MEDICAL SURGICAL MEDICAL SURGICAL NURSING 1NURSING 1This is a self-guided learning.Just read the This is a self-guided learning.Just read the bullets and try to remember and understand the bullets and try to remember and understand the concepts. Take your time reading.You dont need concepts. Take your time reading.You dont need to copy, JUST R!" and trust that youll to copy, JUST R!" and trust that youll assimilate the content of this learning process#assimilate the content of this learning process#RESPIRATORY RESPIRATORY SYSTEMSYSTEMSealing off the insertion site with an ol!si"e #ressing ta$es to% %riorit& when a hest t!'e 'eo(es #islo#ge) This %re"ents air fro( reentering the %le!ral s%ae thro!gh the o%ening in the hest wall) After the insertion site is seale# off* the #otor sho!l# 'e notifie# so that a new hest t!'e an 'e inserte#) Plaing the %atient on his si#e wo!l#n+t hel% hi( at this ti(e) The %atient sho!l# %erfor( "alsal"a+s (ane!"er to %re"ent air e('ol!s when aentral "eno!s atheter a% isre%lae#)D!ring 'ronhoso%&* the gag an# o!gh refle,es are s!%%resse# '& an anestheti agent to allow %assage of the 'ronhoso%e) This lea"es the %atient at ris$ for as%iration !ntil these refle,es ret!rn) The %atient (a& also 'e an,io!s* e,%eriene %ain* or 'e at ris$ for in-!r&* '!t airwa& (aintenane (!st alwa&s ta$e to%%riorit&)The n!rse sho!l# tell the %atient to 'low into a %a%er 'ag an# reinhale CO. to sto% the h&%er"entilation) The %atient sho!l# also 'e eno!rage# to ta$e slow e"en 'reaths when feeling an,io!s) Eno!rage the %atient to e,%ress her feelings an# hel% her wor$ thro!gh her an,iet&) If the %atient is e,tre(el& an,io!s* a se#ati"e (a& 'e nee#e#) The %atient sho!l# 'e instr!te# to a"oi# washing off the (ar$s %lae# on s$in to g!i#e ra#iation thera%&) If the (ar$s are washe# off* the %atient (!st reassesses an# the (ar$s rea%%lie#/ a ti(e/ons!(ing tas$) S$in lotions an# %ow#ers are ontrain#iate# 'ea!se the& (a& irritate the s$in in the irra#iate# area) The %atient sho!l# a"oi# wearing onstriti"e lothing* whih #erease ir!lation) Massaging an area alrea#& ten#er fro( ra#iation an a!se irritation an# %ain)P!lse Gra#ingA 10 %!lse in#iates wea$ %!lses an# is assoiate# with #i(inishe# %erf!sion)A 10 %!lse is 'o!n#ing %erf!sion* a 20 is inrease# %erf!sion* a .0 is nor(al %erf!sion* an# 3is a'sent %erf!sion)An ECG is a nonin"asi"e test that #etets nor(al an# a'nor(al heart rh&th(s) A 4olter (onitor ontin!o!sl& reor#s the heart+s eletrial ati"it& for .1 ho!rs) Car#ia atheteri5ation is a fl!oroso%i e,a(ination of intraar#ia str!t!res) An ehoar#iogra( is a test !ses ehoes fro( so!n# wa"es to "is!ali5e intraar#ia str!t!res)6entri!lar fi'rillation is the a!se of ar#ia arrest in 738 to 938 of a#!lts who ha"en+t s!ffere# tra!(a) The $e& to s!r"i"al is earl& #efi'rillation an# %ro(%t CPR) :irst #eter(ine if the %atient is !nres%onsi"e) Then all the EMS* who an %ro"i#e earl& #efi'rillation) ;hile waiting for EMS %ersonnel* initiate CPR)CPRThe reo((en#e# #e%th of hest o(%ressions for an a#!lt is 1 ho!rs after onset of hest %ain) Pea$ with in 1. to 17 ho!rs ret!rn to nor(al within 2 to 1 #a&s)ANGINAPrin5(etal+s or "ariant angina is triggere# '& oronar& arter& s%as() Unsta'le angina is triggere# '& !n%re#ita'le a(o!nt of ati"it&) sta'le angina is triggere# '& ati"ities that inrease (&oar#ial o,&gen#e(an#)Stages of 4&%ertensionStage 1 is 113 to 1A9B93 to 99 ((4g)stage . is 1>3 to 1C9B133 to 139 ((4g)stage 2 is 173 to .39B113 to 119 ((4g) stage 1 is greater than or eD!al to .13B1.3 ((4g):!rose(i#e re#!es ir!lating 'loo# "ol!(e* whih #ereases the heart+s wor$ loa# an# lowers 'loo# %ress!re) :!rose(i#e #oesn+t 'lo$ the s&(%atheti ner"o!s s&ste(* a!se %eri%heral "aso#ilation* or 'lo$ renin angiotensinon"ersion)Arterial 'aroree%tors* whih (onitor arterial %ress!re* are fo!n# in the left "entri!lar wall* aroti# sin!s* an# aorta) None e,ist in the right "entri!lar wall* #orsalis %e#is arter&* or o((on iliaarter&) Se"erel& ele"ate# 'loo# %ress!re #a(ages the inti(a of s(all "essels* res!lting in fi'rin a!(!lation in the "essels* #e"elo%(ent of loal e#e(a* an# %ossi'l& intra"as!lar lothing) Therefore* ere'ro"as!lar ai#ent (a& o!r when a lot s!##enl& i(%airs ere'ral ir!lation in one or (ore 'loo# "essels s!%%l&ing the 'rain) 6iral (eningitis is infla((ation of the (eninges fro( a "iral infetion) A (&oloni sei5!re is a!se# '& an eletrial a'nor(alit& in the 'rain a!sing 'rief in"ol!ntar& (!sle -er$s of the 'o#& or e,tre(ities) Stat!s e%ile%ti!s is aontin!o!s sei5!re state) In Ra&na!#+s #isease e%iso#i "asos%as( o!rs in the s(all %eri%heral arteries an# arterioles* res!lting in &anosis an# n!('ness in the e,tre(ities when the %atient is e,%ose# to ol# or stress) @!erger+s #isease* seg(ental lesions an# thro('!s %ro#!e inter(ittent la!#iation of the inste%) Thro('o%hle'itis is infla((ation an# thro('!s for(ation in a "ein) MEniFre+s #isease is an inner ear #isor#er)$eurosensory $eurosensory SystemSystem4ea#ahe an# %ro-etile "o(iting are earl& signs of inrease# ICP) Dereases s&stoli 'loo# %ress!re* !nonsio!sness* an# #ilate# %!%ils that #on+t reat to light are onsi#ere# late signs) I((e#iate 'e# rest is neessar& to %re"ent f!rther in-!r&) @oth e&es sho!l# 'e %athe# to a"oi# onsens!al e&e (o"e(ent an# the %atient sho!l# reei"e earl& referral to an o%hthal(ologist) If the (a!la is attahe# an# entral "is!al a!it& is nor(al* an o%hthal(ologist sho!l# treat the on#ition i((e#iatel&) Retinal reattah(ent an 'e ao(%lishe# '& s!rger& onl&) If the (a!la is #etahe# or threatene#*s!rger& is !rgentG %rolonge##etah(ent of the (a!la res!lts in%er(anent loss of entral "ision)Retinal #etah(entMeningitisPositi"e @r!#5ins$i+s sign an# ?ernig+s sign are the are two lassi signsof (eningeal irritation that is %resent with (eningitis) @ri#5ins$i+s an# $ernig+s signs #on+t o!r in C6A* sei5!re #isor#er* or Par$inson+s #isease)Paral&sis Glo'al a%hasia o!rs when all lang!age f!ntions are affete#) Ree%ti"e a%hasia* also $nown as ;erni$e+s a%hasia* affets the a'ilit& to o(%rehen# written or s%o$en wor#s) E,%ressi"e a%hasia* also $nown as @roa+s a%hasia* affets the %atient+s a'ilit& to for( lang!age an# e,%ress tho!ghts) Con#!tion a%hasia refers to a'nor(alities in s%eeh re%etition)Patients with a histor& of hea#ahes* es%eiall& (igraines* sho!l# 'e ta!ght to $ee% a foo# #iar& to i#entif& %otential foo# triggers) T&%ial hea#ahe triggers inl!#eH alohol age# heese %roesse# (eats hoolate affeine/ontaining %ro#!ts In #eere'rate res%onse* or %ost!ring* a %ainf!l sti(!l!s a!ses teeth to 'e lenhe#H ar(s stiffl& e,ten#e#* a##!te#* an# h&%er%ronate#G an# legs stiffl& e,ten#e# with %lantar fle,ion of the feet) Deortiate %ost!ring shows fle,ion of the ar(* wrist* an# fingers with a##!tion of the ar( while the legs e,hi'it e,tension* internal rotation* an# %lantar fle,ion) Toni loni ati"it& is (ar$e# '& rh&th(i -er$ing rela,ation of the (!sles #!ring generali5e# sei5!re ati"it&) Athetosis is irreg!lar* slow* sna$eli$e (!s!lar (o"e(ents)The Glasgow o(a sale e"al!ates the %atient+s 'est e&e/o%ening* 'est "er'al an# 'est (otor res%onses)The o((on a#"erse effet of Phen&toin is gingi"al h&%er%lasia) Other a#"erse effets (a& inl!#e onsti%ation an# #rowsiness) Phen&toin #oesn+t affet olor "ision) The %atient with 'rain in-!r& is e,hi'iting signs an# s&(%to(s of s&n#ro(e of ina%%ro%riate anti#i!reti hor(one ISIAD4J #!e to his hea# in-!r&) 4&%ertoni fl!i#s sho!l# 'e a#(inistere# to orret the assoiate# h&%onatre(ia) Classi signs of #ia'etes insi%i#!s inl!#eH !rine o!t%!t greater than 233 (lBhr for 2 onse!ti"e ho!rs) An# a low s%eifi gra"it&) Irrigation of the in#welling !rinar& atheter won+t orret the low !rine o!t%!t 'ea!se the s&(%to(s are relate# to a hor(onal %ro'le( not a atheter 'lo$age) :l!i# a#(inistration sho!l# 'e li(ite# in the %atient with SIAD4)Classi signs of frontal lo'e 'rain t!(or inl!#e %ersonalit& hanges* ina%%ro%riate 'eha"ior* an# sei5!res) oi%ital lo'e affet "ision* ere'ellar t!(ors gait)'rain ste( t!(ors affet heart f!ntion an# 'reathing)The hea# of the %atient+s 'e# is ele"ate# to failitate "eno!s ret!rn fro( the 'rain* whih #erease intraranial %ress!re) Maintaining the %atient in the se(i/fowler %osition with the hea# of her 'e# at 23 #egrees #oesn+t inrease ir!lating 'loo# "ol!(e to the 'rain* (aintain a%atent airwa&* or %re"ent%!l(onar& ongestion)4o(on&(o!s he(iano%sia is loss of one/half of the "is!al fiel# in 'oth e&es Ieither the right half or left halfJ) To o(%ensate* the %atient (!st 'e ta!ght to san his "is!al fiel# t!rning the hea# 'a$ an# forth) A%%roahing the %atient on the left si#e won+t 'e effeti"e 'ea!se the "ision loss is in 'oth e&es) 4o(on&(o!s he(iano%sia #oesn+t affet hearing or swallowingOf the #iagnose# with G!illain/@arrE s&n#ro(e* >38 to C38 ha"e e,%eriene an !%%er res%irator& or GI "iral infetion 1 to 1 wee$s 'efore the onset of s&(%to(s) G!illain/@arrE s&n#ro(e isn+t here#itar& or relate# to e,%os!re to foreign tra"el) It #oesn+t+ affet the lothing asa#e)G!illain/@arrE s&n#ro(e res!lts fro( seg(ental loss of (&elin along the %eri%heral ner"e a,on) Asen#ing flai# (otor %aral&sis is the (ost o((on %resenting sign) This s&n#ro(e #oesn+t affet le"el of onsio!sness or %!%il reati"it& or a!se #isorientation with ina%%ro%riate 'eha"ior)Gastrointestinal S&ste(Inrease %ress!re within the %ortal "eins a!ses eso%hageal "aries to '!lge* lea#ing to r!%t!re an# 'lee#ing into the lower eso%hag!s) @lee#ing assoiate# with eso%hageal "aries #oesn+t ste( fro( eso%hageal %erforation* %!l(onar& h&%ertension* or %e%ti !lers)Diarrhea a!ses the 'o#& to lose 'iar'onate whih (a& a!se (eta'oli ai#osis) Res%irator& ai#osis is a!se# '& al"eolar h&%o"entilation) Car'oni ai# e,ess o!rs with res%irator& al$alosis) 6o(iting sho!l# lea# to (eta'oli al$alosis)Pain in the e%igastri area is assoiate# with gastri !ler #isease) Pain 'elow or at the !('ili!s is assoiate# with a%%en#iitis) A'#o(inal %ain that o!rs after a high fat (eal is assoiate# with hole&stitis)K S!ralfate %rotet the !ler+s s!rfae '& for(ing a 'arrier so healing an ta$e %lae) @lee#ing isn+t ro!tinel& %resent with %e%ti !ler #isease) K 4ista(ine 'lo$ers* s!h as i(eti#ine ITaga(etJ* :a(oti#ine IPe%i#J* Raniti#ine ILantaJ* an# Ni5ati#ine IA,i#J* inhi'it the ation of hista(ine at the ree%tor sites of %arietal ells* #ereasing gastri ai# seretion)KProton %!(% inhi'itors s!h as lanso%ra5ole I%re"ai#J an# O(e%ra5ole IPriloseJ* inhi'it the ati"it& of theai# IProtonJ %!(% to 'lo$ the for(ation of gastri ai#)A "agoto(&M re#!es the %ro#!tion of sto(ah ai# '& #ereasing holinergi sti(!lation of %arietal ells) reates gastri stasis an# re#!es gastri e(%t&ing) won+t regenerate gastri (!osa or sto% stress/relate# reations) Sign an# s&(%to(s assoiate# with #!(%ing s&n#ro(e o!r A to 23 (in!tes after eating an# inl!#e #ia%horesis* tah&ar#ia* s&no%e* %allor* "ertigo* #iarrhea* na!sea* a'#o(inal ra(%ing an# a'#o(inal #istension) S&(%to(s !s!all& s!'si#e in > to 1. (onths) In #!(%ing s&n#ro(e* large a(o!nts of h&(e ra%i#l& enter the s(all intestine* a!sing the assoiate# "aso(otor s&(%to(s of #ia%horesisan# tah&ar#ia)The %atient with %eritonitis is at ris$ for #e"elo%ing se%tie(ia* whih* !ntreate#* an lea# to se%ti sho$ an# #eath) The %atient #e"elo%s a fl!i# #efiit fro( the fl!i# shift that o!rs* whih #e%letes ir!lating 'loo# "ol!(e) Peritonitis inhi'its%eristalsis '!t #oesn+t a!se #iarrhea)Re'o!n# ten#erness in the right lower D!a#rant of the a'#o(en is a lassi sign of a%%en#iitis) Urinar& retention (a& 'e %resent '!t isn+t a!se# '& a%%en#iitis) Pain inreases when the %atient with a%%en#iitis a('!lates* infla((ation assoiate# with a%%en#iitis a!ses 'owelati"it& to #erease)Di"erti!litis o!rs when retaine# !n#igeste# foo# (i,e# with 'aterial a!(!lates in the #i"erti!l!( Io!t/%o!hing in the intestineJ* for(ing a har# (ass of feal (atter) The (ass !ts off 'loo# s!%%l& to the #i"erti!l!(+s thin walls inreasing its s!se%ti'ilit& to atta$ '& oloni'ateria) Infla((ation follows 'aterial infetion) If the #i"erti!l!( %erforates* %eritonitis #e"elo%s) Peritonitis also #e"elo%s as a res!lt of a%%en#i, r!%t!re) A %eritoneal la"age o!l# %lae the %atient at ris$ for %eritonitis* '!t it #oesn+t a!se #i"erti!litis) Cra(%&* left lower D!a#rant %ain an# a low/gra#e fe"er are o((on s&(%to(s of #i"erti!litis) The %atient with #i"erti!litis (a& ha"e so(e retal 'lee#ing with 'o!t of onsti%ation* '!t 'lee#ing isn+t e,essi"e) E%igastri %ain that ra#iates to the 'a$* h&%otension* an# tah&ar#ia are assoiate# with %anreatitis) Na!sea* "o(iting* right lower D!a#rant %ain* an# fe"er areassoiate# witha%%en#iitis) Ps&lli!( is a '!l$ for(ing la,ati"e that a'sor's water an# e,%an#s to inrease '!l$ an# (oist!re ontent of stool* th!s eno!raging %eristalsis an# 'owel (o"e(ent)Mineral oil Ifleet (ineral oilJ is an e,a(%le of a l!'riant la,ati"e) It wor$s '& inreasing water retention in the stool '& reating a 'arrier 'etween the olon wall an# fees that %re"ents olonirea'sor%tion of fealwater* Do!sate So#i!( IolaeJ is an e,a(%le of a stool softener* an# it wor$s '& re#!ing s!rfae tension of interfaing liD!i# ontents of the 'owel) This #etergent ati"it& %ro(otes inor%oration of a##itional liD!i# into the stool* th!s for(ing a softer (ass) Castor oil Ie(!lsoilJ is a sti(!lant la,ati"e that inreases %eristalsis %ro'a'l& '& #iret affet on thes(ooth (!sle of theintestine)Crohn+s #isease an o!r an&where in the GI trat* '!t it !s!all& o!rs in the #istal ile!() Crohn+s #isease affets the f!ll thi$ness of the 'owel wall) Ulerati"e olitis affets the ret!( an# olon* en#ing at the ileoeal -!ntion) :ist!las are a o(%liation of Crohn+s #isease)The %atient sho!l# e(%t& the olosto(& 'ag whene"er it+s a'o!t one/thir# f!ll) If the 'ag is allowe# to get too f!ll* it (a& a!se the a%%liane to se%arate fro( the s$in an# a!se lea$age) The 'ag (a& nee# to 'e e(%tie# (ore than three ti(es a #a&) The %atient sho!l# 'e eno!rage# to (anage her olosto(& herself if she+s %h&siall& a'le) An ing!inal hernia is loate# in the groin area is a!se# '& a wea$ness in the o%ening in the a'#o(inal wall where the "as #eferens %asse# thro!gh the a'#o(inal wall) A hernia that o!rs at the site of a %re"io!s s!rgial %roe#!re is a "entral hernia) A wea$ness or #efet in the ret!s a'#o(inis is an !('ilial hernia) Ing!inal hernias o!r three ti(es (ore o((onl& in (en than wo(en) Celia #isease is a here#itar& #isor#er in whih the %erson is sensiti"e to gl!ten an# therefore annot tolerate foo#s that ontain %arel& R&e &ats 'heat Mil$ %ro#!ts* fresh fr!its* an# "egeta'les an 'e eaten '& a %atient with elia #isease) @ea!se elia #isease #estro&s the a'sor'ing s!rfae of the intestine* fat isn+t a'sor'e# '!t is %asse# in the stool) Steatorhea is '!l$&* fatt& stools that ha"e a fo!l o#or) Na!n#ie# slearae res!lt fro( ele"ate# @ilir!'in le"els) Cla&/olore# stools are seen with 'iliar& #isease when 'ile flow is 'lo$e#)Celia #isease #oesn+t a!se a wi#ene# %!lse %ress!re A h&%ertoni sol!tion a!ses water to shift fro( the ell into %las(a 'ea!se the h&%ertoni sol!tion has a greater os(oti %ress!re than the ells) A h&%otoni sol!tion has a lower os(oti %ress!re than that of the ells) It a!ses fl!i# to shift into the ells* %ossi'l& res!lting in r!%t!re) An isotoni sol!tion* whih has the sa(e os(oti %ress!re as the ells* wo!l#n+t a!se an& shift) A sol!tion+s al$alinit& is relate# to the hrogen ion onentration* not its os(oti effet)Tenting of hest s$in when %inhe# in#iates #erease# s$in elastiit& #!e to #ehration) 4an# "eins fill slowl& with #ehration* not ra%i#l&) A %!lse that isn+t easil& o'literate# an# ne$ "ein #istention in#iate fl!i# o"erloa#*not #ehration) A#(inistering ta% water ene(a !ntil ret!rn is lear wo!l# (ost li$el& ontri'!te to a h&%o/os(olar state) @ea!se ta% water is h&%otoni* it wo!l# 'e a'sor'e# '& the 'o#&* #il!ting the 'o#& fl!i# onentration an# lowering os(olarit&) ;eighing the %atient is the easiest* (ost a!rate (etho# to #eter(ine fl!i# hanges) Therefore* it hel%s i#entif& rather than ontri'!te to fl!i# i('alane) Nasogastri t!'e irrigation with nor(al saline sol!tion wo!l#n+t a!se a shift in fl!i# 'alane)Drin$ing 'roth wo!l#n+t ontri'!te to h&%o/os(olar state 'ea!se it #oesn+t re%laeso#i!( an# water lost thro!gh e,essi"e%ers%iration) An orthostati 'loo# %ress!re in#iates e,traell!lar fl!i# "ol!(e #efiit) IThe e,traell!lar o(%art(ent onsists of 'oth the intra"as!lar o(%art(ent an# interstitial s%ae)J A fl!i# "ol!(e #efiit within the intra"as!lar o(%art(ent wo!l# a!se tah&ar#ia* not 'ra#&ar#ia or othostati 'loo# %ress!re hange) A entral "eno!s %ress!re of > ((4g is in the high nor(al range* in#iating a#eD!ate hration) Pitting e#e(a in#iate# fl!i# "ol!(e o"erloa#)END O: T4E END O: T4E @ULLETS@ULLETSCongratulations! You have completed the Nursing Bullets for this learning tool.You are now ready to take the test!!!Each question is followed by the bullet from where youll find the right answer or rationale for the preceding question!1) As the n!rse hel%+s Mr) Co o!t of 'e#* his hest t!'e 'eo(es #islo#ge an# falls to the floor) ;hih of the following (!st 'e #one firstOa) Positioning the %atient on the si#e where the hest t!'e was %lae#') Reinserting the hest t!'e) Sealing off the insertion site#) 4a"ing the %atient %erfor( 6alsal"a (ane!"er) Sealing off the insertion siteSealing off the insertion site with an ol!si"e #ressing ta$es to% %riorit& when a hest t!'e 'eo(es #islo#ge) This %re"ents air fro( reentering the %le!ral s%ae thro!gh the o%ening in the hest wall) After the insertion site is seale# off* the #otor sho!l# 'e notifie# so that a new hest t!'e an 'e inserte#) Plaing the %atient on his si#e wo!l#n+t hel% hi( at this ti(e) The %atient sho!l# %erfor( "alsal"a+s (ane!"er to %re"ent air e('ol!s when a entral "eno!s atheter a% is re%lae#).) The n!rse aring for Ms) T!ason i((e#iatel& following her 'ronhoso%&) ;hih of the following #iagnoses sho!l# reei"e %riorit&Oa) Pain relate# to throat irritation') Ris$ for as%iration relate# to gag refle, s!%%ression) Ris$ for in-!r& relate# to restraint !se #!ring the %roe#!re#) An,iet& relate# to %ossi'le #iagnosis') Ris$ for as%iration relate# to gag refle, s!%%ressionD!ring 'ronhoso%&* the gag an# o!gh refle,es are s!%%resse# '& an anestheti agent to allow %assage of the 'ronhoso%e) This lea"es the %atient at ris$ for as%iration !ntil these refle,es ret!rn) The %atient (a& also 'e an,io!s* e,%eriene %ain* or 'e at ris$ for in-!r&* '!t airwa& (aintenane (!st alwa&s ta$e to%%riorit&)2) Ms) @!( has a'nor(all& #ee%* gas%ing res%irations) This 'reathing %attern is $nown asHa) @ra#&%nea') Che&ne/sto$es res%irations) @iot+s res%irations#) ?!ss(a!l+s res%irations#) ?!ss(a!l+s res%irationsThe n!rse sho!l# tell the %atient to 'low into a %a%er 'ag an# reinhale CO. to sto% the h&%er"entilation) The %atient sho!l# also 'e eno!rage# to ta$e slow e"en 'reaths when feeling an,io!s) Eno!rage the %atient to e,%ress her feelings an# hel% her wor$ thro!gh her an,iet&) If the %atient is e,tre(el& an,io!s* a se#ati"e (a& 'e nee#e#)1) Mr) 4owar# reD!ires ra#iation thera%& on an o!t %atient 'asis to treat the aner) ;hen teahing Mr) 4owar# a'o!t s$in are* the n!rse sho!l# eno!rage hi( toHa) Use s$in lotions an# %ow#ers on the irra#iate# area') A"oi# washing off the (ar$s %lae on his s$in to g!i#e ra#iation thera%&) ;ear onstriti"e lothing#) Massage the irra#iate# area to inrease ir!lation') A"oi# washing off the (ar$s %lae on his s$in to g!i#e ra#iation thera%&The %atient sho!l# 'e instr!te# to a"oi# washing off the (ar$s %lae# on s$in to g!i#e ra#iation thera%&) If the (ar$s are washe# off* the %atient (!st reassesses an# the (ar$s rea%%lie#/ a ti(e/ons!(ing tas$) S$in lotions an# %ow#ers are ontrain#iate# 'ea!se the& (a& irritate the s$in in the irra#iate# area) The %atient sho!l# a"oi# wearing onstriti"e lothing* whih #ereaseir!lation) Massaging an areaalrea#& ten#er fro( ra#iation an a!se irritation an# %ain)(ardio)ascular SystemA) The n!rse is %erfor(ing her a#(ission assess(ent of a %atient) ;hen gra#ing arterial %!lses* a 10 %!lse in#iatesHa) A'o"e nor(al %erf!sion') A'sent %erf!sion) Nor(al %erf!sion#) Di(inishe# %erf!sion#) Di(inishe# %erf!sionA 10 %!lse in#iates wea$ %!lses an# is assoiate# with #i(inishe# %erf!sion) A 10 %!lse is 'o!n#ing %erf!sion* a 20 is inrease# %erf!sion* a .0 is nor(al %erf!sion* an# 3 is a'sent %erf!sion)>) The #otor or#ers %reli(inar& test to hel% assess Mr) Sawer+s on#ition) The #iagnosti test that #e%is a gra%hial re%resentation of the hearts eletrial ati"it& is alle#Ha) A 4olter (onitor') A ar#ia atheteri5ation) An ehoar#iogra(#) An eletroar#iogra( IECGJ#) An eletroar#iogra( IECGJAn ECG is a nonin"asi"e test that #etets nor(al an# a'nor(al heart rh&th(s) A 4olter (onitor ontin!o!sl& reor#s the heart+s eletrial ati"it& for .1 ho!rs) Car#ia atheteri5ation is a fl!oroso%i e,a(ination of intraar#ia str!t!res) An ehoar#iogra( is a test !ses ehoes fro( so!n# wa"es to "is!ali5e intraar#ai str!t!res)Sit!ationH N!an Dela Cr!5* age >A* is stan#ing at the '!s sto% with his #a!ghter when he s!##enl& groans an# olla%ses)C) The n!rse is wal$ing #own the streets when she hears Mr) Dela Cr!5 #a!ghter srea(ing for hel%) 4ow sho!l# the n!rse inter"eneOa) She sho!l# #eter(ine if the "iti( is !nres%onsi"e* s!((on e(ergen& (e#ial ser"ies IEMSJ* an# initiate ar#io%!l(onar& res!sitation ICPRJ in the interi()') She sho!l# %ro"i#e efforts for 1 (in!te* then ati"ate the EMS s&ste() She sho!l# assess the "iti(+s %!lse an# 'reathing* o%en his airwa&* an# ati"ate the EMS#) She sho!l# o%en the "iti(+s airwa&* assess his 'reathing* %ro"i#e res!e 'reathing* assess his %!lse* an# then ati"ate EMS)a) She sho!l# #eter(ine if the "iti( is !nres%onsi"e* s!((on e(ergen& (e#ial ser"ies IEMSJ* an# initiate ar#io%!l(onar& res!sitation ICPRJ in the interi() 6entri!lar fi'rillation is the a!se of ar#ia arrest in 738 to 938 of a#!lts who ha"en+t s!ffere# tra!(a) The $e& to s!r"i"al is earl& #efi'rillation an# %ro(%t CPR) :irst #eter(ine if the %atient is !nres%onsi"e) Then all the EMS* who an %ro"i#e earl& #efi'rillation) ;hile waiting for EMS%ersonnel* initiate CPR)7) The n!rse tells so(eone to all for an a('!lane an# re%ort a ar#ia arrest while she 'egins ar#io%!l(onar& res!sitation) 4ow #ee%l& sho!l# the n!rse a%%l& o(%ressions to the lower stern!( on this %atientOa) 1= to .= I.)A to A (J') 1 7B137 ((4gG whih stage of h&%ertension is thisOa) Stage 1 I(il#J') Stage . I(o#erateJ) Stage 2 I se"ereJ#) Stage 1 I"er& se"ereJ') Stage . I(o#erateJStage 1 is 113 to 1A9B93 to 99 ((4g)stage . is 1>3 to 1C9B133 to 139 ((4g)stage 2 is 173 to .39B113 to 119 ((4g) stage 1 is greater than or eD!al to .13B1.3 ((4g)12) ?!rt+s #a!ghter arri"e# at thehos%ital an# state# that her :ather ta$es a Q;ater %ill= for high 'loo# %ress!re) The #otor or#ers f!rose(i#e ILasi,J for Mr) ?!rt) 4er #a!ghter as$s the n!rse how f!rose(i#e lowers 'loo# %ress!re) The n!rse+s 'est res%onse wo!l# 'e that f!rose(i#e re#!es the heart+s wor$loa# '&Ha) Re#!ing the ir!lating 'loo# "ol!(e') @lo$ing the s&(%atheti ner"o!s s&ste() Ating as a %eri%heral "aso#ilator#) @lo$ing rennin angiotensin on"ersiona) Re#!ing the ir!lating 'loo# "ol!(e:!rose(i#e re#!es ir!lating 'loo# "ol!(e* whih #ereases the heart+s wor$ loa# an# lowers 'loo# %ress!re) :!rose(i#e #oesn+t 'lo$ the s&(%atheti ner"o!s s&ste(* a!se %eri%heral "aso#ilation* or 'lo$ renin angiotensin on"ersion)11) ;hen teahing Mr) Lan#o a'o!t the %atho%h&siolog& of h&%ertension* the n!rse states that arterial 'aroree%tors are fo!n# in the aroti# sin!s an# aorta) Arterial 'aroree%tors are also fo!n# in theHa) Left "entri!lar wall') Right "entri!lar wall) Dorsalis %e#is arter) Co((on ilia arter&a) Left "entri!lar wallArterial 'aroree%tors* whih (onitor arterial %ress!re* are fo!n# in the left "entri!lar wall* aroti# sin!s* an# aorta) None e,ist in the right "entri!lar wall* #orsalis %e#is arter&* or o((on ilia arter&)1A) Mr) Ni( is #iagnose# with (alignant h&%ertension) The n!rse $nows that he sho!l# 'e ta!ght a'o!t the o(%liations of !ntreate# h&%ertension* s!h asHa) 6iral (eningitis') M&oloni sei5!re) Cere'ro"as!lar ai#ent#) Stat!s e%ile%ti!s) Cere'ro"as!lar ai#entSe"erel& ele"ate# 'loo# %ress!re #a(ages the inti(a of s(all "essels* res!lting in fi'rin a!(!lation in the "essels* #e"elo%(ent of loal e#e(a* an# %ossi'l& intra"as!lar lothing) Therefore* ere'ro"as!lar ai#ent (a& o!r when a lot s!##enl& i(%airs ere'ral ir!lation in one or (ore 'loo# "essels s!%%l&ing the 'rain) 6iral (eningitis is infla((ation of the (eninges fro( a "iral infetion) A (&oloni sei5!re is a!se# '& an eletrial a'nor(alit& in the 'rain a!sing 'rief in"ol!ntar& (!sle -er$s of the 'o#& or e,tre(ities) Stat!s e%ile%ti!s is a ontin!o!s sei5!re state)1>) Mrs) Issa* age 21* is a#(itte# with s&ste(i l!%!s er&the(atos!s) She tells the n!rse #!ring a ro!tine e,a(ination that her fingers 'eo(e &anoti an# n!(' when it+s ol# o!tsi#e) She is (ost li$el& to 'e s!ffering fro( whih of the following #isor#ersOa) @!erger+s #isease') Ra&n!a#+s #isease) Thro(o%hle'itis #) MEniFre+s #isease') Ra&n!a#+s #isease In Ra&na!#+s #isease e%iso#i "asos%as( o!rs in the s(all %eri%heral arteries an# arterioles* res!lting in &anosis an# n!('ness in the e,tre(ities when the %atient is e,%ose# to ol# or stress) @!erger+s #isease* seg(ental lesions an# thro('!s %ro#!e inter(ittent la!#iation of the inste%) Thro('o%hle'itis is infla((ation an# thro('!s for(ation in a "ein) MEniFre+s #isease is an inner ear #isor#er)$eurosensory System 1C) The n!rse teahing fa(il& (e('ers of a %atient with a on!ssion a'o!t the earl& signs of inrease# intra ranial %ress!re IICPJ) ;hih of the following wo!l# she ite as an earl& sign of inrease# ICPOa) Dereases s&stoli 'loo# %ress!re') 4ea#ahe an# "o(iting) Ina'ilit& to wa$e the %atient with no,io!s sti(!li#) Dilate# %!%ils that #on+t reat to light') 4ea#ahe an# "o(iting4ea#ahe an# %ro-etile "o(iting are earl& signs of inrease# ICP) Dereases s&stoli 'loo# %ress!re* !nonsio!sness* an# #ilate# %!%ils that #on+t reat to light are onsi#ere# latesigns)17) Gar& is #iagnose# with retinal #etah(ent) ;hih inter"ention is the (ost i(%ortant for this %atientOa) A#(itting hi( to the hos%ital on strit 'e# rest') Pathing 'oth of his e&es) Referring hi( to an o%hthal(ologist#) Pre%aring hi( for s!rger&a) A#(itting hi( to the hos%ital on strit 'e# rest I((e#iate 'e# rest is neessar& to %re"ent f!rther in-!r&) @oth e&es sho!l# 'e %athe# to a"oi# onsens!al e&e (o"e(ent an# the %atient sho!l# reei"e earl& referral to an o%hthal(ologist) If the (a!la is attahe# an# entral "is!al a!it& is nor(al* an o%hthal(ologist sho!l# treat the on#ition i((e#iatel&) Retinal reattah(ent an 'e ao(%lishe# '& s!rger& onl&) If the (a!la is #etahe# or threatene#*s!rger& is !rgentG %rolonge##etah(ent of the (a!la res!lts in%er(anent loss of entral "ision)19) The n!rse is assessing a %atient an# notes a @r!#5ins$i+s sign an# ?ernig+s sign) These are two lassi signs of whih of the following #isor#ersOa) Cere'ro"as!lar ai#ent IC6AJ') Meningitis) Sei5!re #isor#er#) Par$inson+s #isease') MeningitisPositi"e @r!#5ins$i+s sign an# ?ernig+s sign are the are two lassi signsof (eningeal irritation that is %resent with (eningitis) @ri#5ins$i+s an# $ernig+s signs #on+t o!r in C6A* sei5!re #isor#er* or Par$inson+s #isease).3) Nas(ine s!ffere# a ere'ro"as!lar ai#ent that left her !na'le to o(%rehen# s%eeh an# !na'le to s%ea$) This t&%e of a%hasia is $nown asHa) Ree%ti"e a%hasia') E,%ressi"e a%hasia) Glo'al a%hasia#) on#!tion a%hasia) Glo'al a%hasia Glo'al a%hasia o!rs when all lang!age f!ntions are affete#) Ree%ti"e a%hasia* also $nown as ;erni$e+s a%hasia* affets the a'ilit& to o(%rehen# written or s%o$en wor#s) E,%ressi"e a%hasia* also $nown as @roa+s a%hasia* affets the %atient+s a'ilit& to for( lang!age an# e,%ress tho!ghts) Con#!tion a%hasia refers to a'nor(alities in s%eeh re%etition).1) C&nthia o(%lains that her hea#ahes are o!rring (ore freD!entl& #es%ite ta$ing (e#iations) Patients with a histor& of hea#ahes sho!l# 'e ta!ght to a"oi#Ha) :reshl& %re%are# (eats') Citr!s fr!its) S$i( (il$#) Choolate#) Choolate Patients with a histor& of hea#ahes* es%eiall& (igraines* sho!l# 'e ta!ght to $ee% a foo# #iar& to i#entif& %otential foo# triggers) T&%ial hea#ahe triggers inl!#eH alohol age# heese %roesse# (eats hoolate affeine/ontaining %ro#!ts..) Ms) Ella 6) is o(atose* '!t when %ainf!l sti(!li are a%%lie# she e,ten#s a##!ts* an# h&%er%ronates her !%%er e,tre(ities an# has %lantar fle,ion of the feet) This a'nor(al res%onse is ter(e#Ha) Deortiate res%onse') Deere'rate res%onse) Cloni/toni ati"it) Athetosis') Deere'rate res%onse In #eere'rate res%onse* or %ost!ring* a %ainf!l sti(!l!s a!ses teeth to 'e lenhe#H ar(s stiffl& e,ten#e#* a##!te#* an# h&%er%ronate#G an# legs stiffl& e,ten#e# with %lantar fle,ion of the feet) Deortiate %ost!ring shows fle,ion of the ar(* wrist* an# fingers with a##!tion of the ar( while the legs e,hi'it e,tension* internal rotation* an# %lantar fle,ion) Toni loni ati"it& is (ar$e# '& rh&th(i -er$ing rela,ation of the (!sles #!ring generali5e# sei5!re ati"it&) Athetosis is irreg!lar* slow* sna$eli$e (!s!lar (o"e(ents).2) The Glasgow Co(a sale is !se# to assess Ms) Ella 6)+s le"el of onsio!sness) This tool e"al!atesHa) 6er'al* sensation* an# (otor res%onses') E&e* (otor* an# "er'al res%onses)) 6er'al* %ain* an# refle, res%onses#) E&e* %ain* an# "er'al res%onses ') E&e* (otor* an# "er'al res%onses)The Glasgow o(a sale e"al!ates the %atient+s 'est e&e/o%ening* 'est "er'al an# 'est (otor res%onses).1) Mr) Tho(as was starte# on Phen&toin IDilantinJ to hel% %re"ent sei5!res* whih an 'e a o(%liation after hea# in-!r&) ;hih of the following o((on a#"erse effet of the #r!gOa) Diarrhea') 4&%eralertness) Loss of olor "ision#) Gingi"al h&%er%lasia#) Gingi"al h&%er%lasiaThe o((on a#"erse effet of Phen&toin is gingi"al h&%er%lasia) Other a#"erse effets (a& inl!#e onsti%ation an# #rowsiness) Phen&toin #oesn+t affet olor "ision).A) Mr) Peters is o(atose) 4e is 'eing treate# for se"ere 'rain in-!r& that he s!staine# fro( an assa!lt while wal$ing his #og) 4is !rine o!t%!t is less than 23 (lBho!r* his !rine s%eifi gra"it& is 1)3.9* an# his ser!( so#i!( is 1.3(EDBL) the n!rse sho!l# e,%et toHa) Inrease his fl!i# inta$e') Contin!e to (onitor the %atient) A#(inister h&%ertoni fl!i#s#) Irrigate in#welling atheter an# inrease the I)6) inf!sion rate)) A#(inister h&%ertoni fl!i#s The %atient is e,hi'iting signs an# s&(%to(s of s&n#ro(e of ina%%ro%riate anti#i!reti hor(one ISIAD4J #!e to his hea# in-!r&) 4&%ertoni fl!i#s sho!l# 'e a#(inistere# to orret the assoiate# h&%onatre(ia) Classi signs of #ia'etes insi%i#!s inl!#eH !rine o!t%!t greater than 233 (lBhr for 2 onse!ti"e ho!rs) An# a low s%eifi gra"it&) Irrigation of the in#welling !rinar& atheter won+t orret the low !rine o!t%!t 'ea!se the s&(%to(s are relate# to a hor(onal %ro'le( not a atheter 'lo$age) :l!i# a#(inistration sho!l# 'e li(ite# in the %atient with SIAD4).>) @ea!se Ms) Ch!i has a histor& of loali5e# sei5!re an# %ersonalit&an# 'eha"ioral hanges* her 'rain t!(or is (ost li$el& loate# in the a) :rontal lo'e') Oi%ital lo'e) Cere'ell!(#) @rain ste(a) :rontal lo'e Classi signs of frontal lo'e 'rain t!(or inl!#e %ersonalit& hanges* ina%%ro%riate 'eha"ior* an# sei5!res) oi%ital lo'e affet "ision* ere'ellar t!(ors gait)'rain ste( t!(ors affet heart f!ntion an# 'reathing).C) ;hen Ms) Ch!i ret!rns fro( the o%erating roo(* she+s %lae# in the se(i fowlers %osition with the hea# of the 'e# ele"ate# 23 #egrees) This is #one toHa) Inrease the ir!lating "ol!(e of 'loo# to the 'rain') :ailitate "eno!s ret!rn of 'loo# fro( the 'rain) Maintain a %atent airwa) Pre"ent %!l(onar& ongestion') :ailitate "eno!s ret!rn of 'loo# fro( the 'rain The hea# of the %atient+s 'e# is ele"ate# to failitate "eno!s ret!rn fro( the 'rain* whih #erease intraranial %ress!re) Maintaining the %atient in the se(i/fowler %osition with the hea# of her 'e# at 23 #egrees #oesn+t inrease ir!lating 'loo# "ol!(e to the 'rain* (aintain a %atent airwa&* or %re"ent %!l(onar& ongestion).7) Mr) A#a(+s ere'ro"as!lar ai#ent has left hi( with ho(on&(o!s he(iano%sia on the left si#e) ;hen aring for this %atient* the n!rse sho!l# 'e s!re toHa) S%ea$ learl& into his ear') A%%roah hi( on the left si#e) Teah hi( to san "is!al fiel# '& t!rning his hea# 'a$ an# forth#) Teah hi( to hew slowl& an#thoro!ghl& 'efore swallowing) Teah hi( to san "is!al fiel# '& t!rning his hea# 'a$ an# forth 4o(on&(o!s he(iano%sia is loss of one/half of the "is!al fiel# in 'oth e&es Ieither the right half or left halfJ) To o(%ensate* the %atient (!st 'e ta!ght to san his "is!al fiel# t!rning the hea# 'a$ an# forth) A%%roahing the %atient on the left si#e won+t 'e effeti"e 'ea!se the "ision loss is in 'oth e&es) 4o(on&(o!s he(iano%sia #oesn+t affet hearing or swallowing.9) Ms) S!e is #iagnose# with G!illain/'arrE s&n#ro(e* whih of the following D!estions is i(%ortant to inl!#e when assessing Ms) S!eOa) Q4as an&one in &o!r fa(il& e"er ha# G!illain/'arrE s&n#ro(eO=') QDi# &o! ha"e an !%%er res%irator& trat infetion reentl&O=) QDo &o! 'r!ise easil&O=#) Q4a"e &o! 'een o!t of the o!ntr& #!ring the %ast 1 (onthsO=') QDi# &o! ha"e an !%%er res%irator& trat infetion reentl&O= Of the #iagnose# with G!illain/@arrE s&n#ro(e* >38 to C38 ha"e e,%eriene an !%%er res%irator& or GI "iral infetion 1 to 1 wee$s 'efore the onset of s&(%to(s) G!illain/@arrE s&n#ro(e isn+t here#itar& or relate# to e,%os!re to foreign tra"el) It #oesn+t+ affetthe lothing asa#e)23) ;hen assessing Ms) S!e with G!illain/'arrE s&n#ro(e* what harateristis s&(%to(s wo!l# the n!rse e,%et to o'ser"eOa) Deteriorating le"el of onsio!sness ') Dilate# %!%ils* faial n!('ness* an# #&s%hagia) Disorientation with ina%%ro%riate 'eha"ior an# (!sle wea$ness#) Asen#ing flai# (otor %aral&sis#) Asen#ing flai# (otor %aral&sisG!illain/@arrE s&n#ro(e res!lts fro( seg(ental loss of (&elin along the %eri%heral ner"e a,on) Asen#ing flai# (otor %aral&sis is the (ost o((on %resenting sign) This s&n#ro(e #oesn+t affet le"el of onsio!sness or %!%il reati"it& or a!se #isorientation with ina%%ro%riate 'eha"ior)21) ;hen aring for a %atient with eso%hageal "aries* the n!rse $nows that 'lee#ing in this #isor#er !s!all& ste(s fro(a) Eso%hageal %erforation') P!l(onar& h&%ertension) Portal h&%ertension#) Pe%ti !lers) Portal h&%ertension Inrease %ress!re within the %ortal "eins a!ses the( to '!lge* lea#ing to r!%t!re an# 'lee#ing into the lower eso%hag!s) @lee#ing assoiate# with eso%hageal "eries #oesn+t ste( fro( eso%hageal %erforation* %!l(onar&h&%ertension* or %e%ti!lers)2.) ;hih ai# 'ase i('alane o!l# Mrs) Chin #e"elo% as a res!lt of #iarrheaOa) Res%irator& ai#osis') Meta'oli ai#osis) Car'oni ai# #efiit#) Meta'oli al$alosis') Meta'oli ai#osis Diarrhea a!ses the 'o#& to lose 'iar'onate whih (a& a!se (eta'oli ai#osis) Res%irator& ai#osis is a!se# '& al"eolar h&%o"entilation) Car'oni ai# e,ess o!rs with res%irator& al$alosis) 6o(iting sho!l# lea# to (eta'oli al$alosis)Sit!ationH Mr) Piolo* age 1A is the %resi#ent of a (a-or or%oration) 4e o(es to the hos%ital o(%laining of a'#o(inal %ain) 4e+s a#(itte# with a s!s%ete# %e%ti !ler)22) If Mr) Piolo is #iagnose# with a gastri !ler* the n!rse wo!l# e,%et his %ain to o!rHa) @elow the !('ili!s') At the !('ili!s) In the e%igastri area#) After a high fat (eal) In the e%igastri areaPain in the e%igastri area is assoiate# with gastri !ler #isease) Pain 'elow or at the !('ili!s is assoiate# with a%%en#iits) A'#o(inal %ain that o!rs after a high fat (eal isassoiate# withhole&titis)21) Mr) Piolo+s #otor %resri'es s!ralfate ICarafateJ) The n!rse $nows that s!ralfate is gi"en toHa) Pre"ent a##itional 'lee#ing') Inhi'it the ation of hista(ine) Inhi'it the ati"it& of the ai# %!(% an# 'lo$ the for(ation %f gastri ai##) Protet the !ler+s s!rfae '& for(ing a 'arrier#) Protet the !ler+s s!rfae '& for(ing a 'arrierK S!ralfate %rotet the !ler+s s!rfae '& for(ing a 'arrier so healing an ta$e %lae) @lee#ing isn+t ro!tinel& %resent with %e%ti !ler #isease) 4ista/(ine 'lo$ers* s!h as i(eti#ine ITaga(etJ* :a(oti#ine IPe%i#J* Raniti#ine ILantaJ* an# Ni5ati#ine IA,i#J* inhi'it the ation of hista(ine at the ree%tor sites of%arietal ells* #ereasing gastriai# seretion) Proton %!(% inhi'itors s!h as lanso%ra5ole I%re"ai#J an# O(e%ra5ole IPriloseJ* inhi'it the ati"it& ofthe ai# IProtonJ %!(% to 'lo$ the or(ation of gastri ai#)21) Mr) @ernar#+s #otor %erfor(e# a %arietal gastreto(& with a "ogoto(&) ;hat was the %!r%ose of %erfor(ing the "agoto(&Oa)To inrease gastri e(%t&ing') )To regenerate the gastri (!ose)To sto% stress/relate# reations#) *To re#!e ai# %ro#!tion#) To re#!e ai# %ro#!tionA "agoto(&M re#!es the %ro#!tion of sto(ah ai# '& #ereasing holinergi sti(!lation of %arietal ells) reates gastri stasis an# re#!es gastri e(%t&ing) won+t regenerate gastri (!osa or sto% stress/relate# reations)2>) Posto%erati"el&* Mr) @ernar# sho!l# 'e assesse# for #!(%ing s&n#ro(e* a o(%liation of %arietal gastreto(&) ;hih of the following are earl& signs an# s&(%to(s of #!(%ing s&n#ro(eOa) Dia%horesis an# tah&ar#ia') 4ea#ahe an# onsti%ation) 4!nger an# #erease 'owel so!n#s #) 4&%ogl&e(ia an# 'l!rre# "isiona) Dia%horesis an# tah&ar#ia Sign an# s&(%to(s assoiate# with #!(%ing s&n#ro(e o!r A to 23 (in!tes after eating an# inl!#e #ia%horesis* tah&ar#ia* s&no%e* %allor* "ertigo* #iarrhea* na!sea* a'#o(inal ra(%ing an# a'#o(inal #istension) S&(%to(s !s!all& s!'si#e in > to 1. (onths) In #!(%ing s&n#ro(e* large a(o!nts of h&(e ra%i#l& enter the s(all intestine* a!sing the assoiate# "aso(otor s&(%to(s of #ia%horesis an#tah&ar#ia)2C) Mr) Logan is at ris$ of #e"elo%ing whih of the following o(%liations assoiate# with %eritonitisOa) 4&%ertension') :l!i# o"erloa#) Se%ti sho$#) Diarrhea ) Se%ti sho$The %atient with %eritonitis is at ris$ for #e"elo%ing se%tie(ia* whih* !ntreate#* an lea# to se%ti sho$ an# #eath) The %atient #e"elo%s a fl!i# #efiit fro( the fl!i# shift that o!rs* whih #e%letes ir!lating 'loo# "ol!(e) Peritonitis inhi'its%eristalsis '!t #oesn+t a!se#iarrhea)27) The #otor s!s%ets that Mr) Tra"is has a%%en#iitis) ;hih of the following is a lassi sign of a%%en#iitis that lea#s to his s!s%iionOa) Urinar& retention') Pain relie"e# '& wal$ing) Re'o!n# a'#o(inal ten#erness#) Inrease# lower 'owel ati"it& on a!s!ltation) Re'o!n# a'#o(inal ten#erness Re'o!n# ten#erness in the right lower D!a#rant of the a'#o(en is a lassi sign of a%%en#iitis) Urinar& retention (a& 'e %resent '!t isn+t a!se# '& a%%en#iitis) Pain inreases when the %atient with a%%en#iitis a('!lates* infla((ation assoiate# with a%%en#iitis a!ses 'owelati"it& to #erease)29) The n!rse !n#erstan#s that Mr) Lei+s Di"erti!litis o!rre# 'ea!seHa) A feal (aterial or 'ateria 'ea(e tra%%e# in the o!t%o!hing of the (!osa') The o!t%o!hing in the (!osal lining %erforate#) The a%%en#i, r!%t!re# an# release# 'ateria an# to,ins into the %eritone!(#) A %eritoneal la"age was %erfor(e# an# the (!osal lining was irritate#a) A feal (aterial or 'ateria 'ea(e tra%%e# in the o!t%o!hing of the (!osa Di"erti!litis o!rs when retaine# !n#igeste# foo# (i,e# with 'aterial a!(!lates in the #i"erti!l!( Io!t%o!hing in the intestineJ* for(ing a har# (ass of feal (atter) The (ass !ts off 'loo# s!%%l& to the #i"erti!l!(+s thin walls inreasing its s!se%ti'ilit& to atta$ '& oloni'ateria) Infla((ation follows'aterial infetion) If the #i"erti!l!( %erforates* %eritonitis #e"elo%s) Peritonitis also #e"elo%s as a res!lt of a%%en#i, r!%t!re) A %eritoneal la"age o!l# %lae the %atient at ris$ for %eritonitis* '!t it #oesn+t a!se #i"erti!litis)13) The n!rse wo!l# e,%et Mr) Lei to e,hi'it whih of the following signs an# s&(%to(s assoiate# with #i"erti!litisOa) Left lower a'#o(inal %ain an# e,essi"e retal 'lee#ing') E%igastri %ain that ra#iates to the 'a$* h&%otension* an# tah&ar#ia) Na!sea* "o(iting* right lower D!a#rant re'o!n# ten#erness* an# fe"er#) Cra(%&* left lower D!a#rant %ain an#low/gra#e fe"er#) Cra(%&* left lower D!a#rant %ain an# low/gra#e fe"er Cra(%&* left lower D!a#rant %ain an# a low/gra#e fe"er are o((on s&(%to(s of #i"erti!litis) The %atient with #i"erti!litis (a& ha"e so(e retal 'lee#ing with 'o!t of onsti%ation* '!t 'lee#ing isn+t e,essi"e) E%igastri %ain that ra#iates to the 'a$* h&%otension* an# tah&ar#ia are assoiate# with %anreatitis) Na!sea* "o(iting* right lower D!a#rant %ain* an# fe"er are assoiate# witha%%en#iitis)11) The #otor or#ers %s&lli!( IMeta(iilJ for Mr) Lei) The n!rse e,%lains that %s&lli!( is an e,a(%le of whih t&%e of la,ati"eHa) @!l$/for(ing la,ati"e') L!'riant la,ati"e) Stool softener#) sti(!lanta) @!l$/for(ing la,ati"ePs&lli!( is a '!l$ for(ing la,ati"e that a'sor's water an# e,%an#s to inrease '!l$ an# (oist!re ontent of stool* th!s eno!raging %eristalsis an# 'owel (o"e(ent) Mineral oil Ifleet (ineral oilJ is an e,a(%le of a l!'riant la,ati"e) It wor$s '& inreasing water retention in the stool '& reating a 'arrier 'etween the olon wall an# fees that %re"ents oloni rea'sor%tion of feal water* Do!sate So#i!( IolaeJ is an e,a(%le of a stool softener* an# it wor$s '& re#!ing s!rfae tension of interfaing liD!i# ontents of the 'owel) This #etergent ati"it& %ro(otes inor%oration of a##itional liD!i# into the stool* th!s for(ing a softer (ass) Castor oil Ie(!lsoilJ is a sti(!lant la,ati"e that inreases %eristalsis %ro'a'l& '& #iret affet on the s(ooth (!sle of the intestine)1.) There are (an& #ifferenes 'etween !lerati"e olitis an# Crohn+s #isease whih of the following state(ents is tr!eOa) Crohn+s #isease in"ol"es the (!osal area onl&)') Crohn+s #isease an o!r an&where in the GI trat) Ulerati"e olitis affets the right ile!(#) Ulerati"e olitis (a& lea# tofist!las') Crohn+s #isease an o!r an&where in the GI tratCrohn+s #isease an o!r an&where in the GI trat* '!t it !s!all& o!rs in the #istal ile!() Crohn+s #isease affets the f!ll thi$ness of the 'owel wall) Ulerati"e olitis affets the ret!( an# olon* en#ing at the ileoeal -!ntion) :ist!las are a o(%liation of Crohn+s #isease)12) The n!rse is teahing Mrs) Moone& olosto(& are) To re"iew* the n!rse as$s her when she sho!l# e(%t& the olosto(& 'ag) Teahing is effeti"e if Mrs) Moone& re%liesHa) Qe"er& ti(e I see stool in the 'ag I sho!l# e(%t& it=') QI sho!l# e(%t& the 'ag at least three ti(e a #a&=) Q I sho!l# e(%t& the 'ag when it+s a'o!t one thir# f!ll=#) QI+ll let (& h!s'an# e(%t& it) 4e #oesn+t(in#)=) Q I sho!l# e(%t& the 'ag when it+s a'o!t one thir# f!ll= The %atient sho!l# e(%t& the olosto(& 'ag whene"er it+s a'o!t one/thir# f!ll) If the 'ag is allowe# to get too f!ll* it (a& a!se the a%%liane to se%arate fro( the s$in an# a!se lea$age) The 'ag (a& nee# to 'e e(%tie# (ore than three ti(es a #a&) The %atient sho!l# 'e eno!rage# to (anage her olosto(& herself if she+s %h&siall& a'le)11) The n!rse e,%lains to Mr) @al'as that an ing!inal hernia)a) is a %rotr!sion of a'#o(inal ontents following a s!rgial %roe#!re') is a!se# '& a #efet or wea$ness in the ret!s a'#o(inal (!sle) is a!se# '& a wea$ness in the o%ening where the "as #eferens e(erges#) is seen raref& in &o!nghealth&(en) is a!se# '& a wea$ness in the o%ening where the "as #eferens e(erges An ing!inal hernia is loate# in the groin area is a!se# '& a wea$ness in the o%ening in the a'#o(inal wall where the "as #eferens %asse# thro!gh the a'#o(inal wall) A hernia that o!rs at the site of a %re"io!s s!rgial %roe#!re is a "entral hernia) A wea$ness or #efet in the ret!s a'#o(inis is an !('ilial hernia) Ing!inal hernias o!r three ti(es (ore o((onl& in (en than wo(en)1A) The n!rse !n#erstan#s that a %atient with elia #isease has %oor a'sor%tion of fats an# ar'ohrates an# intolerane ofHa) Cereal gl!ten') Mil$ %ro#!ts) :resh fr!its #) 6egeta'les a) Cereal gl!ten Celia #isease is a here#itar& #isor#er in whih the %erson is sensiti"e to gl!ten an# therefore annot tolerate foo#s that ontain %arel& R&e &ats 'heat )Mil$ %ro#!ts* fresh fr!its* an#"egeta'les an 'e eaten '& a%atient with elia #isease)1>) ;hen assessing the %atient with elia #isease* the n!rse an e,%et to fin# whih of the followingOa) Steatorrhea') Na!n#ie slerae) Cla&/olore# stools#) ;i#ene# %!lse %ress!rea) Steatorrhea @ea!se elia #isease #estro&s the a'sor'ing s!rfae of the intestine* fat isn+t a'sor'e# '!t is %asse# in the stool) Steatorhea is '!l$&* fatt& stools that ha"e a fo!l o#or) Na!n#ie# slearae res!lt fro( ele"ate# @ilir!'in le"els) Cla&/olore# stools are seen with 'iliar& #isease when 'ile flow is 'lo$e#)Celia #isease #oesn+t a!se a wi#ene# %!lse %ress!reRenal System1C) ;hih t&%e of sol!tion a!ses water to shift fro( the ells into the %las(aOa) 4&%ertoni') 4&%otoni) Isotoni#) Al$alinea) 4&%ertoni A h&%ertoni sol!tion a!ses water to shift fro( the ell into %las(a 'ea!se the h&%ertoni sol!tion has a greater os(oti %ress!re than the ells) A h&%otoni sol!tion has a lower os(oti %ress!re than that of the ells) It a!ses fl!i# to shift into the ells* %ossi'l& res!lting in r!%t!re) An isotoni sol!tion* whih has the sa(e os(oti %ress!re as the ells* wo!l#n+t a!se an& shift) A sol!tion+s al$alinit& is relate# to the hrogen ion onentration* not its os(oti effet)17) ;hih assess(ent fin#ings in#iates #ehrationOa) tenting of hest s$in when %inhe#') ra%i# filing of han# "eins) a %!lse that isn+t easil& o'literate##) ne$ "ein #istentiona) tenting of hest s$in when %inhe#Tenting of hest s$in when %inhe# in#iates #erease# s$in elastiit& #!e to #ehration) 4an# "eins fill slowl& with #ehration* not ra%i#l&) A %!lse that isn+t easil& o'literate# an# ne$ "ein #istention in#iate fl!i# o"erloa#*not #ehration)19) ;hih n!rsing inter"ention wo!l# (ost li$el& lea# to a h&%o/os(olar stateOa) Perfor(ing nasogastri t!'e irrigation with nor(al saline sol!tion') ;eighing the %atient #ail&) A#(inistering ta% water ene(a !ntil ret!rn is lear#) Eno!raging the %atient withe,essi"e %ers%iration to #rin$ 'roth) A#(inistering ta% water ene(a !ntil ret!rn is lear A#(inistering ta% water ene(a !ntil ret!rn is lear wo!l# (ost li$el& ontri'!te to a h&%o/os(olar state) @ea!se ta% water is h&%otoni* it wo!l# 'e a'sor'e# '& the 'o#&* #il!ting the 'o#& fl!i# onentration an# lowering os(olarit&) ;eighing the %atient is the easiest* (ost a!rate (etho# to #eter(ine fl!i# hanges) Therefore* it hel%s i#entif& rather than ontri'!te to fl!i# i('alane) Nasogastri t!'e irrigation with nor(al saline sol!tion wo!l#n+t a!se a shift in fl!i# 'alane)Drin$ing 'roth wo!l#n+t ontri'!te to h&%o/os(olar state 'ea!se it #oesn+t re%laeso#i!( an# water lost thro!gh e,essi"e%ers%iration)A3) ;hih assess(ent fin#ing wo!l# in#iate an e,traell!lar fl!i# "ol!(e #efiitOa) @ra#&ar#ia') A entral "eno!s %ress!re of > ((4g) Pitting e#e(a#) An orthostati 'loo# %ress!re hange#) An orthostati 'loo# %ress!re hange An orthostati 'loo# %ress!re in#iates e,traell!lar fl!i# "ol!(e #efiit) IThe e,traell!lar o(%art(ent onsists of 'oth the intra"as!lar o(%art(ent an# interstitial s%ae)J A fl!i# "ol!(e #efiit within the intra"as!lar o(%art(ent wo!l# a!se tah&ar#ia* not 'ra#&ar#ia or othostati 'loo# %ress!re hange) A entral "eno!s %ress!re of > ((4g is in the high nor(al range* in#iating a#eD!ate hration) Pitting e#e(a in#iate# fl!i# "ol!(e o"erloa#)