Exit HESI Version 2 Study guide.
Grave's disease signs and symptoms
-Enlarged thyroid
-Acceleration of body process: weight loss, increased appetite, diarrhea, heat
intolerance, tachycardia, palpitations, increased BP, diaphoresis, nervousness,
insomnia
-Exopthalamos
-Increased T3 and T4 levels
-Low TSH levels
Grave's disease test
-Radioactive Iodine Uptake to detect how the thyroid is working
-Ultrasound
-Bloodwork
-Imaging tests
Grave's disease treatment
-Goal: inhibit production of thyroid hormones and block effect on the body
-Radioactive iodine therapy: destroys overactive thyroid cells over time
-Propylthiouracil, methimazole
-Betablockers
-Subtotal or full thyroidectomy (risk of damaging vocal cords and parathyroid glands)
Nursing interventions for a pt with COPD
-Sit upright (positioning)
-Pursed lip breathing
-Diaphragmatic breathing
-HOB up
-Not too much O2: decreases stimulus to breathe
-O2 is not first choice!
Considerations when choosing an IV site
-Avoid restricted extremities (fistula, breast CA (mastectomy/lymphedema), cellulitis)
-If no upper extremities available, can use legs
-Infiltration is a problem, dont reinstill IV access; keep IV in but start a new line
Pheochromocytoma
-Tumor on the adrenals that causes release of catecholamines (epi and norepi)
-Can cause hypertensive crisis (above 240)
-Monitor BP frequently
-Mosly cardio sx: increased HR and BP
General teaching points for pt taking meds
-Take the full dose of antibiotics (can build resistance)
-Pay attention to timing and whether you take with food or on an empty stomach
Describe post-surgical nursing assessment
-VITALS!!
-Take VS first to give you "the lay of the land" and plan further treatment
-Watch for shock and hemorrhaging
-Make sure BP is above 90
,-Give O2 if decreased sat
-Look/ask about pain if HR increased
Describe Lupus and pt education
-*Autoimmune disorder
-Could have a decreased WBC count; increased risk for infection
-Avoid crowds, avoid sick people, avoid sunlight (trigger)
Explain safe insulin administration practice and how to teach another nurse
-Give in SubQ fat, rotate spots
-Sliding scale dose is based on most recent glucose level
-Check orders in the computer if forget dose/med
-Clean area with alcohol
-Make sure you have the right pt
Assessment points for pt with constipation
-Assess current medications
-Check measures that they're currently taking (daily enemas, laxatives, etc)
-Assessment: no bowel sounds, abd distention
-Make a doctors appointment
-Assess current nutrition, diet, and exercise
-Drink more water
Osteomalacia and implications for pt teaching
-Focus on nutritional support
-Sunlight is a good source of vitamin D
-Vitamin D is important to absorb calcium and phosphorous
-Check vitamin D levels
Osteomyelitis
-Bone infection
-Treat with antibiotics
-Poor healing, injury entered the bone
UTI
-Pt doesn't always report sx!
-Urine sample is foul smelling and cloudy
-Send sample to lab for urinalysis
-Order a secondary test (culture and sensitivity) to choose the correct tx
Assessment and nursing interventions for hip fx
-Assess for pain
-Hip fracture sometimes shortens the leg/rotates it
-Treat like its a hip fracture even if no testing done yet
-Assess circulation (pulse, cap refill, feeling, movement, wiggle toes, color)
-Don't elevate the leg
-No extra motion until hip is stabilized
-Assess skin and circulation if in traction
Care and assessment for adrenalectomy
-Pt at risk for electrolyte abnormalities
-Put on telemetry
-Daily serum electrolytes
, -Monitor VS
-Watch for dysrhythmias
Tracheostomy pt teaching
-Maintain airway: suctioning
-Communicate with white boards
-Cough and suction on the way out
-No more than 10 seconds
Steps of the chain of infection
-Causative agent
-Reservoir
-Portal of exit: ex: wound, dressing change
-Mode of transmission: nurse could be mode if they wear a gown in the hallway
-Portal of entry
-Susceptible host: decreased immune system, also have wounds (entry site)
*Ways to block transmission: precautions, wash hands
Aseptic handwashing
-Wash clean to dirty
-Point arms down so dirty water runs from clean to dirty
Chrones Diet
-Low fat
-High-calorie: dried fruit increases calories and nutrients
-High nutrient foods
-Ex: eggs w/o yolk, lean meat, fish, seafood, chicken
Heart Failure Diet
-No canned/processed food
-No cheese or salami
-Limit sodium (fluid retention)
-Vegetables and fruits
Mormon Diet
-No alcohol
-No caffeine
-Give milk, juice, or water
-If diabetic, no juice
-Church = latter day saints
Muslim Diet
-Ramadan: fast for one month each year from dawn till after dark
-Respect this
-No alcohol
Enema administration and nursing considerations
-Monitor pt for cramping and abd pain
-Coach and support pt through this pain
-Need to get procedure done, take break, deep breaths, then continue
Trapeze bar and considerations
Grave's disease signs and symptoms
-Enlarged thyroid
-Acceleration of body process: weight loss, increased appetite, diarrhea, heat
intolerance, tachycardia, palpitations, increased BP, diaphoresis, nervousness,
insomnia
-Exopthalamos
-Increased T3 and T4 levels
-Low TSH levels
Grave's disease test
-Radioactive Iodine Uptake to detect how the thyroid is working
-Ultrasound
-Bloodwork
-Imaging tests
Grave's disease treatment
-Goal: inhibit production of thyroid hormones and block effect on the body
-Radioactive iodine therapy: destroys overactive thyroid cells over time
-Propylthiouracil, methimazole
-Betablockers
-Subtotal or full thyroidectomy (risk of damaging vocal cords and parathyroid glands)
Nursing interventions for a pt with COPD
-Sit upright (positioning)
-Pursed lip breathing
-Diaphragmatic breathing
-HOB up
-Not too much O2: decreases stimulus to breathe
-O2 is not first choice!
Considerations when choosing an IV site
-Avoid restricted extremities (fistula, breast CA (mastectomy/lymphedema), cellulitis)
-If no upper extremities available, can use legs
-Infiltration is a problem, dont reinstill IV access; keep IV in but start a new line
Pheochromocytoma
-Tumor on the adrenals that causes release of catecholamines (epi and norepi)
-Can cause hypertensive crisis (above 240)
-Monitor BP frequently
-Mosly cardio sx: increased HR and BP
General teaching points for pt taking meds
-Take the full dose of antibiotics (can build resistance)
-Pay attention to timing and whether you take with food or on an empty stomach
Describe post-surgical nursing assessment
-VITALS!!
-Take VS first to give you "the lay of the land" and plan further treatment
-Watch for shock and hemorrhaging
-Make sure BP is above 90
,-Give O2 if decreased sat
-Look/ask about pain if HR increased
Describe Lupus and pt education
-*Autoimmune disorder
-Could have a decreased WBC count; increased risk for infection
-Avoid crowds, avoid sick people, avoid sunlight (trigger)
Explain safe insulin administration practice and how to teach another nurse
-Give in SubQ fat, rotate spots
-Sliding scale dose is based on most recent glucose level
-Check orders in the computer if forget dose/med
-Clean area with alcohol
-Make sure you have the right pt
Assessment points for pt with constipation
-Assess current medications
-Check measures that they're currently taking (daily enemas, laxatives, etc)
-Assessment: no bowel sounds, abd distention
-Make a doctors appointment
-Assess current nutrition, diet, and exercise
-Drink more water
Osteomalacia and implications for pt teaching
-Focus on nutritional support
-Sunlight is a good source of vitamin D
-Vitamin D is important to absorb calcium and phosphorous
-Check vitamin D levels
Osteomyelitis
-Bone infection
-Treat with antibiotics
-Poor healing, injury entered the bone
UTI
-Pt doesn't always report sx!
-Urine sample is foul smelling and cloudy
-Send sample to lab for urinalysis
-Order a secondary test (culture and sensitivity) to choose the correct tx
Assessment and nursing interventions for hip fx
-Assess for pain
-Hip fracture sometimes shortens the leg/rotates it
-Treat like its a hip fracture even if no testing done yet
-Assess circulation (pulse, cap refill, feeling, movement, wiggle toes, color)
-Don't elevate the leg
-No extra motion until hip is stabilized
-Assess skin and circulation if in traction
Care and assessment for adrenalectomy
-Pt at risk for electrolyte abnormalities
-Put on telemetry
-Daily serum electrolytes
, -Monitor VS
-Watch for dysrhythmias
Tracheostomy pt teaching
-Maintain airway: suctioning
-Communicate with white boards
-Cough and suction on the way out
-No more than 10 seconds
Steps of the chain of infection
-Causative agent
-Reservoir
-Portal of exit: ex: wound, dressing change
-Mode of transmission: nurse could be mode if they wear a gown in the hallway
-Portal of entry
-Susceptible host: decreased immune system, also have wounds (entry site)
*Ways to block transmission: precautions, wash hands
Aseptic handwashing
-Wash clean to dirty
-Point arms down so dirty water runs from clean to dirty
Chrones Diet
-Low fat
-High-calorie: dried fruit increases calories and nutrients
-High nutrient foods
-Ex: eggs w/o yolk, lean meat, fish, seafood, chicken
Heart Failure Diet
-No canned/processed food
-No cheese or salami
-Limit sodium (fluid retention)
-Vegetables and fruits
Mormon Diet
-No alcohol
-No caffeine
-Give milk, juice, or water
-If diabetic, no juice
-Church = latter day saints
Muslim Diet
-Ramadan: fast for one month each year from dawn till after dark
-Respect this
-No alcohol
Enema administration and nursing considerations
-Monitor pt for cramping and abd pain
-Coach and support pt through this pain
-Need to get procedure done, take break, deep breaths, then continue
Trapeze bar and considerations
