerve impulse transmission because of deficiency of acetylcholine at myoneural junction o Signs/Symptoms: diplopia, ptosis, weakness of muscles, difficult chewing, symptoms of respiratory failure o Treatment: anticholinesterase drugs, corticosteroids, immunosuppressant's. Tracheotomy o Nursing care: educate patient how to conserve energy, avoid stress, self-care
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• Positron Emission Tomography (PET):
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used to assess metabolic and physiologic function of the brain to diagnose stroke, brain tumor, epilepsy, Parkinson's disease, and head injury o Nursing care: explain what is involved in testing procedure, refrain from tobacco, caution about sensations that may be felt during test (dizziness, lightheadedness, headache)
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• Tuberculosis:
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infectious disease of insidious onset that primarily affects the lungs, may spread anywhere in the body o Signs/Symptoms: fever, persistent cough, hemoptysis, fatigue, weight loss, altered mental state o Treatment: prevention, first-line drugs (Isoniazid) o Nursing care: transmitted through airborne transmission, keep airways clean, adhering to drug regimen, multidrug treatment, nutrition, vital signs
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• Peripheral Venous Disease:
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caused by thrombus formation, venous insufficiency, varicose veins, insufficient blood flow through the peripheral veins o Signs/Symptoms: aching pain, pulses present, thickened and tough skin, ulcers, varicose veins o Treatment: elastic support stockings, compression devices, anticoagulation o Nursing care: assess anticoagulant therapy, comfort measures, compression devices, proper body position
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• Dysphagia
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difficulty swallowing, most common symptom of esophageal disease o Symptoms: abnormal sensation of food sticking back, acute pain while swallowing o Nursing care: baseline weight, nutrition, eat slowly and include more fluids, prepare meals in appealing manner, upright after for 30-45 minutes
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• Pneumothorax:
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lung collapse caused by accumulation of air in the pleural cavity o Signs/Symptoms: sudden sharp chest pain, decreased breath sounds on affected side, asymmetrical chest movement, shortness of breath, rapid shallow respirations o Treatment: bedrest, needle aspiration, thoracotomy o Nursing care: assess breath sounds, use incentive spirometry, pulmonary hygiene measures, response to therapy
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• Lung Cancer
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malignancy of epithelium of respiratory tract, cigarette smoking is the primary risk facto, no effective screening test, limited treatment options, usually poor prognosis o Signs/Symptoms: cough, hoarseness, wheezing, unexplained dyspnea, hemoptysis, weakness, pain in arm/shoulder o Treatment: depends on stage of disease, radiation, surgery, chemotherapy o Nursing care: supportive care, maintain patent airway, home oxygen therapy, quit smoking
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• Sickle Cell Anemia:
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hereditary severe chronic anemia condition in which abnormal hemoglobin distorts erythrocytes, increases their fragility and causes them to become sickled in shape and rigid o Signs/Symptoms: aching bones, increased susceptibility to infection, chronic fatigue, chest pain, dyspnea o Treatment: preventative and palliative, analgesia o Nursing care: avoid sickle cell crisis, avoid tight clothing, monitor regularly for pain/infection
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• Myocardial Infarction
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an occlusion of a coronary artery that leads to oxygen deprivation, myocardial ischemia, and eventual necrosis o Signs/Symptoms: severe chest pain, feeling of impending doom, fatigue, nausea, shortness of breath, perspiration o Treatment: thrombolytic therapy (within 3 hours) oxygen, nitroglycerin, aspirin, morphine, IV heparin o Nursing care: ECG readings, blood pressure, assess pain, analgesics, signs of fluid retention, ROM, provide comfort
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• Metered-Dose Inhalant:
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aerosolized, pressurized inhaler allows bronchodilators. Mast cell stabilizers, and corticosteroids to be applied directly to site of action o Lungs/airways are site of action, through mouth, maintenance inhalers used daily to prevent acute respiratory distress
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• Mantoux Test:
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tuberculin skin test, tubercle bacillus extract, PPD given intradermal in the forearm, read in 48-72 hours, induration of 5 or more mm is considered positive
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• Hypoxia
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insufficient cellular tissue oxygenation available to the cells o Signs/Symptoms: apprehension, restlessness, dizziness, confusion, fatigue, tachycardia, dyspnea o Client may use multiple pillows to avoid lying down flat to ease breathing
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• Cough and Deep Breathe
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after surgery or immobility for any period of time, client develops pulmonary disorders, will help alleviate these problems, incentive spirometry
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• Normal Breath Sounds:
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vesicular- soft, low pitched, over peripheral lung fields, bronchovesicular- harsh, over mainstem bronchi, bronchial- loud, course blowing sounds over trachea o Auscultation is the main way to assess breath sounds, deep breaths, listen for abnormalities- crackles, rhonchi, wheezes
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• Chest Tubes:
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placed in pleural space to drain air and blood so that the lung can re-expand, collection contained placed below the chest and water seal is used to keep air from entering chest o Nursing care: reassure patient, baseline vitals, lidocaine, stabilize chest tube, routinely assess function, drainage assessment, obtain vitals
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• Suctioning:
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removal of secretions with an aspiration device, necessary if patient is unable to cough/remove secretions o Helps maintain a patent airway, stimulates cough reflex, collects sputum/sample of respiratory secretions
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• Migraine Headache
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recurring vascular headache, lasts 4-72 hours, usually manifests as a unilateral pulsating pain that becomes more generalized over time o Signs/Symptoms: auras, hemianopia (defective vision in part of one eye or both eyes, unilateral parenthesia, irritability, photophobia
