FINAL EXAM BLUE PRINT OCT 2020 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 OCT 2020 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 OCT 2020 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
