FINAL EXAM BLUE PRINT NR325 MEDSURGE 2
Cervical cord injury-With head injury, select all that apply nursing assessment and
interventions for cervical vital signs, hypovolemic shock Look at case study Check ICP,
suspect spine injury with head, Shock: tachypnea, tachycardia, hypotension
Spinal cord injury- meds: glucocorticoids, vasopressors, muscle relaxers (baclofen), stool
softeners Neurogenic shock S/S: occurs after SCI for several days to weeks. Symptoms:
hypotension, dependent edema, temperature regulation issues
Autonomic Dysreflexia (S/S): extreme hypertension, severe headache blurred vision,
diaphoresis Nursing actions: sit patient up, notify provider, determine cause (distended
bladder, fecal impaction, tight clothing, undiagnosed injury) treat cause (catheterize patient,
remove impaction, remove tight clothing), administer antihypertensives)
ICP- Indicated for patient with GCS score of 8 or less (Or in Coma)
Symptoms: Irritability (early sign!), restlessness, headache, decreased LOC, Pupil abnormalities,
abnormal breathing (ex: Cheyne stokes), abnormal posturing bradycardia
Normal ICP: 5-15
NO LUMBAR PUNCTURE IF PT HAS INCREASED ICP, can cause hematoma
Lumbar Puncture- Cerebral Spinal Fluid (CSF) sample is taken from the spinal canal
for analysis Used to diagnose multiple sclerosis, syphilis, meningitis, infection in CSF
Pre procedure: have pt. void, position patient in cannonball position on their side, or
have patient stretch over table while sitting.
Post procedure: patient should lay flat for several hours, if puncture does not heal CSF
may leak, resulting in headache (Pain meds & Fluids) Report headache
- Monitor fluids, check sensation in toes, monitor for nausea
- Increase fluid in patient with headache and lumbar puncture. Headaches indicates CSF
leakage Contraindication- A lumbar puncture is contraindicated in the presence of increased
intracranial pressure (risk of downward herniation from CSF removal) or infection at the site of puncture.
Subdural hematoma
epidural hematoma
Pancreatitis- Look at case study! Medications given further discharge teachings,
S/S: Severe LUQ or epigastric pain (radiating to the back or left shoulder) n/v, Turners sign
(ecchymoses on flanks), Cullen’s sign (Blue/grey discoloration around umbilicus), jaundice,
ascites, tetany ( Hypocalcemia test for choveks and trousses sign)
Labs: Increased amylase, Lipase, WBC, Bilirubin, glucose, Decreased Calcium, Mg+,
Platelets Complications: Hypovolemia (due to third spacing), chronic pancreatitis, pancreatic
pseudocyst, Type 1 diabetes Mellitus, coagulations
, FINAL EXAM BLUE PRINT NR325 MEDSURGE 2
Nursing Care: NPO, NG Tube, antiemetics, insulin, IV fluids, and electrolytes, opioid
analgesics, progress to low fat/ bland diet
Urolithiasis- Presence of stones (calculi) in urinary tract, calcium phosphate, calcium
oxalate or uric acid.
S&S: Severe pain (flank pain, radiating to abdomen), dysuria, fever, diaphoresis, n/v, pallor,
tachycardia, tachypnea, oliguria, hematuria(smoky-looking urine)
3 types of diagnostic tests: IVP, Ultrasound, Cat scan KNOW THIS!!! CAT scan, IVP, ultrasonography
PAIN WHEN THE STONE PASSES THROUGH THE URETER and INCREASE IN PAIN
ESWL- focused on the affected kidney shock wave shatters the stone and excreted through
urine (KNOW the Procedure)
Flank pain, UTI, family hx, dehydration,
ESWL: educate client regarding procedure, assess for gross hematuria and strain urine
following the procedure,
Lithotripsy (break up stones), strain urine following procedure, hematuria at site
expected Client Education: bruising is normal, at the site. Explain to the client that there
will be hematuria postprocedural
Discharge Teaching: inform pt. to drink a lot of water to strain the urine and heating pack for
comfort and tell to take pain meds, fluid intake 3000ML/day and he is at risk for dehydration. No
Coffee puts pt at risk for dehydration.
UTI- You need to obtain a clean-catch urine sample from L.M. to send for urinalysis NCLEX
FAVORITE! To collect this specimen, what instructions do you give L.M.? MIDSTREAM
URINE not the first urine. Med administration 1,2,3,4, Blood administration, CVAD module
What are some important measures to teach L.M. to prevent recurrence of a urinary tract infection
(UTI)? Proper hygiene, wiping properly, fluid intake, urinating regularly, cranberry juice
S&S- Pain with urination/ Dysuria and incontinence. Urge incontinence, Blood in urine
is a good indication, will have pain when doing CVA tenderness will say the patient
Cystitis- inflammation of the bladder
Hemodialysis- Informed consent, assess patency of a long-term device
Hemodiaylsis provider will insert 2 needs one into the artery and one into the vein
AVF should be placed at least 3 months before the need to initiate HD. The fistula is the
preferred access for HD.
Normally, a thrill (buzzing sensation) can be felt by palpating the fistula, and a bruit (rushing
sound) can be heard with a stethoscope. The thrill and bruit are created by arterial blood
moving at a high velocity through the vein.
▪ If patient is allergic to heparin, use Alteplase (cathflo R) is used instead of heparin. NCLEX
▪ Take vital signs every 30 to 60 minutes/ Assess Fluid and Electrolyte balance
Hemodialysis is more aggressive Hemodialysis Complications: Hypotension, Muscle
cramps, Loss of blood, hepatitis, Fluid and Electrolyte imbalance
▪ Complications: Anemia, hypotension, infectious disease
Cervical cord injury-With head injury, select all that apply nursing assessment and
interventions for cervical vital signs, hypovolemic shock Look at case study Check ICP,
suspect spine injury with head, Shock: tachypnea, tachycardia, hypotension
Spinal cord injury- meds: glucocorticoids, vasopressors, muscle relaxers (baclofen), stool
softeners Neurogenic shock S/S: occurs after SCI for several days to weeks. Symptoms:
hypotension, dependent edema, temperature regulation issues
Autonomic Dysreflexia (S/S): extreme hypertension, severe headache blurred vision,
diaphoresis Nursing actions: sit patient up, notify provider, determine cause (distended
bladder, fecal impaction, tight clothing, undiagnosed injury) treat cause (catheterize patient,
remove impaction, remove tight clothing), administer antihypertensives)
ICP- Indicated for patient with GCS score of 8 or less (Or in Coma)
Symptoms: Irritability (early sign!), restlessness, headache, decreased LOC, Pupil abnormalities,
abnormal breathing (ex: Cheyne stokes), abnormal posturing bradycardia
Normal ICP: 5-15
NO LUMBAR PUNCTURE IF PT HAS INCREASED ICP, can cause hematoma
Lumbar Puncture- Cerebral Spinal Fluid (CSF) sample is taken from the spinal canal
for analysis Used to diagnose multiple sclerosis, syphilis, meningitis, infection in CSF
Pre procedure: have pt. void, position patient in cannonball position on their side, or
have patient stretch over table while sitting.
Post procedure: patient should lay flat for several hours, if puncture does not heal CSF
may leak, resulting in headache (Pain meds & Fluids) Report headache
- Monitor fluids, check sensation in toes, monitor for nausea
- Increase fluid in patient with headache and lumbar puncture. Headaches indicates CSF
leakage Contraindication- A lumbar puncture is contraindicated in the presence of increased
intracranial pressure (risk of downward herniation from CSF removal) or infection at the site of puncture.
Subdural hematoma
epidural hematoma
Pancreatitis- Look at case study! Medications given further discharge teachings,
S/S: Severe LUQ or epigastric pain (radiating to the back or left shoulder) n/v, Turners sign
(ecchymoses on flanks), Cullen’s sign (Blue/grey discoloration around umbilicus), jaundice,
ascites, tetany ( Hypocalcemia test for choveks and trousses sign)
Labs: Increased amylase, Lipase, WBC, Bilirubin, glucose, Decreased Calcium, Mg+,
Platelets Complications: Hypovolemia (due to third spacing), chronic pancreatitis, pancreatic
pseudocyst, Type 1 diabetes Mellitus, coagulations
, FINAL EXAM BLUE PRINT NR325 MEDSURGE 2
Nursing Care: NPO, NG Tube, antiemetics, insulin, IV fluids, and electrolytes, opioid
analgesics, progress to low fat/ bland diet
Urolithiasis- Presence of stones (calculi) in urinary tract, calcium phosphate, calcium
oxalate or uric acid.
S&S: Severe pain (flank pain, radiating to abdomen), dysuria, fever, diaphoresis, n/v, pallor,
tachycardia, tachypnea, oliguria, hematuria(smoky-looking urine)
3 types of diagnostic tests: IVP, Ultrasound, Cat scan KNOW THIS!!! CAT scan, IVP, ultrasonography
PAIN WHEN THE STONE PASSES THROUGH THE URETER and INCREASE IN PAIN
ESWL- focused on the affected kidney shock wave shatters the stone and excreted through
urine (KNOW the Procedure)
Flank pain, UTI, family hx, dehydration,
ESWL: educate client regarding procedure, assess for gross hematuria and strain urine
following the procedure,
Lithotripsy (break up stones), strain urine following procedure, hematuria at site
expected Client Education: bruising is normal, at the site. Explain to the client that there
will be hematuria postprocedural
Discharge Teaching: inform pt. to drink a lot of water to strain the urine and heating pack for
comfort and tell to take pain meds, fluid intake 3000ML/day and he is at risk for dehydration. No
Coffee puts pt at risk for dehydration.
UTI- You need to obtain a clean-catch urine sample from L.M. to send for urinalysis NCLEX
FAVORITE! To collect this specimen, what instructions do you give L.M.? MIDSTREAM
URINE not the first urine. Med administration 1,2,3,4, Blood administration, CVAD module
What are some important measures to teach L.M. to prevent recurrence of a urinary tract infection
(UTI)? Proper hygiene, wiping properly, fluid intake, urinating regularly, cranberry juice
S&S- Pain with urination/ Dysuria and incontinence. Urge incontinence, Blood in urine
is a good indication, will have pain when doing CVA tenderness will say the patient
Cystitis- inflammation of the bladder
Hemodialysis- Informed consent, assess patency of a long-term device
Hemodiaylsis provider will insert 2 needs one into the artery and one into the vein
AVF should be placed at least 3 months before the need to initiate HD. The fistula is the
preferred access for HD.
Normally, a thrill (buzzing sensation) can be felt by palpating the fistula, and a bruit (rushing
sound) can be heard with a stethoscope. The thrill and bruit are created by arterial blood
moving at a high velocity through the vein.
▪ If patient is allergic to heparin, use Alteplase (cathflo R) is used instead of heparin. NCLEX
▪ Take vital signs every 30 to 60 minutes/ Assess Fluid and Electrolyte balance
Hemodialysis is more aggressive Hemodialysis Complications: Hypotension, Muscle
cramps, Loss of blood, hepatitis, Fluid and Electrolyte imbalance
▪ Complications: Anemia, hypotension, infectious disease
