lOMoARcPSD|392 084 5
HESI I MEDSURG STUDY GUIDE
Hematemesis Information Nursing Processes
Please use this guide as such, a guide however remember to utilize the basics, the nursing
process, ABC’s and prioritize accordingly.
• Hematemesis (vomiting blood) – typically upper GI bleed
a. What to assess?
i. Remember ABC’s (pt having diff breathing?), check vital signs first*
ii. Assess stool (blood present? – if so, what color. Dark red = upper GI
bleed, usually more serious)
iii. Check if they are on iron supplements
iv. Worried about hypovolemic shock
1. S/S: restlessness, agitation, inc HR and RR, cool, pale, sweaty
• Open vs Close angle glaucoma
b. Def: condition characterized by inc intraocular pressure (IOP > 22 mmHg) r/t
aqueous fluid being inadequately drained from eye gradual painless vision
loss. Generally asymptomatic in early stages (seen in reg eye exam)
i. No cure, can be treated pharmacologically and surgically
c. Patient teaching
i. Develop a teaching plan that includes the following: (p. 131)
1. Careful adherence to eye-drop regimen can prevent blindness
2. Vision already lost cannot be restored
3. Eyes drops are needed for rest of life
a. Eye drops used to cause pupillary constriction – mvmt
4. ***Proper eye-drop instillation technique. Obtain a return
demonstration.
a. Wash hands and external eye
b. Tilt head back slightly
c. Instill drop into lower lid, s touching the lid c the tip of
the dropper
d. Release lid, and sponge excess fluid from lid and cheek
e. Close eye gentle, and leave closed for 3-5 min
f. Apply gentle pressure on inner canthus to decrease
systemic absorption
g. (Caution: Vision may be blurred for 1-2 hrs post admin
and adaption to dark environments difficult r/t
pupillary constriction (FALL RISK))
i. Blurring tends to dec c inc use of meds
, lOMoARcPSD|392 084 5
2
5. Safety measures to prevent injuries
a. Remove throw rugs
b. Adjust lighting to meet needs
6. Avoid activities that main inc IOP
a. Emotional upset
b. Exertion: pushing, heavy lifting, shoveling
c. Coughing severely or excessive sneezing (Get medical
attn before URI worsens)
d. Wearing constrictive clothing (tight color or tie, tight
belt, or girdle)
e. Straining at stool and constipation
i. Increased pressure, asymptomatic, seen at eye exam
ii. Can lead to blindness if untreated
iii. Eye drops needed for rest of their life
iv. Pt teaching – safety measures to prevent injury (remove throw rugs,
adequate lighting)
• Syndrome of inappropriate anti-diuretic hormone: SIADH
o Def: excessive production/release of vasopressin (ADH). Char by dec u/o, inc
specific gravity, dec sodium
▪ Other manifestation (r/t hyponatremia)
• Anorexia, N, wt gain, weakness, confusion, irritability, sz/coma
▪ Etiology (usually result of underlying condition, aka treat cause)
• Excess (synthetic vasopressin) DDAVP (Desmopressin) to treat DI,
CNS infections, generalized sz’s, surgery to hypothalamus/pituitary
o Pt is retaining fluid but so thirsty
▪ What else to give them? Hard piece of candy* (want them to salivate)
• Hyperthyroidism/hypothyroidism
o Signs/symptoms
▪ Hyperthyroidism: (p pg. 96, 111)
• Exophthalmos (bulging eyes)
• Enlarger thyroid gland
• Weight loss
• T3 elevated
• T4 elevated (>12 mcg/dL)
• Diarrhea
• Tachycardia, palpitations, inc BP
2
HESI I MEDSURG STUDY GUIDE
Hematemesis Information Nursing Processes
Please use this guide as such, a guide however remember to utilize the basics, the nursing
process, ABC’s and prioritize accordingly.
• Hematemesis (vomiting blood) – typically upper GI bleed
a. What to assess?
i. Remember ABC’s (pt having diff breathing?), check vital signs first*
ii. Assess stool (blood present? – if so, what color. Dark red = upper GI
bleed, usually more serious)
iii. Check if they are on iron supplements
iv. Worried about hypovolemic shock
1. S/S: restlessness, agitation, inc HR and RR, cool, pale, sweaty
• Open vs Close angle glaucoma
b. Def: condition characterized by inc intraocular pressure (IOP > 22 mmHg) r/t
aqueous fluid being inadequately drained from eye gradual painless vision
loss. Generally asymptomatic in early stages (seen in reg eye exam)
i. No cure, can be treated pharmacologically and surgically
c. Patient teaching
i. Develop a teaching plan that includes the following: (p. 131)
1. Careful adherence to eye-drop regimen can prevent blindness
2. Vision already lost cannot be restored
3. Eyes drops are needed for rest of life
a. Eye drops used to cause pupillary constriction – mvmt
4. ***Proper eye-drop instillation technique. Obtain a return
demonstration.
a. Wash hands and external eye
b. Tilt head back slightly
c. Instill drop into lower lid, s touching the lid c the tip of
the dropper
d. Release lid, and sponge excess fluid from lid and cheek
e. Close eye gentle, and leave closed for 3-5 min
f. Apply gentle pressure on inner canthus to decrease
systemic absorption
g. (Caution: Vision may be blurred for 1-2 hrs post admin
and adaption to dark environments difficult r/t
pupillary constriction (FALL RISK))
i. Blurring tends to dec c inc use of meds
, lOMoARcPSD|392 084 5
2
5. Safety measures to prevent injuries
a. Remove throw rugs
b. Adjust lighting to meet needs
6. Avoid activities that main inc IOP
a. Emotional upset
b. Exertion: pushing, heavy lifting, shoveling
c. Coughing severely or excessive sneezing (Get medical
attn before URI worsens)
d. Wearing constrictive clothing (tight color or tie, tight
belt, or girdle)
e. Straining at stool and constipation
i. Increased pressure, asymptomatic, seen at eye exam
ii. Can lead to blindness if untreated
iii. Eye drops needed for rest of their life
iv. Pt teaching – safety measures to prevent injury (remove throw rugs,
adequate lighting)
• Syndrome of inappropriate anti-diuretic hormone: SIADH
o Def: excessive production/release of vasopressin (ADH). Char by dec u/o, inc
specific gravity, dec sodium
▪ Other manifestation (r/t hyponatremia)
• Anorexia, N, wt gain, weakness, confusion, irritability, sz/coma
▪ Etiology (usually result of underlying condition, aka treat cause)
• Excess (synthetic vasopressin) DDAVP (Desmopressin) to treat DI,
CNS infections, generalized sz’s, surgery to hypothalamus/pituitary
o Pt is retaining fluid but so thirsty
▪ What else to give them? Hard piece of candy* (want them to salivate)
• Hyperthyroidism/hypothyroidism
o Signs/symptoms
▪ Hyperthyroidism: (p pg. 96, 111)
• Exophthalmos (bulging eyes)
• Enlarger thyroid gland
• Weight loss
• T3 elevated
• T4 elevated (>12 mcg/dL)
• Diarrhea
• Tachycardia, palpitations, inc BP
2
