HESI Med-Surg LVN/LPN Review
HESI Med-Surg LVN/LPN Review
Delegation
If giving to LVN/LPN or other nurse that is floating or not critical care- giver
... [Show More] nurse the most STABLE client.
Center of Gravity-
Older individuals center of gravity is the upper torso.
Adults- hips
ABC’s
Airway, Breathing, Circulation
(CAB)- compression, airway, breathing
Provide if unwitnessed cardiac arrest occurs.
If unconscious- begin with circulation, airway, breathing; begin CPR.
30:2 with partner
15:2 alone
Place hands at lower half of sternum; above xiphoid process
Reposition head to validate proper position to open airway if chest is not moving
When carotid pulse is felt, there is return of cardiac function, with return of breathing
• Signs of effective tissue perfusion should be noticed
Preoperative-
• Nurses role is to educate/advocate, reduce anxiety, ensure consent has been signed within past 24 hours (valid for 45 days)
• Teaching/Learning- outcome is best when demonstrated and not only verbalized; returned demonstration is best method.
• KNOW ALLERGIES, OTC, herbal meds
• Know any issues with previous surgical experiences
• Know about person’s culture
• Often no blood transfusions for Jehovah’s Witness
• Often NPO after midnight; clear liquids sometimes allowed up to 6 hrs before surgery
o If client does not follow, surgery will be rescheduled
• Ensure client is both emotionally and physically prepared for surgery
Surgical Risk Factors-
• Age-young and old
• Nutrition- obese and malnutrition
• Fluid/Electrolyte-dehydration/hypovolemia
• Infection
• Cardiac conditions
• Blood coagulation disorders
• URI/COPD- exacerbated by general anesthesia
• Renal disease- impairs F/E balance
• Uncontrolled DM- infection & delayed healing
• Liver disease- inability to detoxify meds
Meds that increase risk:
• Anticoagulants- increases bleeding
• Tranquilizers- hypotension
• Heroin- decreased CNS response
• Antibiotics- may be incompatible with anesthesia
• Diuretics- may cause electrolyte imbalance
• Steroids
• OTC herbal meds-
o THINK THREE G’s: ginseng, garlic, gingko- increase bleeding
o Fish oil, dong quai, feverfew- increase bleeding
o Prolong anesthesia- kava, Valerian, St. John’s (also interacts with EVERYTHING)
Postoperative-
Immediate Care:
VS- BP, pulse, respirations
o Especially if client has slurred speech- may indicate neuro deficits
o If SOB, may need to intubate
LOC, skin color & condition
Dressing location and condition
IV fluids
Urine output
o Notify HCP if dark and less than 30mL/hr
Drainage tubes & position
O2 saturation
Monitor for S&S:
Shock/hemorrhage
o Compensatory mechanism is activation of SNS that will increase RR & pulse to restore BP; constricts arterioles and causes oliguria
o Client will show elevated BP as compensatory mechanism
Narrow pulse pressure
Rapid weak pulse
Cold, moist skin
Increased cap refill
Position client on side to prevent aspiration and to allow client to cough out airway; side rails should be up.
N/V- suction
When getting out of bed for first time, if client had HOB down, allow client to sit with bed in high fowlers position.
Help client sit and dangle legs on side of bed.
Place chair at a right angle to bedside.
Encourage deep breathing prior to standing.
Most common complications:
Urinary retention- monitor hydration status and I&O; offer bedpan/commode
Pulmonary problems- assist to turn, cough, deep breath Q1-2 hrs., Keep hydrated, early ambulation, incentive spirometry.
Wound-healing- teach splinting when patient coughs, monitor for S&S of infection, malnutrition, dehydration HIGH PROTEIN DIET
UTI- increase fluids, empty bladder Q4-6 hrs, monitor I&O, avoid catheterization if possible, remove ASAP
Thrombophlebitis- leg exercises, early ambulation, SCD’s, avoid pressure that may obstruct venous flow; TO NOT PLACE PILLOWS BENEATH KNEES; avoid crossing legs at knees; LMWH- lovenox
Decreased GI peristalsis/constipation/Paralytic ileus- NG tubing to decompress GI tract; client to limit use of narcotics (possibly use stool softeners); encourage ambulation
Wound dehiscence
Patient may feel as if something “gave way”
Observe for serosanguinous drainage
Bowel evisceration- Apply sterile dressing
Gastrointestinal
TPN/Insulin-
ONLY Regular insulin may be given IV. If any other type of insulin is added to a mixture, it must be returned to the pharmacy and should NEVER be used.
The most important lab value to monitor when administering TPN is glucose.
They contain high levels of glucose and sugar should be monitored as often as Q6H.
Monitor fluid and electrolytes
Diabetes Mellitus
Insulin- Assess willingness of client to learn injection sites when newly diagnosed
Monitor clients for issues related to osmotic diuresis from elevated glucose levels
Medications
Rapid – “LOG” fast acting; onset <15 mins; peak 1-2 hours
Regular- Humulin/novolin- onset in 30-60 minutes; peak 2-4 hours
NPH- “LIN”- onset 2-4 hours; peak 4-8 hrs
Long acting- “Lantus”; onset 1-2 no peak.
Metformin- biguanide; do not administer within 48 hours of IV contrast- hard on kidneys
Sulfonylureas- allergic to sulfa’s
Patient will often have Hx of obesity.
Patient should be counseled on nutrition and weight loss.
Diabetic neuropathy- loss of feeling in lower extremities; if serum glucose is decreased with a new diabetic numbness may improve.
Increased risk for stroke.
Pedal pulses can be weak or absent with decreased blood supply.
Patient may experience vascular scarring r/t atherosclerotic changes in vessels causing decreased perfusion, delaying wound healing
Microalbuminuria is earliest sign of diabetic nephropathy
Very important to know if patient is allergic to any sulfa drugs as they are some of the anti-hyperglycemic agents (sulfonylurea- we generally see glyburide, glipizide, glimepiride)
o Prescribed for type 2 diabetics
o Can cause hypersensitivity reaction- trouble breathing, swelling of lips, tongue, face, throat- contact HCP
o May cause Low blood glucose (S&S: sweating, dizzy, confusion, tachycardia, trembling)
Cold and clammy give candy, shakiness- provide orange juice or simple sugar
Rule of 15g (3x)- peanut butter cracker, oj, candy
Cannot be used if pregnant/breastfeeding
Renal insufficiency- Nocturia is S&S
Polyphagia, Polyuria, polydipsia
• Polyphagia- consequence of cellular malnourishment
o No insulin; cannot get glucose into cells
• Polyuria-
o Increased glucose concentration- osmotic diuresis
Glucose so high that it is excreted in urine and water follows
• Polydipsia-
o Increased glucose concentration dehydration
o Often occurs with DKA
Nutrition- fresh fruits, lean meats and fish, vegetables and low grain
Avoid high fat. Use low fat dairy and avoid white bread, essential nutrients are removed.
Teach a patient newly diagnosed with DM 2 to have vision exam
Diabetic Tests
A1C- past three months; - check if noncompliant
Fasting glucose- 70-110
OGTT- drink glucose; after 2 hours if below 140 mg/dL
o 140-199: impaired glucose tolerance, or prediabetes
o 200 or higher: diabetes
Monitor clients with DM
If hypoglycemic- check LOC before performing any actions
Check blood glucose level again to ensure – assess
Hypoglycemic Shock
Teach patients and family S&S of shock
Gastric lavage Unconscious-
• Check BS and begin feeding with peristalsis returns
• High fowlers with towel over chest
• Check tube placement
• Connect tube to funnel or large syringe
• Check residual and return residual.
• Poor feeding into tilted funnel, unclamp tubing to allow feeding to flow by gravity
• Regulate flow by raising/lowering container
o TOO QUICK- diarrhea, distention, pain
o TOO SLOW- possible obstruction of flow
• After feeding, irrigate with tepid water and clamp.
• Keep HOB elevated 30 degrees or more during feeding and for one hour after.
o Preventing aspiration
• May be used when patient has swallowed corrosive substance
o If damaging to mucosa- do not induce vomiting
Gastric decompression and charcoal
Small bowel obstruction
If fever presents, peritonitis is possible possible rupture of bowel and infection
o Monitor VS and S&S of infection
Abdominal cramping is expected
Characterized by severe fluid and electrolyte imbalances
NPO- irrigate NG tube with air only
Erythromycin and neomycin
S&S of perforation and peritonitis: tx with IV fluids, abx, pain, NG suction
Guarding
Increased temp and chills
Pallor
Progressive abdominal distention and abdominal pain
Restlessness
Tachycardia and tachypnea
Assess gag reflex 1st. If not, patient could aspirate.
NG tube for obstruction
Insert and place on intermittent low suction with HOB elevated to 60-90 degrees
Bowel Management-
Can evacuate after last tube feeding of day
Stimulate with insertion of glycerin suppository 15-30 mins before scheduled evac.
Ensure fiber in tube feedings- and fluid 2-4L/day
Diverticulitis
Diverticulosis- outpouching; often goes unnoticed
Diverticulitis- inflammation; peritonitis
Most important- Place client on NPO.
They are at risk for peritonitis and intestinal obstruction and should be made NPO to reduce intestinal rupture.
Assess client’s temperature- often has low-grade fever; if high could indicate peritonitis
Patient will most likely have LLQ pain and low-grade fever
Diverticulitis often occurs in sigmoid colon
Obtain stool specimen. – check for occult blood
Administer IV fluids; increase fluid to 3L
Hard, rigid abdomen and elevated WBC immediate attention; peritonitis is a medical emergency!! Report to HCP
Teach client that they should consume a high fiber diet w/fluids when they have diverticulosis and it is not inflamed
o Do not consume when inflammation is occurring
o Stool softeners- No laxatives; enemas
Acute- NPO, graduate to liquids
Recovery- no fiber or irritating
Maintenance- high fiber, bran; avoid nuts, seeds, popcorn
Ulcerative Colitis
Velvety red, begins in colon and continues
Pain in LLQ
Abdominal pain and intermittent tenesmus (cramping rectal pain and feeling that bowel still needs to be emptied)
Exacerbations of severe diarrhea
o May contain occult blood
Ulcerative colitis is 4-5 times more common with Jewish
Weak and fatigue- anemia
UC peaks between ages 15-25
Second peak is between 55-65 years of age
Low residue, high fat, high protein, high calorie
No dairy
Vitamins and supplements
Avoid smoking, caffeine, pepper, alcohol
Bowel rest- IV
Mesalamine, sulfasalazine
Monitor I&O and F/E
Weight 2x week
Give pain meds (narcotics) with caution
Appendicitis
Severe pain at McBurney’s Point and nausea- radiates to right side
McBurney’s point is located at the right iliac area of RLQ
Pain that suddenly stops
Avoid application of heat
Coughing, sneezing, deep inhalation can worsen pain
Keep NPO
Keep right side position or low fowlers position
Cholestyramine
Used for hyperlipidemia- lowers cholesterol; bile acid sequestrant
This binds bile in GI to prevent reabsorption
Evaluate for vitamin K deficiency
Monitor for increase in PT and INR
Drug absorbs fat soluble vitamins- ADEK
Can be used to treat liver failure
Can be used to treat pruritus
Can be used to treat cholestasis
Binds with oxalate in GI- reduces urine oxalate and calcium oxalate stone formation
Can be used with C. diff to absorb toxins A&B
Max dose 24g/d
Pancreatitis
Digested by own enzymes
o Alcohol, biliary tract disease
o Stop alcohol consumption
• Elevated amylase, lipase, glucose levels
• Lipase and amylase are lab values
• Mid-epigastric pain radiating to back- alcohol or fatty meal
• Abdominal guarding; rigid, boardlike abdomen, and abdominal pain
• Elevated temp, tachy, decreased BP
• Weight loss
• Bluish discoloration of flanks (grey turners)
• Periumbiical area- cullen’s sign
Chronic-
Continuous burning or gnawing pain
Ascites
Steatorrhea, diarrhea
Weight loss
Jaundice, dark urine
o Inflammation and obstruction of bile duct
Signs and symptoms of diabetes mellitus
o Because they have no insulin
NPO, maintain NG tube to suction, TPN is given.
Hydromorphone and fentanyl
Antacids, H2, anticholinergic, PPIs
Position on side to with legs drawn up to chest; hurts when supine
Avoid alcohol, caffeine, fatty foods, spicy foods
Monitor blood sugar, regular insulin
Monitor for hypocalcemia
o Body is not making enzymes to digest calcium
o Tetany, chovtesk’s, trousseau, numbness around mouth
Pancreatic enzyme replacement
Bland, low fat- diet
Crohn’s Disease
Mouth to anus; cobblestone, skipped lesions
• May need to use elimination diet to find trigger foods
• Teach client about remission and exacerbation
• Fatty diarrhea stools- steatorrhea
• Diarrhea
• Low residue, low fat, no dairy, avoid spicy foods
• No smoking, caffeine, pepper, alcohol
• High protein, high calorie
• Administer vitamins and iron
• TPN if necessary
• Monitor I&O, F/E
• Weight 2x weekly
• Provide emotional support
• Encourage to talk with enterostomal therapist before surgery
Celiac Disease
Autoimmune, decreases absorption of fat, carbs, protein
Iron deficiency anemia is common
GERD
Melena
COFFEE GROUND VOMIT- obtain vital signs; symptom of bleeding
Test for occult blood.
Duodenal- relived by eating- DO EAT
Gastric- pain with food- NO GO
Antacids- “AFTER MEALS”
PPI- take before meals; omeprazole; pantoprazole
Mucosal healing agents- before meals
Upright position one hour after meals.
Elevate head of bed 6-8 hours.
Small, frequent meals.
Avoid bedtime snacks.
No NSAIDS, alcohol, smoking
Billroth II surgery
Pulmonary embolism and pneumothorax are risks associated
Monitor client VS- administer O2 with any signs of decreased O2 level
Esophageal Varices
Portal hypertension- causes varices which is dilation of vessel
Caused by scar tissue or blockage of liver;
RESPIRATORY
Tracheostomy-
• Inflate cuff prior to the tube feeding if cuffed tracheostomy is in place.
• Keep inflated to prevent aspiration of food into respiratory system.
• The cuff blocks the trachea and prevents food from entering.
• Keep old ties in place until a new one is secured
Teach glottal stop technique to remove secretions, deep breath, momentarily occlude trach tube, cough, and simultaneously remove finger from tube). Observe patient with laryngectomy tube for any S&S of bleeding or occlusion, greatest immediate post-operative risk.
Insert catheter until resistance or coughing occurs.
Turn suction to 80-120 mmHg.
Catheter should be withdrawn 1-2 cm at a time with continuous rotation and intermittent suctioning.
Keep extra tracheostomy at bedside- one size smaller
Medicalert bracelet- neck breathers
If dislodged- try to reinsert
COPD-
Smoking is one of the biggest risk factors; modifiable.
Client taking steroids for extended period of time are at risk for infection- assess S&S.
Steroids- cause immunosuppression and increase glucose- monitor for S&S of infection!!!
Small, frequent meals
Fluids should be taken between meals not with meals
Blue Bloaters- cyanosis, increase calories and protein; bronchitis; can lead to LHF- cor pulmonale
Pink puffers- barrel chest- puffed out; elasticity of alveoli is gone; accessory muscles
When teaching diaphragmatic breathing- place small book or magazine on abdomen and make it rise while inhaling deeply.
Diaphragmatic or abdominal breathing uses the diaphragm instead of accessory muscles to achieve maximum inhalation and to slow the respiratory rate. The client should protrude the abdomen on inhalation and contract it with exhalation.
Purse lips when exhaling not inhaling (inhale through nose, exhale through mouth)
Use O2 1-2 L
Bronchodilator 1st ; steroid 2nd
Copd- Hyperresonance
Flail Chest-
Treatment- prevent atelectasis and related complications of compromised ventilation- encourage cough and deep breathing.
Condition is generally diagnosed with clients who have 3+ fractured ribs; paradoxic movement of segment of chest wall. Suctioning may be necessary.
Tuberculosis
Place patient on airborne infection precautions; negative pressure room
Nurses wear N95
If exposed- obtain skin test 4-6 weeks after exposure.
Night sweats, anorexia, fever, frothy pink tinged sputum
Antibiotics for 6-9 months; three medications
o Rifampin-body secretions can be red
Monitor alt/ast
BCG – may make you test positive; x-ray will be needed
Ventilator
Patient: 74 years old; respiratory failure secondary to pneumonia. Vt is 750mL, IMV 10 breaths/min
Client: pH 7.48 (alk) , PaCO2 30mmHg (alk) , PaO2 64 mmHg (decreased), HCO3 25 mEq/L (normal)
Fio2: 0.80…… This patient has Respiratory Alkalosis; blowing off too much acid (hyperventilation) . ADD PEEP helps improve oxygenation
Normal: pH 7.35-7.45; PaCO2 35-45; PaO2 80-100 mmHg; HCO3 22-26
Laryngectomy
Teach client to be safe and carry medic alert card/bracelet stating that he is a total neck breather in case CPR is required. – THINK SAFETY!!!
Mouth to neck breathing will need to be done; mouth to mouth will NOT help!
Hyperresonance- copd/
Saying “99” and the lungs sounding clear
Increased clarity of spoken words is indicative of consolidation- pneumonia
Increase in vibrations- fluid
If clear sounds it’s consolidation. Lung parenchyma can be fluid or tissue.
Pneumonia- dull
Absent/Diminished Lung Sounds
Lungs may be filled with more air than normal
Pneumothorax/Emphysema
Acute Respiratory Distress Disorder
Widespread inflammation of the lung
Respiratory failure- diffuse lung injury
“Wet lung”
prone position is best, but dangerous
Critically ill
Mortality rate is high
Elevate HOB to 30 degrees
Assist with daily awakening or sedation vacation
Comprehensive hygiene and mobilization
Emphysema
Pink Puffers- Normal skin coloring
Increased AP diameter (barrel chest- “puffer”)
Nail bed clubbing
Fatigue
Promote energy management with paced activities and rest periods
May need to help clients increase fluid intake
Alveoli become overstretched and retain gases
Chronic Bronchitis
Productive cough with grayish-white sputum that usually occurs in morning; often ignored by smokers
Generally occurs for 3 months out of 1 year for 2 years for dx.
Blue Bloaters- cyanosis, increase calories and protein; bronchitis; can lead to LHF- cor pulmonale
Pneumonia
Gram Positive
Gram Negative- more resistant to ABX therapy; makes recovery difficult; can affect all lobes of the lung
o E. coli, Klebsiella, Pseudomonas and Proteus
Pneumococcal Pneumonia- generally strikes debilitated persons- alcoholics, diabetics, those with chronic lung diseases; mean age is 50 years old
Older clients- often are not febrile; may show confusion, tachycardia
Vaccine- offered once to older adults or persons with hx of chronic illness
Asthma
Administer bronchodilators- opens airway and relaxes smooth muscle
Adrenaline or epi can cause dilation- relaxes muscles
Stress, environment, exercise
NO beta blockers “LOL”
o Metoprolol, atenolol, propranolol, labetolol
LIVER
Hepatitis B
Ensure all employees have Hep B series
o prevention
Staff could contract Hep B if exposed to blood or body fluids
Wear gloves and gown when coming into contact with body fluids
Blood borne
Can only get Hep D if already have Hep B
No treatment
Hepatitis C
Medications such as interferon-alfa-2a and ribavirin can cause depression; review medication side effects.
Blood borne
Viral Hepatitis- A&E
Patient may have fatigue and diarrhea
Wash hands!!!!
Cirrhosis- End Stage Liver Disease-
Extensive degeneration and destruction
Liver tissue is replaced by fibrosis
Alcohol and NAFLD
Hep C
Early S&S: Fatigue and enlarged liver
S&S: NV, fatigue, muscle and joint weakness, jaundice, dark urine, clay colored stool, fever, abdominal tenderness RUQ, elevation of ALT/AST and bilirubin (this is why there is clay colored stool)
Late signs: liver failure, portal hypertension, jaundice, peripheral edema, ascites, skin lesions (spider angiomas, palmar erythema r/t increased circulation of estrogen) hematologic disorders, endocrine disturbances
Men gynecomastia, loss of hair (axillary/pubic), testicular atrophy, impotence
Younger women amenorrhea
Older women vaginal bleeding
Hematologic: thrombocytopenia, leukopenia, anemia, coagulation disorders
Leukopenia, anemia, thrombocytopenia backing up into spleen; causes splenomegaly
Peripheral neuropathythiamine, folic acid, cobalamin (B12)
Plan rest periods, high calorie, high carb, low sodium diet with moderate fats and protein.
Serve small, frequent meals with vitamin supplements.
Remove any strong odors, administer antiemetics, and have client sit up.
Prevent infection to others!!
Avoid any hepatotoxic drugs- alcohol, aspirin, acetaminophen, sedatives, anti-seizure meds or any medication that is contraindicated with liver damage
Vitamin K may be prescribed due to normal clotting mechanism being damaged
Fluids may be restricted due to ascites that accompanies cirrhosis
Hepatic encephalopathy
o Fector hepaticus- musty, sweet odor of breath
o Alters LOC – buildup of ammonia
Lethargy, somnolence, lack of coordination, decreased memory
Tx: Lactulose
o Asterixis- liver flap
Hand is extended upward at wrist
Resembles bird flapping wings
o Changes in mood, personality, movement
can cause difficulty with handwriting
cerebral edema
death
Cirrhosis of liver
Hct and Hgb decrease
Decreased serum ammonia
- If blood or protein is removed; intestines no longer breakdown as much protein which forms ammonia.
- Lower protein diet or restriction may be necessary
- High carb/calorie diet
- Low sodium diet < 2g
KIDNEY
GFR 125ml/min
Chronic Renal Disease-
Labs:
Azotemia
Increased Cr & BUN
Decreased Ca- no vit D absorption
Elevated Phos and Mag- (use phosphate binders, no mag-based antacids/Maalox)
Elevated potassium; metabolic acidosis; low calcium
Anemia (administer antianemic drug)
o Erythropoietin- use in caution with older adults; may increase risk for thrombosis
o Do not give with high HCT**
Monitor Digoxin levels
o Level can increase with kidney disease- S&S of toxicity: N/V/A, headache, visual disturbances, dysrhythmias, pulse 60 BPM
Digoxin
MONITOR K level. If patient has hypokalemia it can cause digitalis toxicity- N/V/A, headache, eye complications (seeing halos)
Therapeutic range for DIG is 0.8-2ng/mL
Withhold if apical pulse is LESS THAN 60 BPM.
Patient with chronic renal failure often have:
HTN, edema, pulmonary edema- pain, discomfort
Protein must be restricted with CRF
GFR is used as indicator of level of protein consumption.
Monitor electrolytes
Weigh daily
Monitor I&O
Check for JVD and other signs of fluid overload; edema/pulmonary edema
o Monitor for wet sounds
o Demonstrate method for splinting incision when coughing and deep breathing if patient has had transplant
Provide low-protein, low-sodium, low-potassium, low-phosphate.
High calorie diet. Protein is restricted until blood shows ability to handle protein catabolites; give hard candy, jelly beans, flavored carb powders.
Protein- eggs, milk, meat.
Fluid allowance- 500-600 mL greater than previous day’s 24 hour output.
Periods of rest and activity.
Strict adherence to med therapy.
If hyperkalemia- Kayexalate (sodium polystyrene)
Hyperkalemia with ESRD
If transplant occurs, inform patient to ensure immunosuppressants are taken daily
Hemodialysis
If blood pressure drops- lower head of chair and elevate feet
Monitor for bruit or thrill to ensure patency of graft or shunt/artertiovenous fistula
Avoid taking blood pressure in arm with graft/shunt/artertiovenous fistula
Decrease sodium intake
Polycystic Kidney Disease
UTI- requires prompt attention; bacteria will be in urine
o Can cause scarring and further damage
Hematuria is expected finding
Early S&S- steady, dull flank pain
Kidney pain may also be abrupt, episodic, colicky with bleeding into cysts
Primary Aldosteronism
Increase in fluid retention and sodium hypertension is most prominent sign
Hypokalemia- wastes Potassium
Sodium is normal or elevated depending on water reabsorption
Acute Renal Failure
• Nephrotoxic drugs can cause nephron obstruction which can cause patients to require dialysis until ATN subsides.
• Best indicator of GFR is creatinine. Needs to be > 60; creatinine is 70-135 mL/min
o Elevated creatinine level indicates nephron loss, reducing filtration.
o Creatinine- product of muscle metabolism
Phases of ARF
Oliguric- 600 ml plus previous 24 hour fluid loss; not diuresing; daily weight
May gain 1 Ib/day [Show Less]