Download Nursing Considerations for Radiation, LASIK, Knee Arthroplasty, Chest Tube, and Mastectomy and more Study notes Nursing in PDF only on Docsity!
Adult Health / Med-Surg When in doubt, the correct answer may be the low urine output (Urine output less than 30 mL/hr) Strong indication of a hematologic disorder = Absence of hair on the legs Rationale: Thinning or absence of hair on the extremities indicates poor arterial circulation to that area Brachytherapy Treatment Procedure that involves placing radioactive material inside of the body Indication o Commonly used to treat prostate cancer o Cervical cancer o Uterine (endometrial) cancer o Brest cancer, lung cancer, eye cancer, and skin cancer Nursing Consideration o Nurse needs to educate the client on the importance of remaining on bed rest with limited movement while the radioactive implant is in place to prevent dislodgment o Nurse should wear a lead apron when providing direct care to provide protection from radiation source and not turn their back toward the client o Limit each of the client’s visitors to 30 minutes per day o Instruct visitors to remain at least 6 feet from client receiving radiation at all times Indication of Pancreatitis Increased serum lipase level o Rationale: due to the release of lipase into the pancreas and autodigestion Increased WBC count (because of the inflammatory process) Decreased albumin level (due to the inflammatory process) Increase in blood glucose levels (due to a drop-in insulin production) Polycythemia Vera type of blood cancer that causes bone marrow to make too many red blood cells. Nursing Interventions o Patient should elevate their legs when sitting Rationale: to avoid venous pooling with subsequent clot formation o Patient should drink at least 3 Liters of fluid per day to help lower blood viscosity o Patient should wear support hose/TED hose/SCD when awake o Patient should use a soft toothbrush to clean their teeth (avoid flossing or anything that increasing the risk for bleeding)
Pyelonephritis A bacterial infection of the kidney and renal pelvis Nursing consideration o The nurse should instruct the client about the importance of wiping from front to back following fecal elimination to avoid introducing bacteria into the urinary tract Dumping Syndrome information: Preventing Dumping Syndrome Eliminate/avoid simple sugars and sugar alcohols from the client’s diet to prevent dumping syndrome o Sugar, honey, and sugar alcohols increase hypertonicity and propel food through the intestines faster than food without sweeteners The client should ingest protein at every meal to slow gastric emptying (preventing dumping syndrome) The client should drink beverages between meals ONLY (about 1 hour after eating solid foods) o Rationale: Mixing food and fluids propels the mixture through the gastrointestinal tract faster than solid food alone). Electroencephalogram (EEG) Nursing Consideration o Pre-Operative care Thoroughly shampoo the client’s hair prior to the EEG o Instruct the client to be sleep-deprived prior to the EEG to increase the likelihood of recording seizure activity o Instruct client to lie still in reclining chair or bed and to keep their eyes closed (for the initial recording) o EEG takes 45 minutes to 2 hours o EEG documents brain activity How to Avoid Sickle Cell Crisis Avoid strenuous physical activities that cause overexertion Drinking 3 to 4 liters of fluid per day Avoid traveling to high altitudes and in airplanes (since passenger cabins are non- pressurized) Avoid recreational activities that require persistent exposure to cold weather EKG/ECG/Telemetry Reading A flattened T wave or the development of U waves is indicative of Hypokalemia Elevated ST Segment = Hyperkalemia Widen QRS = Hyperkalemia Prolonged QT Intervals = Hypocalcemia o Manifestations of Hypocalcemia
o Nurse and other facility should wear a dosimeter badge (to monitor their exposure to radiation) o Educate the client to avoid direct exposure to the sun Rationale: skin in the radiation path is especially sensitive to sun damage Dietary consideration for Radiation Therapy o Instruct the client to use gravies or sauces to soften foods and make them easier to eat o Avoid eating dry, coarse foods (such as graham crackers) Rationale: type of food can make the client’s mouth feel dry and unpleasant o Instruct patient to consume foods containing citrus to stimulate saliva o Instruct patient to rinse the mouth with an alcohol-free mouthwash before eating Rationale: Because if they use alcohol, it can make their mouth dryer Findings that Indicate Tension Pneumothorax Tracheal Deviation to the unaffected side Absent breath sounds on the affected side Neck vein distention o due to the increased difficulty breathing leading to compression of blood flow return Tachypnea (until chest tube is inserted) Respiratory distress (until chest tube is inserted) What is Transillumination? Fat Embolism Syndrome Manifestation of Fat Embolism Syndrome o When Fat globules occlude small blood vessels Expected findings o Triad of neurological changes o Petechial rash o Hypoxemia Risk factors o Multiple fractures o Fracture of a long bone Increased Intracranial Pressure (ICP) Manifestation o Widened Pulse Pressure
o Sleepiness o Bradycardia o Severe hypertension o pupil changes o Change in the level of consciousness o Nausea and Vomiting o Seizures o Alterations in breathing pattern o Distended jugular veins o Decerebrate posturing o Decorticate posturing Nursing Consideration o Monitor vital signs every 2 hours o Assess neurological status every 4 hours o Keep the client’s room darkened o Maintain client’s bed at 30 to 45 degrees LASIK Surgery indication o procedure to correct nearsightedness, farsightedness, and astigmatism by changing the shape of the cornea Adverse effects of LASIK Surgery o Dryness of the eyes o Blurred vision Hodgkin’s Lymphoma Early manifestation o Enlarged lymph nodes o Night sweats o Unexplained weight loss o fevers o pruritus (itching) Prone position is associated with Amputations Nursing consideration o Assist the client into a prone position (on their stomach) for 20 to 30 minutes every 3 to 4 hours following an amputation Rationale: to reduce the risk of flexion contractures What is an Electromyogram (EMG)? A procedure shows electrical activity within the muscles during contraction
o Dyspnea o Coughing o Distended neck veins Herpes Zoster (Shingles) vs Herpes Simplex Virus (Genital Herpes) Herpes Zoster (Shingles) manifestation o Unilateral, localized, nodular skin lesions Herpes Simplex Virus (Genital Herpes) manifestation o Fluid-filled vesicular rash in the genital region Urinary Tract Infection (UTIs) Manifestations o Back pain and flank pain o frequency of urination o Urgency of urination o Cloudy urine o Foul-smelling urine Pan-hysterectomy for Uterine Cancer Discharge teaching o Educate and inform the client that a Pan-hysterectomy includes the removal of the uterus and the ovaries Causes Manifestations of Menopause Hot flashes Night Sweats Vaginal Dryness (treatment = use water-based lubricant when having sexual intercourse) Unstable Angina Nursing consideration o Patients experiencing Unstable Angina will have chest pain lasting longer than 15 minutes Gout and Urolithiasis How to prevent future uric acid stones o Take allopurinol as prescribed (medication used to reduce uric acid) o Exercise several times a week o Limit intake of foods high in purine Purine increases the risk of uric acid stone formation: examples
organ meats poultry (chicken) fish red wine gravy Right-hemispheric stroke expected neurologic deficits o Visual spatial deficits (loss of depth perception) o Left hemianopsia (blindness in the left half of the visual field) o one-sided neglect Left-hemispheric stroke expected neurologic deficits o Expressive aphasia (inability to express what one wants to convey) o Right hemiplegia (blindness in the right half of the visual field) Hypertonic Dehydration Expected finding o Urine specific gravity greater than 1.030 (ex. 1.045 Urine Specific Gravity) o Sodium level greater than 145 mEq/L o Increased respiratory rate Acute Cholecystitis Expected finding o Tachycardia (priority finding) o Abdominal pain radiating to the right shoulder o Anorexia o Rebound abdominal tenderness Colorectal Cancer Recommend Dietary Alterations o Consume a diet that is high in high, low in fat, and low in refined carbohydrates Brassica Vegetables (food that are high in fiber) Cabbage Cauliflower Broccoli Irritable Bowel Syndrome (IBS) Dietary Consideration o Foods to avoid Dairy products
o Altered emotional state (irritability, depression) o Decreased libido Addison’s Disease Expected Finding/Manifestations o Weight loss o Craving for salt o Hyperpigmentation of the skin and mucous membranes o Weakness and fatigue o Nausea, anorexia, and vomiting o Abdominal pain o Constipation or diarrhea o Dizziness with orthostatic hypotension o Severe Hypotension o Dehydration o Hyponatremia o Hyperkalemia o Hypoglycemia o Hypercalcemia Total Knee Arthroplasty (will most likely be on the final exam) Nursing consideration o Instruct the patient to flex their foot every hour when awake Rationale: To reduce the risk for thromboembolism and promote venous return o Avoid placing pillows under the knee to prevent flexion contractures o Instruct client to elevate the leg when sitting in a chair to reduce edema and pain o Instruct the patient to remain their legs in a neutral position when resting in bed to prevent dislocation of the knee Chest Tube/Atrium System Bubbling in the water seal chamber ceases when the lung re-expands Nursing Consideration o Instruct the client to perform the Valsalva maneuver during removal o Nurse should provide the client with pain medication prior to the procedure to promote comfort during the removal of the chest tube o The nurse should cover the insertion site with an occlusive dressing to prevent air entry into the pleural space Pressure injury Nursing consideration o Change position every 1 to 2 hours (to decrease pressure on bony prominences) o Instruct client to keep the skin clean and to dry and to moisturize the skin with a cream or lotion
o avoid massaging or rubbing the affected area (can cause further skin breakdown) Hemodialysis expected findings o increased temperature (ex. 99 degrees) rationale: caused by the dialysis machine slightly warming the blood o Decrease in blood pressure (ex. 100/70 mm Hg) Rationale: occurs as a result of the removal of excess fluid from the client’s blood o Weight loss Rationale: occurs as a result of the removal of excess fluid from the client’s blood Complication of Hemodialysis o Disequilibrium Syndrome caused by the rapid removal of electrolytes from the client’s blood and can lead to dysrhythmias or seizures Manifestations of Disequilibrium Syndrome Restlessness Nausea Vomiting Fatigue Headache DKA Expected finding o Hyperkalemia o Low pH/less than 7.35 (ex. pH 7.28) o Glucose greater than 300 mg/dL o Low Bicarbonate levels/less than 22 (ex. HCO3 level of 14) Indication of improved status/therapeutic effect o A glucose reading less than 300 mg/dL AIDS information Nursing consideration o Avoid flossing teeth (to prevent gum inflammation) Rationale: flossing could create an opportunity for infection
Rheumatoid Arthritis Nursing Consideration o Alternate application of heat and cold to the affected joints (to decrease joint inflammation and pain) Rationale: Cold helps to relieve joint swelling; Heat helps to decrease joint stiffness and pain o Regular exercise is important to prevent stiffness (however, it may be painful) Modified Radical Mastectomy Nursing consideration o Instruct the client that the drain will be removed when there is 25 mL of output or less over a 24-hr period o Instruct the client to start exercising the right arm 24 hour after surgery o Nurse should elevate the arm of the affected side on a pillow to promote lymphatic fluid return o Nurse should elevate the head of bed to at least 30 degrees (to promote drainage from the surgical site and facilitate breathing) Client Education for Modified Radical Mastectomy o Instruct client that numbness can occur near the incision and along the inside of the affected arm due to nerve injury o Instruct client to stand upright and avoid flexing the affected arm when ambulating (to reduce risk for elbow contracture) o Instruct the client to begin active range-of-motion exercises 1 week after surgery (to increase mobility without causing stress on the incision) o Instruct client to dress loose-fitting clothing (to reduce the risk of stress on the incision) Diabetes Insipidus Expected findings o Low urine specific gravity o Hypotension (due to dehydration caused by excessive excretion of urine) o Weak peripheral pulses Manifestation o polydipsia (excess thirst) o polyuria (excess urination) Hemolytic Transfusion Reaction Expected finding/Manifestations o Low back pain and apprehension
o Hypotension o Tachycardia Transcutaneous Electrical Nerve Stimulation (TENS) What effect does this have when applied to a painful area? o A tingling sensation replacing the pain A TENS unit applies small electric currents to the painful area, with the client increasing the current until the “pins and needles” sensation overrides the pain. Latex Allergy Allergy reaction/Sensitivity to the following foods indicate latex allergy o Strawberries o Bananas o Avocado Warfarin Nursing consideration o Drug is contraindicated for patient undergoing eye or central nervous system surgery Rationale: Warfarin is an anticoagulant, which increases the client’s risk for bleeding Amphotericin B Indication o patient with AIDS Adverse effects of this drug o Elevated BUN o Elevated Creatinine levels Nursing Consideration o Amphotericin B is nephrotoxic Mannitol (Osmotic diuretic medication) Manifestations o Pulmonary Edema (Crackles heard on auscultation may indicate Pulmonary Edema) o Dyspnea o Decreased oxygen saturation o Electrolyte loss o Tachycardia (should be reported)
Pernicious Anemia Foods to eat that are high in Vitamin B o Dairy products o Animal protein o Poultry o Shellfish o Eggs Meniere’s Disease disorder of the inner ear that causes episodes of vertigo and leads to hearing loss Condition of the inner ear in which excess fluid distorts the inner ear canal system This condition decreases hearing via dilation of the cochlear duct, leading to vertigo from damage to the vestibular system Nursing Consideration o Avoid sudden movements Rationale: sudden movements can increase manifestations of Meniere’s Disease Acute Diverticulitis Nursing Consideration o Patient should maintain a diet very low in fiber white bread low-fat milk Yogurt with active cultures Poached eggs Canned soft fruit Bleeding Duodenal Ulcer Expected finding o Emesis with a coffee-ground appearance or bright red in color o Decreased blood pressure (due to bleeding and fluid loss) o Melena stools (which are tarry or dark in colon and sticky) Types of Memory Remote (long-term memory) o Asking questions such as where and when the client was born, his age, when he/she graduated high school, and what the names, ages, and birth dates of his children are o Nurse can verify this information with the client’s family or friends Sensory (short-term memory)
o Momentary recollection of some form of stimuli from the environment. Immediate (new memory) o can test by giving the client a 3-step command and observing for completion of all 3 steps Recall (recent memory) o Test by asking questions about recent activities that the nurse can verify in the client’s medical record o Ex. asking how the client got to the facility or which provider he saw in the past few days Types of Respirations Cheyne-Stokes o Breathing pattern of deep to shallow breaths followed by periods of apnea o May occur due to drug overdose or increased intracranial pressure and can precede death Orthopnea o Shortness of breath when in a supine position and is able to breathe easily when sitting upright Paradoxical Respirations (A Flail chest) o Pattern of breathing in which the chest wall contracts during inspiration and expands during expiration o Occur in a client who has sustained rib fractures Kussmaul Respirations o Deep, rapid respiratory pattern of hyperventilation that can occur in a client who has diabetic ketoacidosis Total Parenteral Nutrition (TPN) Adverse effects o Hyperglycemia Nursing consideration o Weigh the client daily (due to risk of fluid and electrolyte imbalance while administering TPN) o Change the tubing every 24 hours (to prevent bacteria from developing in the tubing o The nurse should check the client’s blood glucose every 4 hours while the client is receiving TPN o Nurse should apply a new dressing to the client’s IV site every 24 to 72 hours
Nursing Consideration o Expect an increased erythrocyte sedimentation rate Rheumatoid Arthritis (RA) Symmetrical joint impairment Autoimmune disease in which the body’s immune system attacks itself; also involving other body organs Deep Vein Thrombosis (DVT) Expected Physical assessment findings o Asymptomatic o Calf or groin pain o Tenderness o Sudden onset of edema of the extremity o Warmth and Edema o Induration and hardness over the involved blood vessel o Changes in circumferences of right and left calf and thigh over time Localized edema over the affected area o Note: Shortness of breath and chest pain can indicate that the embolus has moved to the legs (Pulmonary Embolism) Nursing Consideration/Nursing Care for DVT and Thrombophlebitis o Encourage ambulation following initiation of anticoagulant therapy. Encourage dorsiflexion/plantar flexion exercises of the foot when in bed. Occasionally elevate the legs above the level of the heart while the client is in bed. (Avoid using a knee gatch or pillow under the knees.) o Administer intermittent or continuous warm moist compresses as prescribed (not cold compresses for DVT) o Do not massage the affected limb. o Provide thigh-high compression or anti-embolism stockings. o Prepare the client for an inferior vena cava interruption surgery (a filter traps emboli and prevents them from reaching the heart) as indicated. o Maintain client on bedrest Rationale: to prevent dislodging the clot Ostomies: Main types of ostomies performed in the abdominal area Ileostomy = A surgical opening into the ileum to drain stool, which is typically frequent and liquid because large intestine is bypassed o Indication of Ileostomy when the entire colon must be removed due to disease (Crohn’s disease, ulcerative colitis).
Colostomy = A surgical opening into the large intestine to drain stool, with the ascending colon producing more liquid stools, the transverse colon producing more formed stools, and the sigmoid colon producing near-normal stool o Indication of Colostomy When a portion of the bowel must be removed (cancer, ischemic injury) or requires rest for healing (diverticulitis, trauma). Post-procedure Nursing Consideration for Ostomies Nursing Actions for Ostomies o Assess the type and fit of the ostomy appliance. Monitor for leakage (risk to skin integrity). Fit the ostomy appliance based on the following. Type and location of the ostomy Visual acuity and manual dexterity of the client o Assess peristomal skin integrity and appearance of the stoma. The stoma should appear pink and moist. o Apply skin barriers and creams (adhesive paste) to peristomal skin and allow to dry before applying a new appliance. o Evaluate stoma output. Output should be more liquid and more acidic the closer the ostomy is to the proximal small intestine. o Empty the ostomy bag when it is one-third to one-half full of drainage. o Assess for fluid and electrolyte imbalances, particularly with a new ileostomy. o Evaluate ability of the client or support person to perform ostomy care. Client Education for Ostomies o Follow instructions regarding dietary changes and use ostomy appliances that can help manage flatus and odor. Foods that can cause odor include fish, eggs, asparagus, garlic, beans, and dark green leafy vegetables. Buttermilk, cranberry juice, parsley, and yogurt help to decrease odor. Foods that can cause gas include dark green leafy vegetables, beer, carbonated beverages, dairy products, and corn. Chewing gum, skipping meals, and smoking can also cause gas. Yogurt, crackers, and toast can be ingested to decrease gas. After an ostomy involving the small intestine is placed, avoid high-fiber foods for the first 2 months after surgery, chew food well, increase fluid intake, and evaluate for evidence of blockage when slowly adding high- fiber foods to the diet. Proper appliance fit and maintenance prevent odor when pouch is not open. Filters, deodorizers, or a breath mint can be placed in the pouch to minimize odor while the pouch is open. o Discuss feelings about the ostomy and concerns about its effect on life. Look at and touch the stoma. o Consider joining a local ostomy support group.
