Medical Surgical Nursing Bullets (NLE & NCLEX)

In a patient with hypokalemia (serum potassium level below 3.5 mEq/L),

presenting signs an symptoms in!lue mus!le weakness an !aria!
arrhythmias.
"uring !aria! arrest, i# an I.$. route is unavailable, epinephrine !an be
aministere enotra!heally.
%erni!ious anemia results #rom the #ailure to absorb vitamin &'( in the )I
tra!t an !auses primarily )I an neurologi! signs an symptoms.
* patient who has a pressure ul!er shoul !onsume a high+protein, high+
!alorie iet, unless !ontraini!ate.
,he -.+/& isoen0yme level is use to assess tissue amage in myo!arial
in#ar!tion.
*#ter a '(+hour #ast, the normal #asting bloo glu!ose level is 12 to '(2
mg/l.
* patient who is e3perien!ing igo3in to3i!ity may report nausea,
vomiting, iplopia, blurre vision, light #lashes, an yellow+green halos
aroun images.
*nuria is aily urine output o# less than '22 ml.
In remittent #ever, the boy temperature varies over a (4+hour perio,
but remains elevate.
5isk o# a #at embolism is greatest in the #irst 41 hours a#ter the #ra!ture o#
a long bone. It6s mani#este by respiratory istress.
,o help venous bloo return in a patient who is in sho!k, the nurse shoul
elevate the patient6s legs no more than 45 egrees. ,his pro!eure is
!ontraini!ate in a patient with a hea in7ury.
,he pulse e#i!it is the i##eren!e between the api!al an raial pulse
rates, when taken simultaneously by two nurses.
,o reu!e the patient6s risk o# vomiting an aspiration, the nurse shoul
s!heule postural rainage be#ore meals or ( to 4 hours a#ter meals.
&loo pressure !an be measure ire!tly by intra+arterial insertion o# a
!atheter !onne!te to a pressure+monitoring evi!e.
* positive .ernig6s sign, seen in meningitis, o!!urs when an attempt to
#le3 the hip o# a re!umbent patient !auses pain#ul spasms o# the hamstring
mus!le an resistan!e to #urther e3tension o# the leg at the knee.
In a patient with a #ra!ture, islo!ate #emur, treatment begins with
reu!tion an immobili0ation o# the a##e!te leg.
8erniate nu!leus pulposus (intervertebral isk) most !ommonly o!!urs in
the lumbar an lumbosa!ral regions.
Lamine!tomy is surgi!al removal o# the herniate portion o# an
intervertebral isk.
9urgi!al treatment o# a gastri! ul!er in!lues severing the vagus nerve
(vagotomy) to reu!e the amount o# gastri! a!i se!rete by the gastri!
!ells.
$alsalva6s maneuver is #or!e e3halation against a !lose glottis, as when
taking a eep breath, blowing air out, or bearing own.
:hen mean arterial pressure #alls below ;2 mm 8g an systoli! bloo
pressure #alls below 12 mm 8g, vital organ per#usion is seriously
!ompromise.
Lio!aine (<ylo!aine) is the rug o# !hoi!e #or reu!ing premature
ventri!ular !ontra!tions.
* patient is at greatest risk o# ying uring the #irst (4 to 41 hours a#ter a
myo!arial in#ar!tion.
"uring a myo!arial in#ar!tion, the le#t ventri!le usually sustains the
greatest amage.
,he pain o# a myo!arial in#ar!tion results #rom myo!arial is!hemia
!ause by ano3ia.
=or a patient in !aria! arrest, the #irst priority is to establish an airway.
,he universal sign #or !hoking is !lut!hing the han to the throat.
=or a patient who has heart #ailure or !ariogeni! pulmonary eema,
nursing interventions #o!us on e!reasing venous return to the heart an
in!reasing le#t ventri!ular output. ,hese interventions in!lue pla!ing the
patient in high =owler6s position an aministering o3ygen, iureti!s, an
positive inotropi! rugs as pres!ribe.
* positive tuber!ulin skin test is an inuration o# '2 mm or greater at the
in7e!tion site.
,he signs an symptoms o# histoplasmosis, a !hroni! systemi! #ungal
in#e!tion, resemble those o# tuber!ulosis.
In burn vi!tims, the leaing !ause o# eath is respiratory !ompromise.
,he se!on leaing !ause is in#e!tion.
,he e3o!rine #un!tion o# the pan!reas is the se!retion o# en0ymes use to
igest !arbohyrates, #ats, an proteins.
* patient who has hepatitis * (in#e!tious hepatitis) shoul !onsume a iet
that6s moerately high in #at an high in !arbohyrate an protein, an
shoul eat the largest meal in the morning.
Esophageal balloon tamponae shouln6t be in#late greater than (2 mm
8g.
>verprou!tion o# prola!tin by the pituitary glan !an !ause gala!torrhea
(e3!essive or abnormal la!tation) an amenorrhea (absen!e o#
menstruation).
Intermittent !laui!ation (pain uring ambulation or other movement
that6s relieve with rest) is a !lassi! symptom o# arterial insu##i!ien!y in the
leg.
In blaer !ar!inoma, the most !ommon #ining is gross, painless
hematuria.
%arenteral aministration o# heparin soium is !ontraini!ate in patients
with renal or liver isease, )I bleeing, or re!ent surgery or trauma? in
pregnant patients? an in women oler than age ;2.
"rugs that potentiate the e##e!ts o# anti!oagulants in!lue aspirin, !hloral
hyrate, glu!agon, anaboli! sterois, an !hlorampheni!ol.
=or a burn patient, !are priorities in!lue maintaining a patent airway,
preventing or !orre!ting #lui an ele!trolyte imbalan!es, !ontrolling pain,
an preventing in#e!tion.
Elasti! sto!kings shoul be worn on both legs.
*!tive immuni0ation is the #ormation o# antiboies within the boy in
response to va!!ination or e3posure to isease.
%assive immuni0ation is aministration o# antiboies that were pre#orme
outsie the boy.
* patient who is re!eiving igo3in (Lano3in) shouln6t re!eive a !al!ium
preparation be!ause o# the in!rease risk o# igo3in to3i!ity. -on!omitant
use may a##e!t !aria! !ontra!tility an lea to arrhythmias.
Intermittent positive+pressure breathing is in#lation o# the lung uring
inspiration with !ompresse air or o3ygen. ,he goal o# this in#lation is to
keep the lung open.
:ristrop is !ause by paralysis o# the e3tensor mus!les in the #orearm
an han.
=ootrop results #rom e3!essive plantar #le3ion an is usually a
!ompli!ation o# prolonge be rest.
* patient who has gonorrhea may be treate with peni!illin an
probene!i (&enemi). %robene!i elays the e3!retion o# peni!illin an
keeps this antibioti! in the boy longer.
In patients who have glu!ose+;+phosphate ehyrogenase ();%")
e#i!ien!y, the re bloo !ells !an6t metaboli0e aequate amounts o#
glu!ose, an hemolysis o!!urs.
>n+!all mei!ation is mei!ation that shoul be reay #or immeiate
aministration when the !all to aminister it6s re!eive.
I# gagging, nausea, or vomiting o!!urs when an airway is remove, the
nurse shoul pla!e the patient in a lateral position with the upper arm
supporte on a pillow.
:hen a postoperative patient arrives in the re!overy room, the nurse
shoul position the patient on his sie or with his hea turne to the sie
an the !hin e3tene.
In the immeiate postoperative perio, the nurse shoul report a
respiratory rate greater than 32, temperature greater than '22@ = (3A.1@ -)
or below BA@ = (3;.'@ -), or a signi#i!ant rop in bloo pressure or rise in
pulse rate #rom the baseline.
Irreversible brain amage may o!!ur i# the !entral nervous system is
eprive o# o3ygen #or more than 4 minutes.
,reatment #or poly!ythemia vera in!lues aministering o3ygen,
raioisotope therapy, or !hemotherapy agents, su!h as !hlorambu!il an
nitrogen mustar, to suppress bone marrow growth.
* patient with a!ute renal #ailure shoul re!eive a high+!alorie iet that6s
low in protein as well as potassium an soium.
*ison6s isease is !ause by hypo#un!tion o# the arenal glan an is
!hara!teri0e by #atigue, anemia, weight loss, an bron0e skin pigmentation.
:ithout !ortisol repla!ement therapy, it6s usually #atal.
)lau!oma is manage !onservatively with beta+arenergi! blo!kers su!h
as timolol (,imopti!), whi!h e!rease sympatheti! impulses to the eye, an
with mioti! eyerops su!h as pilo!arpine (Isopto -arpine), whi!h !onstri!t
the pupils.
/ioti!s e##e!tively treat glau!oma by reu!ing intrao!ular pressure. ,hey
o this by !onstri!ting the pupil, !ontra!ting the !iliary mus!les, opening the
anterior !hamber angle, an in!reasing the out#low o# aqueous humor.
:hile a patient is re!eiving heparin, the nurse shoul monitor the partial
thromboplastin time.
Crinary #requen!y, in!ontinen!e, or both !an o!!ur a#ter !atheter removal.
In!ontinen!e may be mani#este as ribbling.
:hen tea!hing a patient about !olostomy !are, the nurse shoul instru!t
the patient to hang the irrigation reservoir '1D to ((D (45 to 55 !m) above
the stoma, insert the !atheter (D to 4D (5 to '2 !m) into the stoma, irrigate
the stoma with 'A to 34 o0 (523 to ',225 ml) o# water at a temperature o#
'25@ to ''2@ = (42@ to 43@ -) on!e a ay, !lean the area aroun the stoma
with soap an water be#ore applying a new bag, an use a prote!tive skin
!overing, su!h as a 9tomahesive wa#er, karaya paste, or karaya ring, aroun
the stoma.
,he #irst sign o# 8ogkin6s isease is painless, super#i!ial
lymphaenopathy, typi!ally #oun uner one arm or on one sie o# the ne!k
in the !ervi!al !hain.
,o i##erentiate true !yanosis #rom eposition o# !ertain pigments, the
nurse shoul press the skin over the is!olore area. -yanoti! skin blan!hes,
but pigmente skin oesn6t.
* patient who has a gastri! ul!er is most likely to report pain uring or
shortly a#ter eating.
:iening pulse pressure is a sign o# in!reasing intra!ranial pressure. =or
e3ample, the bloo pressure may rise #rom '(2/12 to ';2/;2 mm 8g.
In a burn vi!tim, a primary goal o# woun !are is to prevent
!ontamination by mi!roorganisms.
,o prevent e3ternal rotation in a patient who has ha hip nailing, the
nurse pla!es tro!hanter rolls #rom the knee to the ankle o# the a##e!te leg.
9evere hip pain a#ter the insertion o# a hip prosthesis ini!ates
islogment. I# this o!!urs, be#ore !alling the physi!ian, the nurse shoul
assess the patient #or shortening o# the leg, e3ternal rotation, an absen!e
o# re#le3es.
*s mu!h as A5E o# renal #un!tion is lost be#ore bloo urea nitrogen an
serum !reatinine levels rise above normal.
:hen !ompensatory e##orts are present in a!i+base balan!e, partial
pressure o# arterial !arbon io3ie (%a->() an bi!arbonate (8->3F) always
point in the same ire!tionG
p8 %a->( 8->3F H respiratory a!iosis !ompensate
p8 %a->( 8->3F H respiratory alkalosis !ompensate
p8 %a->( 8->3F H metaboli! a!iosis !ompensate
p8 %a->( 8->3F H metaboli! alkalosis !ompensate.
%olyuria is urine output o# (,522 ml or more within (4 hours.
,he presenting sign o# pleuritis is !hest pain that is usually unilateral an
relate to respiratory movement.
I# a patient has a gastri! rainage tube in pla!e, the nurse shoul e3pe!t
the physi!ian to orer potassium !hlorie.
*n in!rease pulse rate is one o# the #irst ini!ations o# respiratory
i##i!ulty. It o!!urs be!ause the heart attempts to !ompensate #or a
e!rease o3ygen supply to the tissues by pumping more bloo.
In an ault, a hemoglobin level below '' mg/l suggests iron e#i!ien!y
anemia an the nee #or #urther evaluation.
,he normal partial pressure o# o3ygen in arterial bloo is B5 mm 8g (plus
or minus 5 mm 8g).
$itamin - e#i!ien!y is !hara!teri0e by brittle bones, pinpoint peripheral
hemorrhages, an #riable gums with loosene teeth.
-lini!al mani#estations o# pulmonary embolism are variable, but in!rease
respiratory rate, ta!hy!aria, an hemoptysis are !ommon.
Iormally, intrao!ular pressure is '( to (2 mm 8g. It !an be measure
with a 9!hiJt0 tonometer.
In early hemorrhagi! sho!k, bloo pressure may be normal, but
respiratory an pulse rates are rapi. ,he patient may report thirst an may
have !lammy skin an piloere!tion (goose bumps).
-ool, moist, pale skin, as o!!urs in sho!k, results #rom iversion o# bloo
#rom the skin to the ma7or organs.
,o assess !apillary re#ill, the nurse applies pressure over the nail be until
blan!hing o!!urs, qui!kly releases the pressure, an notes the rate at whi!h
blan!hing #aes. -apillary re#ill ini!ates per#usion, whi!h e!reases in
sho!k, thereby lengthening re#ill time. Iormal !apillary re#ill is less than 3
se!ons.
E3!ept #or patients with renal #ailure, urine output o# less than 32 ml/hour
signi#ies ehyration an the potential #or sho!k.
In elerly patients, the most !ommon #ra!ture is hip #ra!ture.
>steoporosis weakens the bones, preisposing these patients to #ra!ture,
whi!h usually results #rom a #all.
&e#ore angiography, the nurse shoul ask the patient whether he6s
allergi! to the ye, shell#ish, or ioine an avise him to take nothing by
mouth #or 1 hours be#ore the pro!eure.
"uring myelography, appro3imately '2 to '5 ml o# !erebrospinal #lui is
remove #or laboratory stuies an an equal amount o# !ontrast meia is
in7e!te.
*#ter angiography, the pun!ture site is !overe with a pressure ressing
an the a##e!te part is immobili0e #or 1 hours to e!rease the risk o#
bleeing.
I# a water+base meium was use uring myelography, the patient
remains on be rest #or ; to 1 hours, with the hea o# the be elevate 32
to 45 egrees. I# an oil+base meium was use, the patient remains #lat in
be #or ; to (4 hours.
,he level o# amputation is etermine by estimating the ma3imum viable
tissue (tissue with aequate !ir!ulation) neee to evelop a #un!tional
stump.
8eparin soium is in!lue in the ialysate use #or renal ialysis.
%aro3ysmal no!turnal yspnea may ini!ate heart #ailure.
* patient who takes a !aria! gly!osie, su!h as igo3in, shoul !onsume
a iet that in!lues high+potassium #oos.
,he nurse shoul limit tra!heobron!hial su!tioning to '2 to '5 se!ons
an shoul make only two passes.
&e#ore per#orming tra!heobron!hial su!tioning, the nurse shoul ventilate
an o3ygenate the patient #ive to si3 times with a resus!itation bag an
'22E o3ygen. ,his pro!eure is !alle bagging.
9igns an symptoms o# pneumothora3 in!lue ta!hypnea, restlessness,
hypotension, an tra!heal eviation.
,he !arinal sign o# to3i! sho!k synrome is rapi onset o# a high #ever.
* key sign o# pepti! ul!er is hematemesis, whi!h !an be bright re or ark
re, with the !onsisten!y o# !o##ee grouns.
9igns an symptoms o# a per#orate pepti! ul!er in!lue suen, severe
upper abominal pain? vomiting? an an e3tremely tener, rigi (boarlike)
abomen.
-onstipation is a !ommon averse rea!tion to aluminum hyro3ie.
=or the #irst (4 hours a#ter a myo!arial in#ar!tion, the patient shoul use
a besie !ommoe an then progress to walking to the toilet, bathing, an
taking short walks.
*#ter a myo!arial in#ar!tion, the patient shoul avoi overe3ertion an
a a new a!tivity aily, as tolerate without yspnea.
In a patient with a re!ent myo!arial in#ar!tion, #rothy, bloo+tinge
sputum suggests pulmonary eema.
In a patient who has a!quire immunoe#i!ien!y synrome, the primary
purpose o# rugs is to prevent se!onary in#e!tions.
In a patient with a!quire immunoe#i!ien!y synrome, suppression o#
the immune system in!reases the risk o# opportunisti! in#e!tions, su!h as
!ytomegalovirus, %neumo!ystis !arinii pneumonia, an thrush.
* patient with a!quire immunoe#i!ien!y synrome may have rapi
weight loss, a sign o# wasting synrome.
I# the boy oesn6t use glu!ose #or energy, it metaboli0es #at an
prou!es ketones.
*ppro3imately (2E o# patients with )uillain+&arrK synrome have
resiual e#i!its, su!h as mil motor weakness or iminishe lower e3tremity
re#le3es.
8ypertension an hypokalemia are the most signi#i!ant !lini!al
mani#estations o# primary hyperalosteronism.
*#ter per!utaneous aspiration o# the blaer, the patient6s #irst voi is
usually pink? however, urine with #rank bloo shoul be reporte to the
physi!ian.
* urine !ulture that grows more than '22,222 !olonies o# ba!teria per
milliliter o# urine ini!ates in#e!tion.
* patient who is unergoing ialysis shoul take a vitamin supplement
an eat #oos that are high in !alories, but low in protein, soium, an
potassium.
In a patient who has !hroni! obstru!tive pulmonary isease, the most
e##e!tive ways to reu!e thi!k se!retions are to in!rease #lui intake to (,522
ml/ay an en!ourage ambulation.
,he nurse shoul tea!h a patient with emphysema how to per#orm
purse+lip breathing be!ause this slows e3piration, prevents alveolar
!ollapse, an helps to !ontrol the respiratory rate.
-lubbing o# the igits an a barrel !hest may evelop in a patient who has
!hroni! obstru!tive pulmonary isease.
* stroke (Lbrain atta!kM) isrupts the brain6s bloo supply an may be
!ause by hypertension.
In a patient who is unergoing ialysis, esire out!omes are normal
weight, normal serum albumin level (3.5 to 5.5 g/l), an aequate protein
intake ('.( to '.5 g/kg o# boy weight aily).
Intermittent peritoneal ialysis involves per#orming three to seven
treatments that total 42 hours per week.
In a patient with !hroni! obstru!tive pulmonary isease, the best way to
aminister o3ygen is by nasal !annula. ,he normal #low rate is ( to 3 L/
minute.
Isoetharine (&ronkosol) !an be aministere with a hanhel nebuli0er or
by intermittent positive+pressure breathing.
&rain eath is irreversible !essation o# brain #un!tion.
-ontinuous ambulatory peritoneal ialysis requires #our e3!hanges per
ay, A ays per week, #or a total o# ';1 hours per week.
,he !lassi! averse rea!tions to antihistamines are ry mouth,
rowsiness, an blurre vision.
&e!ause o# the risk o# paralyti! ileus, a patient who has re!eive a general
anestheti! !an6t take anything by mouth until a!tive bowel souns are hear
in all abominal quarants.
,he level o# alpha+#etoprotein, a tumor marker, is elevate in patients
who have testi!ular germ !ell !an!er.
-lini!al mani#estations o# or!hitis !ause by ba!teria or mumps in!lue
high temperature, !hills, an suen pain in the involve testis.
,he level o# prostate+spe!i#i! antigen is elevate in patients with benign
prostati! hyperplasia or prostate !an!er.
,he level o# prostati! a!i phosphatase is elevate in patients with
avan!e stages o# prostate !an!er.
%henylephrine (Ieo+9ynephrine), a myriati!, is instille in a patient6s eye
to ilate the eye.
,o promote #lui rainage an relieve eema in a patient with
epiiymitis, the nurse shoul elevate the s!rotum on a s!rotal brige.
=luores!ein staining is !ommonly use to assess !orneal abrasions
be!ause it outlines super#i!ial epithelial e#e!ts.
%resbyopia is loss o# near vision as a result o# the loss o# elasti!ity o# the
!rystalline lens.
,ransient is!hemi! atta!ks are !onsiere pre!ursors to strokes.
* sign o# a!ute appeni!itis, /!&urney6s sign is tenerness at /!&urney6s
point (about (D N5 !mO #rom the right anterior superior ilia! spine on a line
between the spine an the umbili!us).
:hen !aring #or a patient with )uillain+&arrK synrome, the nurse shoul
#o!us on respiratory interventions as the isease pro!ess avan!es.
9igns an symptoms o# !olon !an!er in!lue re!tal bleeing, !hange in
bowel habits, intestinal obstru!tion, abominal pain, weight loss, anore3ia,
nausea, an vomiting.
9ymptoms o# prostatitis in!lue #requent urination an ysuria.
* !han!re is a painless, ul!erative lesion that evelops uring the primary
stage o# syphilis.
"uring the tertiary stage o# syphilis, spiro!hetes invae the internal
organs an !ause permanent amage.
In total parenteral nutrition, weight gain is the most reliable ini!ator o# a
positive response to therapy.
,he nurse may aminister an I.$. #at emulsion through a !entral or
peripheral !atheter, but shouln6t use an in+line #ilter be!ause the #at
parti!les are too large to pass through the pores.
I# a patient who has a prostate!tomy is using a -unningham !lamp,
instru!t him to wash an ry his penis be#ore applying the !lamp. 8e shoul
apply the !lamp hori0ontally an remove it at least every 4 hours to empty
his blaer to prevent in#e!tion.
I# a woman has signs o# urinary tra!t in#e!tion uring menopause, she
shoul be instru!te to rink si3 to eight glasses o# water per ay, urinate
be#ore an a#ter inter!ourse, an per#orm .egel e3er!ises.
I# a menopausal patient e3perien!es a Lhot #lash,M she shoul be
instru!te to seek a !ool, bree0y lo!ation an sip a !ool rink.
-heilosis !auses #issures at the angles o# the mouth an ini!ates a
vitamin &(, ribo#lavin, or iron e#i!ien!y.
,etany may result #rom hypo!al!emia !ause by hypoparathyroiism.
* patient who has !ervi!al !an!er may e3perien!e vaginal bleeing #or '
to 3 months a#ter intra!avitary raiation.
*s!ites is the a!!umulation o# #lui, !ontaining large amounts o# protein
an ele!trolytes, in the abominal !avity. It6s !ommonly !ause by !irrhosis.
Iormal pulmonary artery pressure is '2 to (5 mm 8g. Iormal pulmonary
artery wege pressure is 5 to '( mm 8g.
*#ter !aria! !atheteri0ation, the site is monitore #or bleeing an
hematoma #ormation, pulses istal to the site are palpate every '5 minutes
#or ' hour, an the patient is maintaine on be rest with the e3tremity
e3tene #or 1 hours.
8emophilia is a bleeing isorer that6s transmitte geneti!ally in a se3+
linke (< !hromosome) re!essive pattern. *lthough girls an women may
!arry the e#e!tive gene, hemophilia usually o!!urs only in boys an men.
$on :illebran6s isease is an autosomal ominant bleeing isorer
that6s !ause by platelet ys#un!tion an #a!tor $III e#i!ien!y.
9i!kle !ell anemia is a !ongenital hemolyti! anemia that6s !ause by
e#e!tive hemoglobin 9 mole!ules. It primarily a##e!ts bla!ks.
9i!kle !ell anemia has a homo0ygous inheritan!e pattern. 9i!kle !ell trait
has a hetero0ygous inheritan!e pattern.
%el+Ebstein #ever is a !hara!teristi! sign o# 8ogkin6s isease. =ever
re!urs every #ew ays or weeks an alternates with a#ebrile perios.
)lu!ose+;+phosphate ehyrogenase ();%") e#i!ien!y is an inherite
metaboli! isorer that6s !hara!teri0e by re bloo !ells that are e#i!ient in
);%", a !riti!al en0yme in aerobi! gly!olysis.
%re#erre sites #or bone marrow aspiration are the posterior superior ilia!
!rest, anterior ilia! !rest, an sternum.
"uring bone marrow harvesting, the onor re!eives general anesthesia
an 422 to 122 ml o# marrow is aspirate.
* butter#ly rash a!ross the brige o# the nose is a !hara!teristi! sign o#
systemi! lupus erythematosus.
5heumatoi arthritis is a !hroni!, estru!tive !ollagen isease
!hara!teri0e by symmetri! in#lammation o# the synovium that leas to 7oint
swelling.
9!reening #or human immunoe#i!ien!y virus antiboies begins with the
en0yme+linke immunosorbent assay. 5esults are !on#irme by the :estern
blot test.
,he -.+/& isoen0yme level in!reases 4 to 1 hours a#ter a myo!arial
in#ar!tion, peaks at '( to (4 hours, an returns to normal in 3 ays.
E3!essive intake o# vitamin . may signi#i!antly antagoni0e the
anti!oagulant e##e!ts o# war#arin (-oumain). ,he patient shoul be
!autione to avoi eating an e3!essive amount o# lea#y green vegetables.
* lymph noe biopsy that shows 5ee+9ternberg !ells provies a
e#initive iagnosis o# 8ogkin6s isease.
&ell6s palsy is unilateral #a!ial weakness or paralysis !ause by a
isturban!e o# the seventh !ranial (#a!ial) nerve.
"uring an initial tuber!ulin skin test, la!k o# a wheal a#ter in7e!tion o#
tuber!ulin puri#ie protein erivative ini!ates that the test ose was
in7e!te too eeply. ,he nurse shoul in7e!t another ose at least (D (5 !m)
#rom the initial site.
* tuber!ulin skin test shoul be rea 41 to A( hours a#ter aministration.
In reaing a tuber!ulin skin test, erythema without inuration is usually
not signi#i!ant.
"eath !ause by botulism usually results #rom elaye iagnosis an
respiratory !ompli!ations.
In a patient who has rabies, saliva !ontains the virus an is a ha0ar #or
nurses who provie !are.
* #ebrile nonhemolyti! rea!tion is the most !ommon trans#usion rea!tion.
8ypokalemia (abnormally low !on!entration o# potassium in the bloo)
may !ause mus!le weakness or paralysis, ele!tro!ariographi!
abnormalities, an )I isturban!es.
&eriberi, a serious vitamin &' (thiamine) e#i!ien!y, a##e!ts al!oholi!s who
have poor ietary habits. It6s epiemi! in *sian !ountries where people
subsist on unenri!he ri!e. It6s !hara!teri0e by the phrase LI !an6t,M
ini!ating that the patient is too ill to o anything.
E3!essive seation may !ause respiratory epression.
,he primary postoperative !on!ern is maintenan!e o# a patent airway.
I# !yanosis o!!urs !ir!umorally, sublingually, or in the nail be, the
o3ygen saturation level (9ao () is less than 12E.
* rapi pulse rate in a postoperative patient may ini!ate pain, bleeing,
ehyration, or sho!k.
In!rease pulse rate an bloo pressure may ini!ate that a patient is
e3perien!ing Lsilent painM (pain that !an6t be e3presse verbally, su!h as
when a patient is re!overing #rom anesthesia).
Lio!aine (<ylo!aine) e3erts antiarrhythmi! a!tion by suppressing
automati!ity in the %urkin7e #ibers an elevating the ele!tri!al stimulation
threshol in the ventri!les.
-ullen6s sign (a bluish is!oloration aroun the umbili!us) is seen in
patients who have a per#orate pan!reas.
"uring the postoperative perio, the patient shoul !ough an breathe
eeply every ( hours unless otherwise !ontraini!ate (#or e3ample, a#ter
!raniotomy, !atara!t surgery, or throat surgery).
&e#ore surgery, a patient6s respiratory volume may be measure by
in!entive spirometry. ,his measurement be!omes the patient6s postoperative
goal #or respiratory volume.
,he postoperative patient shoul use in!entive spirometry '2 to '( times
per hour an breathe eeply.
&e#ore ambulating, a postoperative patient shoul angle his legs over
the sie o# the be an per#orm eep+breathing e3er!ises.
"uring the patient6s #irst postoperative ambulation, the nurse shoul
monitor the patient !losely an assist him as neee while he walks a #ew
#eet #rom the be to a steay !hair.
8ypovolemia o!!urs when '5E to (5E o# the boy6s total bloo volume is
lost.
9igns an symptoms o# hypovolemia in!lue rapi, weak pulse? low bloo
pressure? !ool, !lammy skin? shallow respirations? oliguria or anuria? an
lethargy.
*!ute peri!aritis !auses suen severe, !onstant pain over the anterior
!hest. ,he pain is aggravate by inspiration.
9igns an symptoms o# septi!emia in!lue #ever, !hills, rash, abominal
istention, prostration, pain, heaa!he, nausea, an iarrhea.
5o!ky /ountain spotte #ever !auses a persistent high #ever, nonpitting
eema, an rash.
%atients who have unergone !oronary artery bypass gra#t shoul sleep ;
to '2 hours per ay, take their temperature twi!e aily, an avoi li#ting
more than '2 lb (4.5 kg) #or at least ; weeks.
-laui!ation pain (pain on ambulation) is !ause by arterial insu##i!ien!y
as a result o# atheromatous plaque that obstru!ts arterial bloo #low to the
e3tremities.
%a!emakers !an be powere by lithium batteries #or up to '2 years.
,he patient shouln6t voi #or ' hour be#ore per!utaneous suprapubi!
blaer aspiration to ensure that su##i!ient urine remains in the blaer to
make the pro!eure su!!ess#ul.
Le#t+sie heart #ailure !auses pulmonary !ongestion, pink+tinge sputum,
an yspnea. (5emember L #or le#t an lung.)
,he !urrent re!ommene bloo !holesterol level is less than (22 mg/l.
:hen !aring #or a patient who is having a sei0ure, the nurse shoul #ollow
these guielinesG (') *voi restraining the patient, but help a staning
patient to a lying position. (() Loosen restri!tive !lothing. (3) %la!e a pillow
or another so#t ob7e!t uner the patient6s hea. (4) -lear the area o# har
ob7e!ts. (5) "on6t #or!e anything into the patient6s mouth, but maintain a
patent airway. (;) 5eassure an reorient the patient a#ter the sei0ure
subsies.
)ingival hyperplasia, or overgrowth o# gum tissue, is an averse rea!tion
to phenytoin ("ilantin).
:ith aging, most marrow in long bones be!omes yellow, but it retains the
!apa!ity to !onvert ba!k to re.
-lini!al mani#estations o# lympheema in!lue a!!umulation o# #lui in the
legs.
*#terloa is ventri!ular wall tension uring systoli! e7e!tion. It6s in!rease
in patients who have septal hypertrophy, in!rease bloo vis!osity, an
!onitions that !ause blo!kage o# aorti! or pulmonary out#low.
5e bloo !ells !an be store #ro0en #or up to ( years? however, they
must be use within (4 hours o# thawing.
=or the #irst (4 hours a#ter amputation, the nurse shoul elevate the
stump to prevent eema.
*#ter hystere!tomy, a woman shoul avoi se3ual inter!ourse #or 3 weeks
i# a vaginal approa!h was use an ; weeks i# the abominal approa!h was
use.
%arkinson6s isease !hara!teristi!ally !auses progressive mus!le rigiity,
akinesia, an involuntary tremor.
,oni!+!loni! sei0ures are !hara!teri0e by a loss o# !ons!iousness an
alternating perios o# mus!le !ontra!tion an rela3ation.
9tatus epilepti!us, a li#e+threatening emergen!y, is a series o# rapily
repeating sei0ures that o!!ur without intervening perios o# !ons!iousness.
,he ieal onor #or kiney transplantation is an ienti!al twin. I# an
ienti!al twin isn6t available, a biologi!al sibling is the ne3t best !hoi!e.
&reast !an!er is the leaing !an!er among women? however, lung !an!er
a!!ounts #or more eaths.
,he stages o# !ervi!al !an!er are as #ollowsG stage 2, !ar!inoma in situ?
stage I, !an!er !on#ine to the !ervi3? stage II, !an!er e3tening beyon the
!ervi3, but not to the pelvi! wall? stage III, !an!er e3tening to the pelvi!
wall? an stage I$, !an!er e3tening beyon the pelvis or within the blaer
or re!tum.
>ne metho use to estimate bloo loss a#ter a hystere!tomy is !ounting
perineal pas. 9aturating more than one pa in ' hour or eight pas in (4
hours is !onsiere hemorrhaging.
,ransurethral rese!tion o# the prostate is the most !ommon pro!eure #or
treating benign prostati! hyperplasia.
In a !hest rainage system, the water in the water+seal !hamber normally
rises when a patient breathes in an #alls when he breathes out.
9pinal #usion provies spinal stability through a bone gra#t, usually #rom
the ilia! !rest, that #uses two or more vertebrae.
* patient who re!eives any type o# transplant must take an
immunosuppressant rug #or the rest o# his li#e.
In!entive spirometry shoul be use 5 to '2 times an hour while the
patient is awake.
In women, pelvi! in#lammatory isease is a !ommon !ompli!ation o#
gonorrhea.
9!oliosis is lateral 9+shape !urvature o# the spine.
9igns an symptoms o# the se!onary stage o# syphilis in!lue a rash on
the palms an soles, erosion o# the oral mu!osa, alope!ia, an enlarge
lymph noes.
In a patient who is re!eiving total parenteral nutrition, the nurse shoul
monitor glu!ose an ele!trolyte levels.
Cnless !ontraini!ate, on amission to the postanesthesia !are unit, a
patient shoul be turne on his sie an his vital signs shoul be taken.
Eema is treate by limiting #lui intake an eliminating e3!ess #lui.
* patient who has ha spinal anesthesia shoul remain #lat #or '( to (4
hours. $ital signs an neuromus!ular #un!tion shoul be monitore.
* patient who has maple syrup urine isease shoul avoi #oo !ontaining
the amino a!is leu!ine, isoleu!ine, an lysine.
* severe !ompli!ation o# a #emur #ra!ture is e3!essive bloo loss that
results in sho!k.
,o prepare a patient #or peritoneal ialysis, the nurse shoul ask the
patient to voi, measure his vital signs, pla!e him in a supine position, an
using asepti! te!hnique, insert a !atheter through the abominal wall an
into the peritoneal spa!e.
I# more than 3 L o# ialysate solution return uring peritoneal ialysis, the
nurse shoul noti#y the physi!ian.
8emoialysis is the removal o# !ertain elements #rom the bloo by
passing heparini0e bloo through a semipermeable membrane to the
ialysate bath, whi!h !ontains all o# the important ele!trolytes in their ieal
!on!entrations.
)angrene usually a##e!ts the igits #irst, an begins with skin !olor
!hanges that progress #rom gray+blue to ark brown or bla!k.
.iney #un!tion is assesse by evaluating bloo urea nitrogen (normal
range is 1 to (2 mg/l) an serum !reatinine (normal range is 2.; to '.3
mg/l) levels.
* weight+bearing trans#er is appropriate only #or a patient who has at
least one leg that6s strong enough to bear weight, su!h as a patient with
hemiplegia or a single+leg amputation.
>ver#low in!ontinen!e (voiing o# 32 to ;2 ml o# urine every '5 to 32
minutes) is a sign o# blaer istention.
,he #irst sign o# a pressure ul!er is reene skin that blan!hes when
pressure is applie.
Late signs an symptoms o# si!kle !ell anemia in!lue ta!hy!aria,
!ariomegaly, systoli! an iastoli! murmurs, !hroni! #atigue,
hepatomegaly, an splenomegaly.
* me!hani!al ventilator, whi!h !an maintain ventilation automati!ally #or
an e3tene perio, is ini!ate when a patient !an6t maintain a sa#e %a>(
or %a->( level.
,wo types o# me!hani!al ventilators e3istG negative+pressure ventilators,
whi!h apply negative pressure aroun the !hest wall, an positive+pressure
ventilators, whi!h eliver air uner pressure to the patient.
*ngina pe!toris is !hara!teri0e by substernal pain that lasts #or ( to 3
minutes. ,he pain, whi!h is !ause by myo!arial is!hemia, may raiate to
the ne!k, shoulers, or 7aw? is es!ribe as viselike, or !onstri!ting? an
may be a!!ompanie by severe apprehension or a #eeling o# impening
oom.
,he iagnosis o# an a!ute myo!arial in#ar!tion is base on the patient6s
signs an symptoms, ele!tro!ariogram tra!ings, troponin level, an !aria!
en0yme stuies.
,he goal o# treatment #or a patient with angina pe!toris is to reu!e the
heart6s workloa, thereby reu!ing the myo!arial eman #or o3ygen an
preventing myo!arial in#ar!tion.
Iitrogly!erin e!reases the amount o# bloo that returns to the heart by
in!reasing the !apa!ity o# the venous be.
,he patient shoul take no more than three nitrogly!erin tablets in a '5+
minute perio.
8emoialysis is usually per#orme (4 hours be#ore kiney transplantation.
9igns an symptoms o# a!ute kiney transplant re7e!tion are progressive
enlargement an tenerness at the transplant site, in!rease bloo pressure,
e!rease urine output, elevate serum !reatinine level, an #ever.
*#ter a rai!al maste!tomy, the patient6s arm shoul be elevate (with
the han above the elbow) on a pillow to enhan!e !ir!ulation an prevent
eema.
%ostoperative maste!tomy !are in!lues tea!hing the patient arm
e3er!ises to #a!ilitate lymph rainage an prevent shortening o# the mus!le
an !ontra!ture o# the shouler 7oint (#ro0en shouler).
*#ter rai!al maste!tomy, the patient shoul help prevent in#e!tion by
making sure that no bloo pressure reaings, in7e!tions, or venipun!tures
are per#orme on the a##e!te arm.
=or a patient who has unergone maste!tomy an is sus!eptible to
lympheema, a program o# han e3er!ises !an begin shortly a#ter surgery, i#
pres!ribe. ,he program !onsists o# opening an !losing the han tightly si3
to eight times per hour an per#orming su!h tasks as washing the #a!e an
!ombing the hair.
9igns an symptoms o# theophylline to3i!ity in!lue vomiting,
restlessness, an an api!al pulse rate o# more than (22 beats/minute.
,he nurse shouln6t inu!e vomiting in a person who has ingeste poison
an is having sei0ures or is semi!ons!ious or !omatose.
-entral venous pressure (-$%), whi!h is the pressure in the right atrium
an the great veins o# the thora3, is normally ( to 1 mm 8g (or 5 to '( !m
8(>). -$% is use to assess right+sie !aria! #un!tion.
-$% is monitore to assess the nee #or #lui repla!ement in seriously ill
patients, to estimate bloo volume e#i!its, an to evaluate !ir!ulatory
pressure in the right atrium.
,o prevent eep vein thrombosis a#ter surgery, the nurse shoul
aminister 5,222 units o# heparin sub!utaneously every 1 to '( hours, as
pres!ribe.
>ral anti!oagulants, su!h as war#arin (-oumain) an i!umarol, isrupt
natural bloo !lotting me!hanisms, prevent thrombus #ormation, an limit
the e3tension o# a #orme thrombus.
*nti!oagulants !an6t issolve a #orme thrombus.
*nti!oagulant therapy is !ontraini!ate in a patient who has liver or
kiney isease or )I ul!ers or who isn6t likely to return #or #ollow+up visits.
,he nurse !an assess a patient #or thrombophlebitis by measuring the
a##e!te an una##e!te legs an !omparing their si0es. ,he nurse shoul
mark the measurement lo!ations with a pen so that the legs !an be
measure at the same pla!e ea!h ay.
"rainage o# more than 3,222 ml o# #lui aily #rom a nasogastri! tube may
suggest intestinal obstru!tion. Pellow rainage that has a #oul oor may
ini!ate small+bowel obstru!tion.
%reparation #or sigmoios!opy in!lues aministering an enema ' hour
be#ore the e3amination, warming the s!ope in warm water or a sterili0er (i#
using a metal sigmoios!ope), an raping the patient to e3pose the
perineum.
,reatment #or a patient with bleeing esophageal vari!es in!lues
aministering vasopressin (%itressin), giving an i!e water lavage, aspirating
bloo #rom the stoma!h, using esophageal balloon tamponae, proviing
parenteral nutrition, an aministering bloo trans#usions, as neee.
* trauma vi!tim shouln6t be move until a patent airway is establishe
an the !ervi!al spine is immobili0e.
*#ter a maste!tomy, lympheema may !ause a #eeling o# heaviness in the
a##e!te arm.
* ying patient shouln6t be tol e3a!tly how long he6s e3pe!te to live,
but shoul be tol something more general su!h as L9ome people live 3 to ;
months, but others live longer.M
*#ter eye surgery, a patient shoul avoi using makeup until otherwise
instru!te.
*#ter a !orneal transplant, the patient shoul wear an eye shiel when
engaging in a!tivities su!h as playing with !hilren or pets.
*#ter a !orneal transplant, the patient shouln6t lie on the a##e!te site,
ben at the waist, or have se3ual inter!ourse #or ' week. ,he patient must
avoi getting soapsus in the eye.
* /ilwaukee bra!e is use #or patients who have stru!tural s!oliosis. ,he
bra!e helps to halt the progression o# spinal !urvature by proviing
longituinal tra!tion an lateral pressure. It shoul be worn (3 hours a ay.
9hort+term measures use to treat stomal retra!tion in!lue stool
so#teners, irrigation, an stomal ilatation.
* patient who has a !olostomy shoul be avise to eat a low+resiue iet
#or 4 to ; weeks an then to a one #oo at a time to evaluate its e##e!t.
,o relieve postoperative hi!!ups, the patient shoul breathe into a paper
bag.
I# a patient with an ileostomy has a blo!ke lumen as a result o#
unigeste high+#iber #oo, the patient shoul be pla!e in the knee+!hest
position an the area below the stoma shoul be massage.
"uring the initial interview an treatment o# a patient with syphilis, the
patient6s se3ual !onta!ts shoul be ienti#ie.
,he nurse shouln6t aminister morphine to a patient whose respiratory
rate is less than '( breaths/minute.
,o prevent rying o# the mu!ous membranes, o3ygen shoul be
aministere with hyration.
=lavo3ate (Crispas) is !lassi#ie as a urinary tra!t spasmolyti!.
8ypotension is a sign o# !ariogeni! sho!k in a patient with a myo!arial
in#ar!tion.
,he preominant signs o# me!hani!al ileus are !ramping pain, vomiting,
istention, an inability to pass #e!es or #latus.
=or a patient with a myo!arial in#ar!tion, the nurse shoul monitor #lui
intake an output meti!ulously. ,oo little intake !auses ehyration, an too
mu!h may !ause pulmonary eema.
Iitrogly!erin rela3es smooth mus!le, !ausing vasoilation an relieving
the !hest pain asso!iate with myo!arial in#ar!tion an angina.
,he iagnosis o# an a!ute myo!arial in#ar!tion is base on the patient6s
signs an symptoms, ele!tro!ariogram tra!ings, an serum en0yme
stuies.
*rrhythmias are the preominant problem uring the #irst 41 hours a#ter a
myo!arial in#ar!tion.
-lini!al mani#estations o# malabsorption in!lue weight loss, mus!le
wasting, bloating, an steatorrhea.
*sparaginase, an en0yme that inhibits the synthesis o# eo3yribonu!lei!
a!i an protein, is use to treat a!ute lympho!yti! leukemia.
,o relieve a patient6s sore throat that6s !ause by nasogastri! tube
irritation, the nurse shoul provie anestheti! lo0enges, as pres!ribe.
=or the #irst '( to (4 hours a#ter gastri! surgery, the stoma!h !ontents
(obtaine by su!tioning) are brown.
*#ter gastri! su!tioning is is!ontinue, a patient who is re!overing #rom a
subtotal gastre!tomy shoul re!eive a !lear liqui iet.
,he es!ening !olon is the pre#erre site #or a permanent !olostomy.
$alvular insu##i!ien!y in the veins !ommonly !auses vari!osity.
* patient with a !olostomy shoul restri!t #at an #ibrous #oos an shoul
avoi #oos that !an obstru!t the stoma, su!h as !orn, nuts, an !abbage.
* patient who is re!eiving !hemotherapy is pla!e in reverse isolation
be!ause the white bloo !ell !ount may be epresse.
9ymptoms o# mitral valve stenosis are !ause by improper emptying o#
the le#t atrium.
%ersistent bleeing a#ter open heart surgery may require the
aministration o# protamine sul#ate to reverse the e##e!ts o# heparin soium
use uring surgery.
,he nurse shoul tea!h a patient with heart #ailure to take igo3in an
other rugs as pres!ribe, to restri!t soium intake, to restri!t #luis as
pres!ribe, to get aequate rest, to in!rease walking an other a!tivities
graually, to avoi e3tremes o# temperature, to report signs o#
,he nurse shoul !he!k an maintain the paten!y o# all !onne!tions #or a
!hest tube. I# an air leak is ete!te, the nurse shoul pla!e one .elly !lamp
near the insertion site. I# the bubbling stops, the leak is in the thora!i! !avity
an the physi!ian shoul be noti#ie immeiately. I# the leak !ontinues, the
nurse shoul take a se!on !lamp, work own the tube until the leak is
lo!ate, an stop the leak.
In two+person !ariopulmonary resus!itation, the res!uers aminister ;2
!hest !ompressions per minute an ' breath #or every 5 !ompressions.
/itral valve stenosis !an result #rom rheumati! #ever.
*tele!tasis is in!omplete e3pansion o# lung segments or lobules (!lusters
o# alveoli). It may !ause the lung or lobe to !ollapse.
,he nurse shoul instru!t a patient who has an ileal !onuit to empty the
!olle!tion evi!e #requently be!ause the weight o# the urine may !ause the
evi!e to slip #rom the skin.
* patient who is re!eiving !ariopulmonary resus!itation shoul be pla!e
on a soli, #lat sur#a!e.
&rain amage o!!urs 4 to ; minutes a#ter !ariopulmonary #un!tion
!eases.
-lima!teri! is the transition perio uring whi!h a woman6s reprou!tive
#un!tion iminishes an graually isappears.
*#ter in#ratentorial surgery, the patient shoul remain on his sie, #lat in
be.
In a patient who has an ul!er, milk is !ontraini!ate be!ause its high
!al!ium !ontent stimulates se!retion o# gastri! a!i.
* patient who has a positive test result #or human immunoe#i!ien!y virus
has been e3pose to the virus asso!iate with a!quire immunoe#i!ien!y
synrome (*I"9), but oesn6t ne!essarily have *I"9.
* !ommon !ompli!ation a#ter prostate!tomy is !ir!ulatory #ailure !ause
by bleeing.
In right+sie heart #ailure, a ma7or #o!us o# nursing !are is e!reasing
the workloa o# the heart.
9igns an symptoms o# igo3in to3i!ity in!lue nausea, vomiting,
!on#usion, an arrhythmias.
*n asthma atta!k typi!ally begins with whee0ing, !oughing, an
in!reasing respiratory istress.
In a patient who is re!overing #rom a tonsille!tomy, #requent swallowing
suggests hemorrhage.
Ileostomies an 8artmann6s !olostomies are permanent stomas. Loop
!olostomies an ouble+barrel !olostomies are temporary ones.
* patient who has an ileostomy shoul eat #oos, su!h as spina!h an
parsley, be!ause they a!t as intestinal tra!t eoori0ers.
*n arenale!tomy !an e!rease steroi prou!tion, whi!h !an !ause
e3tensive loss o# soium an water.
&e#ore aministering morphine ("uramorph) to a patient who is suspe!te
o# having a myo!arial in#ar!tion, the nurse shoul !he!k the patient6s
respiratory rate. I# it6s less than '( breaths/minute, emergen!y equipment
shoul be reaily available #or intubation i# respiratory epression o!!urs.
* patient who is re!overing #rom supratentorial surgery is normally
allowe out o# be '4 to 41 hours a#ter surgery. * patient who is re!overing
#rom in#ratentorial surgery normally remains on be rest #or 3 to 5 ays.
*#ter a patient unergoes a #emoral+popliteal bypass gra#t, the nurse
must !losely monitor the peripheral pulses istal to the operative site an
!ir!ulation.
*#ter a #emoral+popliteal bypass gra#t, the patient shoul initially be
maintaine in a semi+=owler position to avoi #le3ion o# the gra#t site. &e#ore
is!harge, the nurse shoul instru!t the patient to avoi positions that put
pressure on the gra#t site until the ne3t #ollow+up visit.
># the #ive senses, hearing is the last to be lost in a patient who is
entering a !oma.
-holelithiasis !auses an enlarge, eematous gallblaer with multiple
stones an an elevate bilirubin level.
,he antiviral agent 0iovuine (5etrovir) su!!ess#ully slows repli!ation o#
the human immunoe#i!ien!y virus, thereby slowing the evelopment o#
a!quire immunoe#i!ien!y synrome.
9evere rheumatoi arthritis !auses marke eema an !ongestion,
spinle+shape 7oints, an severe #le3ion e#ormities.
* patient with a!quire immunoe#i!ien!y synrome shoul avise his
se3ual partners o# his human immunoe#i!ien!y virus status an observe
se3ual pre!autions, su!h as abstinen!e or !onom use.
I# a raioa!tive implant be!omes isloge, the nurse shoul retrieve it
with tongs, pla!e it in a lea+shiele !ontainer, an noti#y the raiology
epartment.
* patient who is unergoing raiation therapy shoul pat his skin ry to
avoi abrasions that !oul easily be!ome in#e!te.
"uring raiation therapy, a patient shoul have #requent bloo tests,
espe!ially white bloo !ell an platelet !ounts.
,he nurse shoul aminister an aluminum hyro3ie anta!i at least '
hour a#ter an enteri!+!oate rug be!ause it !an !ause premature release o#
the enteri!+!oate rug in the stoma!h.
*!i+base balan!e is the boy6s hyrogen ion !on!entration, a measure o#
the ratio o# !arboni! a!i to bi!arbonate ions (' part !arboni! a!i to (2
parts bi!arbonate is normal).
*myotrophi! lateral s!lerosis !auses progressive atrophy an wasting o#
mus!le groups that eventually a##e!ts the respiratory mus!les.
/etaboli! a!iosis is !ause by abnormal loss o# bi!arbonate ions or
e3!essive prou!tion or retention o# a!i ions.
8emianopsia is e#e!tive vision or blinness in one+hal# o# the visual #iel
o# one or both eyes.
9ystemi! lupus erythematosus !auses early+morning 7oint sti##ness an
#a!ial erythema in a butter#ly pattern.
*#ter total knee repla!ement, the patient shoul remain in the semi+
=owler position, with the a##e!te leg elevate.
In a patient who is re!eiving transpylori! #eeings, the nurse shoul wat!h
#or umping synrome an hypovolemi! sho!k be!ause the stoma!h is being
bypasse.
I# a total parenteral nutrition in#usion must be interrupte, the nurse
shoul aminister e3trose 5E in water at a similar rate. *brupt !essation
!an !ause hypogly!emia.
9tatus epilepti!us is treate with I.$. ia0epam ($alium) an phenytoin
("ilantin).
"isequilibrium synrome !auses nausea, vomiting, restlessness, an
twit!hing in patients who are unergoing ialysis. It6s !ause by a rapi #lui
shi#t.
*n ini!ation that spinal sho!k is resolving is the return o# re#le3 a!tivity
in the arms an legs below the level o# in7ury.
8ypovolemia is the most !ommon an #atal !ompli!ation o# severe a!ute
pan!reatitis.
In a patient with stomatitis, oral !are in!lues rinsing the mouth with a
mi3ture o# equal parts o# hyrogen pero3ie an water three times aily.
In otitis meia, the tympani! membrane is bright re an la!ks its
!hara!teristi! light re#le3 (!one o# light).
In patients who have peri!ario!entesis, #lui is aspirate #rom the
peri!arial sa! #or analysis or to relieve !aria! tamponae.
Crti!aria is an early sign o# hemolyti! trans#usion rea!tion.
"uring peritoneal ialysis, a return o# brown ialysate suggests bowel
per#oration. ,he physi!ian shoul be noti#ie immeiately.
*n early sign o# ketoa!iosis is polyuria, whi!h is !ause by osmoti!
iuresis.
%atients who have multiple s!lerosis shoul visually inspe!t their
e3tremities to ensure proper alignment an #reeom #rom in7ury.
*spirate re bone marrow usually appears rust+re, with visible #atty
material an white bone #ragments.
,he "i!k test ete!ts s!arlet #ever antigens an immunity or sus!eptibility
to s!arlet #ever. * positive result ini!ates no immunity? a negative result
ini!ates immunity.
,he 9!hi!k test ete!ts iphtheria antigens an immunity or sus!eptibility
to iphtheria. * positive result ini!ates no immunity? a negative result
ini!ates immunity.
,he re!ommene ault osage o# su!ral#ate (-ara#ate) #or uoenal
ul!er is ' g (' tablet) #our times aily ' hour be#ore meals an at betime.
* patient with #a!ial burns or smoke or heat inhalation shoul be amitte
to the hospital #or (4+hour observation #or elaye tra!heal eema.
In aition to patient tea!hing, preparation #or a !olostomy in!lues
withholing oral intake overnight, per#orming bowel preparation, an
aministering a !leansing enema.
,he physiologi! !hanges !ause by burn in7uries !an be ivie into two
stagesG the hypovolemi! stage, uring whi!h intravas!ular #lui shi#ts into
the interstitial spa!e, an the iureti! stage, uring whi!h !apillary integrity
an intravas!ular volume are restore, usually 41 to A( hours a#ter the
in7ury.
,he nurse shoul !hange total parenteral nutrition tubing every (4 hours
an the peripheral I.$. a!!ess site ressing every A( hours.
* patient whose !arbon mono3ie level is (2E to 32E shoul be treate
with '22E humii#ie o3ygen.
:hen in the room o# a patient who is in isolation #or tuber!ulosis, sta##
an visitors shoul wear ultra#ilter masks.
:hen proviing skin !are immeiately a#ter pin insertion, the nurse6s
primary !on!ern is prevention o# bone in#e!tion.
*#ter an amputation, moist skin may ini!ate venous stasis? ry skin may
ini!ate arterial obstru!tion.
In a patient who is re!eiving ialysis, an internal shunt is working i# the
nurse #eels a thrill on palpation or hears a bruit on aus!ultation.
In a patient with viral hepatitis, the paren!hymal, or .up##er6s, !ells o# the
liver be!ome severely in#lame, enlarge, an ne!roti!.
Early signs o# a!quire immunoe#i!ien!y synrome in!lue #atigue, night
sweats, enlarge lymph noes, anore3ia, weight loss, pallor, an #ever.
:hen !aring #or a patient who has a raioa!tive implant, health !are
workers shoul stay as #ar away #rom the raiation sour!e as possible. ,hey
shoul remember the a3iom, LI# you ouble the istan!e, you quarter the
ose.M
* patient who has %arkinson6s isease shoul be instru!te to walk with a
broa+base gait.
,he !arinal signs o# %arkinson6s isease are mus!le rigiity, a tremor that
begins in the #ingers, an akinesia.
In a patient with %arkinson6s isease, levoopa ("opar) is pres!ribe to
!ompensate #or the opamine e#i!ien!y.
* patient who has multiple s!lerosis is at in!rease risk #or pressure
ul!ers.
%ill+rolling tremor is a !lassi! sign o# %arkinson6s isease.
=or a patient with %arkinson6s isease, nursing interventions are palliative.
=at embolism, a serious !ompli!ation o# a long+bone #ra!ture, !auses
#ever, ta!hy!aria, ta!hypnea, an an3iety.
/etrorrhagia (bleeing between menstrual perios) may be the #irst sign
o# !ervi!al !an!er.
/annitol is a hypertoni! solution an an osmoti! iureti! that6s use in the
treatment o# in!rease intra!ranial pressure.
,he !lassi! sign o# an absen!e sei0ure is a va!ant #a!ial e3pression.
/igraine heaa!hes !ause persistent, severe pain that usually o!!urs in
the temporal region.
* patient who is in a blaer retraining program shoul be given an
opportunity to voi every ( hours uring the ay an twi!e at night.
In a patient with a hea in7ury, a e!rease in level o# !ons!iousness is a
!arinal sign o# in!rease intra!ranial pressure.
Ergotamine (Ergomar) is most e##e!tive when taken uring the proromal
phase o# a migraine or vas!ular heaa!he.
,reatment o# a!ute pan!reatitis in!lues nasogastri! su!tioning to
e!ompress the stoma!h an meperiine ("emerol) #or pain.
9ymptoms o# hiatal hernia in!lue a #eeling o# #ullness in the upper
abomen or !hest, heartburn, an pain similar to that o# angina pe!toris.
,he in!ien!e o# !holelithiasis is higher in women who have ha !hilren
than in any other group.
*!etaminophen (,ylenol) overose !an severely amage the liver.
,he prominent !lini!al signs o# avan!e !irrhosis are as!ites an
7auni!e.
,he #irst symptom o# pan!reatitis is steay epigastri! pain or le#t upper
quarant pain that raiates #rom the umbili!al area or the ba!k.
9omnambulism is the mei!al term #or sleepwalking.
Epinephrine (*renalin) is a vaso!onstri!tor.
*n untreate liver la!eration or rupture !an progress rapily to
hypovolemi! sho!k.
>bstipation is e3treme, intra!table !onstipation !ause by an intestinal
obstru!tion.
,he e#initive test #or iagnosing !an!er is biopsy with !ytologi!
e3amination o# the spe!imen.
*rthrography requires in7e!tion o# a !ontrast meium an !an ienti#y
7oint abnormalities.
&rompton6s !o!ktail is pres!ribe to help relieve pain in patients who have
terminal !an!er.
* sar!oma is a malignant tumor in !onne!tive tissue.
*luminum hyro3ie (*mpho7el) neutrali0es gastri! a!i.
9ublu3ation is partial islo!ation or separation, with spontaneous
reu!tion o# a 7oint.
&arbiturates !an !ause !on#usion an elirium in an elerly patient who
has an organi! brain isorer.
In a patient with arthritis, physi!al therapy is ini!ate to promote
optimal #un!tioning.
9ome patients who have hepatitis * may be ani!teri! (without 7auni!e)
an la!k symptoms, but some have heaa!hes, 7auni!e, anore3ia, #atigue,
#ever, an respiratory tra!t in#e!tion.
8epatitis * is usually mil an won6t avan!e to a !arrier state.
In the prei!teri! phase o# all #orms o# hepatitis, the patient is highly
!ontagious.
Enteri! pre!autions are require #or a patient who has hepatitis *.
-hole!ystography is ine##e!tive in a patient who has 7auni!e as a result
o# gallblaer isease. ,he liver !ells !an6t transport the !ontrast meium to
the biliary tra!t.
In a patient who has iabetes insipius, ehyration is a !on!ern be!ause
iabetes !auses polyuria.
In a patient who has a reu!ible hernia, the protruing mass
spontaneously retra!ts into the abomen.
,o prevent purple glove synrome, a nurse shouln6t aminister I.$.
phenytoin ("ilantin) through a vein in the ba!k o# the han, but shoul use a
larger vessel.
"uring stage III o# surgi!al anesthesia, un!ons!iousness o!!urs an
surgery is permitte.
,ypes o# regional anesthesia in!lue spinal, !aual, inter!ostal, epiural,
an bra!hial ple3us.
,he #irst step in managing rug overose or rug to3i!ity is to establish
an maintain an airway.
5espiratory paralysis o!!urs in stage I$ o# anesthesia (to3i! stage).
In stage I o# anesthesia, the patient is !ons!ious an tranquil.
"yspnea an sharp, stabbing pain that in!reases with respiration are
symptoms o# pleurisy, whi!h !an be a !ompli!ation o# pneumonia or
tuber!ulosis.
$ertigo is the ma7or symptom o# inner ear in#e!tion or isease.
Lou talking is a sign o# hearing impairment.
* patient who has an upper respiratory tra!t in#e!tion shoul blow his
nose with both nostrils open.
* patient who has ha a !atara!t remove !an begin most normal
a!tivities in 3 or 4 ays? however, the patient shouln6t ben an li#t until a
physi!ian approves these a!tivities.
9ymptoms o# !orneal transplant re7e!tion in!lue eye irritation an
e!reasing visual #iel.
)raves6 isease (hyperthyroiism) is mani#este by weight loss,
nervousness, yspnea, palpitations, heat intoleran!e, in!rease thirst,
e3ophthalmos (bulging eyes), an goiter.
,he #our types o# lipoprotein are !hylomi!rons (the lowest+ensity
lipoproteins), very+low+ensity lipoproteins, low+ensity lipoproteins, an
high+ensity lipoproteins. 8ealth !are pro#essionals use !holesterol level
#ra!tionation to assess a patient6s risk o# !oronary artery isease.
I# a patient who is taking amphoteri!in & (=ungi0one) blaer irrigations
#or a #ungal in#e!tion has systemi! !aniiasis an must re!eive I.$.
#lu!ona0ole ("i#lu!an), the irrigations !an be is!ontinue be!ause
#lu!ona0ole treats the blaer in#e!tion as well.
%atients with ault respiratory istress synrome !an have high peak
inspiratory pressures. ,here#ore, the nurse shoul monitor these patients
!losely #or signs o# spontaneous pneumothora3, su!h as a!ute eterioration
in o3ygenation, absen!e o# breath souns on the a##e!te sie, an !repitus
beginning on the a##e!te sie.
*verse rea!tions to !y!losporine (9animmune) in!lue renal an
hepati! to3i!ity, !entral nervous system !hanges (!on#usion an elirium),
)I bleeing, an hypertension.
>steoporosis is a metaboli! bone isorer in whi!h the rate o# bone
resorption e3!ees the rate o# bone #ormation.
,he hallmark o# ul!erative !olitis is re!urrent blooy iarrhea, whi!h
!ommonly !ontains pus an mu!us an alternates with asymptomati!
remissions.
9a#er se3ual pra!ti!es in!lue massaging, hugging, boy rubbing, #rienly
kissing (ry), masturbating, han+to+genital tou!hing, wearing a !onom,
an limiting the number o# se3ual partners.
Immunosuppresse patients who !ontra!t !ytomegalovirus (-/$) are at
risk #or -/$ pneumonia an septi!emia, whi!h !an be #atal.
Crinary tra!t in#e!tions !an !ause urinary urgen!y an #requen!y, ysuria,
abominal !ramps or blaer spasms, an urethral it!hing.
/ammography is a raiographi! te!hnique that6s use to ete!t breast
!ysts or tumors, espe!ially those that aren6t palpable on physi!al
e3amination.
,o promote early ete!tion o# testi!ular !an!er, the nurse shoul palpate
the testes uring routine physi!al e3aminations an en!ourage the patient to
per#orm monthly sel#+e3aminations uring a warm shower.
%atients who have thalassemia minor require no treatment. ,hose with
thalassemia ma7or require #requent trans#usions o# re bloo !ells.
* high level o# hepatitis & serum marker that persists #or 3 months or
more a#ter the onset o# a!ute hepatitis & in#e!tion suggests !hroni! hepatitis
or !arrier status.
Ieurogeni! blaer ys#un!tion is !ause by isruption o# nerve
transmission to the blaer. It may be !ause by !ertain spinal !or in7uries,
iabetes, or multiple s!lerosis.
>3ygen an !arbon io3ie move between the lungs an the bloostream
by i##usion.
,o grae the severity o# yspnea, the #ollowing system is useG grae ',
shortness o# breath on mil e3ertion, su!h as walking up steps? grae (,
shortness o# breath when walking a short istan!e at a normal pa!e on level
groun? grae 3, shortness o# breath with mil aily a!tivity, su!h as
shaving? grae 4, shortness o# breath when supine (orthopnea).
* patient with -rohn6s isease shoul !onsume a iet low in resiue, #iber,
an #at, an high in !alories, proteins, an !arbohyrates. ,he patient also
shoul take vitamin supplements, espe!ially vitamin ..
In the three+bottle urine !olle!tion metho, the patient !leans the meatus
an urinates '2 to '5 ml in the #irst bottle an '5 to 32 ml (mistream) in
the se!on bottle. ,hen the physi!ian per#orms prostati! massage, an the
patient vois into the thir bottle.
=inings in the three+bottle urine !olle!tion metho are interprete as
#ollowsG pus in the urine (pyuria) in the #irst bottle ini!ates anterior
urethritis? ba!teria in the urine in the se!on bottle ini!ate blaer
in#e!tion? ba!teria in the thir bottle ini!ate prostatitis.
9igns an symptoms o# aorti! stenosis in!lue a lou, rough systoli!
murmur over the aorti! area? e3ertional yspnea? #atigue? angina pe!toris?
arrhythmias? low bloo pressure? an emboli.
Ele!tive surgery is primarily a matter o# !hoi!e. It isn6t essential to the
patient6s survival, but it may improve the patient6s health, !om#ort, or sel#+
esteem.
5equire surgery is re!ommene by the physi!ian. It may be elaye,
but is inevitable.
Crgent surgery must be per#orme within (4 to 41 hours.
Emergen!y surgery must be per#orme immeiately.
*bout 15E o# arterial emboli originate in the heart !hambers.
%ulmonary embolism usually results #rom thrombi isloge #rom the leg
veins.
,he !ons!ious interpretation o# pain o!!urs in the !erebral !orte3.
,o avoi inter#ering with new !ell growth, the ressing on a onor skin
gra#t site shouln6t be isturbe.
* sequela is any abnormal !onition that #ollows an is the result o# a
isease, a treatment, or an in7ury.
"uring si!kle !ell !risis, patient !are in!lues be rest, o3ygen therapy,
analgesi!s as pres!ribe, I.$. #lui monitoring, an thorough o!umentation
o# #lui intake an output.
* patient who has an ileal !onuit shoul maintain a aily #lui intake o#
(,222 ml.
In a !lose !hest rainage system, !ontinuous bubbling in the water seal
!hamber or bottle ini!ates a leak.
%alpitation is a sensation o# heart pouning or ra!ing asso!iate with
normal emotional responses an !ertain heart isorers.
=at embolism is likely to o!!ur within the #irst (4 hours a#ter a long+bone
#ra!ture.
=ootrop !an o!!ur in a patient with a pelvi! #ra!ture as a result o#
peroneal nerve !ompression against the hea o# the #ibula.
,o promote venous return a#ter an amputation, the nurse shoul wrap an
elasti! banage aroun the istal en o# the stump.
:ater that a!!umulates in the tubing o# a ventilator shoul be remove.
,he most !ommon route #or the aministration o# epinephrine to a patient
who is having a severe allergi! rea!tion is the sub!utaneous route.
,he nurse shoul use =owler6s position #or a patient who has abominal
pain !ause by appeni!itis.
,he nurse shouln6t give analgesi!s to a patient who has abominal pain
!ause by appeni!itis be!ause these rugs may mask the pain that
a!!ompanies a rupture appeni3.
,he nurse shouln6t give analgesi!s to a patient who has abominal pain
!ause by appeni!itis be!ause these rugs may mask the pain that
a!!ompanies a rupture appeni3.
*s a last+it!h e##ort, a barbiturate !oma may be inu!e to reverse
unrelenting in!rease intra!ranial pressure (I-%), whi!h is e#ine as a!ute
I-% o# greater than 42 mm 8g, persistent elevation o# I-% above (2 mm 8g,
or rapily eteriorating neurologi! status.
,he primary signs an symptoms o# epiglottiitis are strior an
progressive i##i!ulty in swallowing.
9alivation is the #irst step in the igestion o# star!h.
* patient who has a eman pa!emaker shoul measure the pulse rate
be#ore rising in the morning, noti#y the physi!ian i# the pulse rate rops by 5
beats/minute, obtain a mei!al ienti#i!ation !ar an bra!elet, an resume
normal a!tivities, in!luing se3ual a!tivity.
,ransverse, or loop, !olostomy is a temporary pro!eure that6s per#orme
to ivert the #e!al stream in a patient who has a!ute intestinal obstru!tion.
Iormal values #or erythro!yte seimentation rate are 2 to '5 mm/hour #or
men younger than age 52 an 2 to (2 mm/hour #or women younger than
age 52.
* -.+/& level that6s more than 5E o# total -. or more than '2 C/L
suggests a myo!arial in#ar!tion.
%ropranolol (Ineral) blo!ks sympatheti! nerve stimuli that in!rease
!aria! work uring e3er!ise or stress, whi!h reu!es heart rate, bloo
pressure, an myo!arial o3ygen !onsumption.
*#ter a myo!arial in#ar!tion, ele!tro!ariogram !hanges (9,+segment
elevation, ,+wave inversion, an Q+wave enlargement) usually appear in the
#irst (4 hours, but may not appear until the 5th or ;th ay.
-ariogeni! sho!k is mani#este by systoli! bloo pressure o# less than 12
mm 8g, gray skin, iaphoresis, !yanosis, weak pulse rate, ta!hy!aria or
bray!aria, an oliguria (less than 32 ml o# urine per hour).
* patient who is re!eiving a low+soium iet shouln6t eat !ottage !heese,
#ish, !anne beans, !hu!k steak, !ho!olate puing, Italian sala ressing,
ill pi!kles, an bee# broth.
8igh+potassium #oos in!lue rie prunes, watermelon ('5.3 mEq/
portion), rie lima beans ('4.5 mEq/portion), soybeans, bananas, an
orang
es.
.ussmaul6s respirations are #aster an eeper than normal respirations
an o!!ur without pauses, as in iabeti! ketoa!iosis.
-heyne+9tokes respirations are !hara!teri0e by alternating perios o#
apnea an eep, rapi breathing. ,hey o!!ur in patients with !entral nervous
system isorers.
8yperventilation !an result #rom an in!rease #requen!y o# breathing, an
in!rease tial volume, or both.
*pnea is the absen!e o# spontaneous respirations.
&e#ore a thyroie!tomy, a patient may re!eive potassium ioie,
antithyroi rugs, an propranolol (Ineral) to prevent thyroi storm uring
surgery.
,he normal li#e span o# re bloo !ells (erythro!ytes) is ''2 to '(2 ays.
$isual a!uity o# (2/'22 means that the patient sees at (2R (; m) what a
person with normal vision sees at '22R (32 m).
Crinary tra!t in#e!tions are more !ommon in girls an women than in boys
an men be!ause the shorter urethra in the #emale urinary tra!t makes the
blaer more a!!essible to ba!teria, espe!ially Es!heri!hia !oli.
%eni!illin is aministere orally ' to ( hours be#ore meals or ( to 3 hours
a#ter meals be!ause #oo may inter#ere with the rug6s absorption.
/il rea!tions to lo!al anestheti!s may in!lue palpitations, tinnitus,
vertigo, apprehension, !on#usion, an a metalli! taste in the mouth.
*bout ((E o# !aria! output goes to the kineys.
,o ensure a!!urate !entral venous pressure reaings, the nurse shoul
pla!e the manometer or transu!er level with the phlebostati! a3is.
* patient who has lost (,222 to (,522 ml o# bloo will have a pulse rate o#
'42 beats/minute (or higher), isplay a systoli! bloo pressure o# 52 to ;2
mm 8g, an appear !on#use an lethargi!.
*rterial bloo is bright re, #lows rapily, an (be!ause it6s pumpe
ire!tly #rom the heart) spurts with ea!h heartbeat.
$enous bloo is ark re an tens to oo0e #rom a woun.
>rthostati! bloo pressure is taken with the patient in the supine, sitting,
an staning positions, with ' minute between ea!h reaing. * '2+mm 8g
e!rease in bloo pressure or an in!rease in pulse rate o# '2 beats/ minute
suggests volume epletion.
* pneumati! antisho!k garment shoul be use !autiously in pregnant
women an patients with hea in7uries.
*#ter a patient6s !ir!ulating volume is restore, the nurse shoul remove
the pneumati! antisho!k garment graually, starting with the abominal
!hamber an #ollowe by ea!h leg. ,he garment shoul be remove uner a
physi!ian6s supervision.
/ost hemolyti! trans#usion rea!tions asso!iate with mismat!hing o# *&>
bloo types stem #rom ienti#i!ation number errors.
:arming o# bloo to more than '2A@ = (4'.A@ -) !an !ause hemolysis.
-aria! output is the amount o# bloo e7e!te #rom the heart ea!h
minute. It6s e3presse in liters per minute.
9troke volume is the volume o# bloo e7e!te #rom the heart uring
systole.
,otal parenteral nutrition solution !ontains e3trose, amino a!is, an
aitives, su!h as ele!trolytes, minerals, an vitamins.
,he most !ommon type o# neurogeni! sho!k is spinal sho!k. It usually
o!!urs 32 to ;2 minutes a#ter a spinal !or in7ury.
*#ter a spinal !or in7ury, peristalsis stops within (4 hours an usually
returns within 3 to 4 ays.
,o3i! sho!k synrome is mani#este by a temperature o# at least '2(@ =
(31.1@ -), an erythematous rash, an systoli! bloo pressure o# less than B2
mm 8g. =rom ' to ( weeks a#ter the onset o# these signs, esquamation
(espe!ially on the palms an soles) o!!urs.
,he signs an symptoms o# anaphyla3is are !ommonly !ause by
histamine release.
,he most !ommon !ause o# septi! sho!k is gram+negative ba!teria, su!h
as Es!heri!hia !oli, .lebsiella, an %seuomonas organisms.
&ruits are vas!ular souns that resemble heart murmurs an result #rom
turbulent bloo #low through a isease or partially obstru!te artery.
Crine p8 is normally 4.5 to 1.2.
Crine p8 o# greater than 1.2 !an result #rom a urinary tra!t in#e!tion, a
high+alkali iet, or systemi! alkalosis.
Crine p8 o# less than 4.5 may be !ause by a high+protein iet, #ever, or
metaboli! a!iosis.
&e#ore a per!utaneous renal biopsy, the patient shoul be pla!e on a
#irm sur#a!e an positione on the abomen. * sanbag is pla!e uner the
abomen to stabili0e the kineys.
Iephroti! synrome is !hara!teri0e by marke proteinuria,
hypoalbuminemia, mil to severe epenent eema, as!ites, an weight
gain.
Cnerwater e3er!ise is a #orm o# therapy per#orme in a 8ubbar tank.
/ost women with tri!homoniasis have a maloorous, #rothy, greenish
gray vaginal is!harge. >ther women may have no signs or symptoms.
$oiing !ystourethrography may be per#orme to ete!t blaer an
urethral abnormalities. -ontrast meium is instille by gentle syringe
pressure through a urethral !atheter, an overhea <+ray #ilms are taken to
visuali0e blaer #illing an e3!retion.
-ystourethrography may be per#orme to ienti#y the !ause o# urinary
tra!t in#e!tions, !ongenital anomalies, an in!ontinen!e. It also is use to
assess #or prostate lobe hypertrophy in men.
8erpes simple3 is !hara!teri0e by re!urrent episoes o# blisters on the
skin an mu!ous membranes. It has two variations. In type ', the blisters
appear in the nasolabial region? in type (, they appear on the genitals, anus,
butto!ks, an thighs.
/ost patients with -hlamyia tra!homatis in#e!tion are asymptomati!, but
some have an in#lame urethral meatus, ysuria, an urinary urgen!y an
#requen!y.
,he hypothalamus regulates the autonomi! nervous system an eno!rine
#un!tions.
* patient whose !hest e3!ursion is less than normal (3D to ;D NA.5 to '5
!mO) must use a!!essory mus!les to breathe.
9igns an symptoms o# to3i!ity #rom thyroi repla!ement therapy in!lue
rapi pulse rate, iaphoresis, irritability, weight loss, ysuria, an sleep
isturban!e.
,he most !ommon allergi! rea!tion to peni!illin is a rash.
*n early sign o# aspirin to3i!ity is eep, rapi respirations.
,he most serious an irreversible !onsequen!e o# lea poisoning is mental
retaration, whi!h results #rom neurologi! amage.
,o assess ehyration in the ault, the nurse shoul !he!k skin turgor on
the sternum.
=or a patient with a pepti! ul!er, the type o# iet is less important than
in!luing #oos in the iet that the patient !an tolerate.
* patient with a !olostomy must establish an irrigation s!heule so that
regular emptying o# the bowel o!!urs without stomal is!harge between
irrigations.
:hen using rotating tourniquets, the nurse shouln6t restri!t the bloo
supply to an arm or leg #or more than 45 minutes at a time.
* patient with iabetes shoul eat high+#iber #oos be!ause they blunt the
rise in glu!ose level that normally #ollows a meal.
Sugular vein istention o!!urs in patients with heart #ailure be!ause the
le#t ventri!le !an6t empty the heart o# bloo as #ast as bloo enters #rom the
right ventri!le, resulting in !ongestion in the entire venous system.
,he leaing !auses o# blinness in the Cnite 9tates are iabetes mellitus
an glau!oma.
*#ter a thyroie!tomy, the patient shoul remain in the semi+=owler
position, with his hea neither hypere3tene nor hyper#le3e, to avoi
pressure on the suture line. ,his position !an be a!hieve with the use o# a
!ervi!al pillow.
%remenstrual synrome may !ause abominal istention, engorge an
pain#ul breasts, ba!ka!he, heaa!he, nervousness, irritability, restlessness,
an tremors.
,reatment o# ehis!en!e (pathologi! opening o# a woun) !onsists o#
!overing the woun with a moist sterile ressing an noti#ying the physi!ian.
:hen a patient has a rai!al maste!tomy, the ovaries also may be
remove be!ause they are a sour!e o# estrogen, whi!h stimulates tumor
growth.
*tropine blo!ks the e##e!ts o# a!etyl!holine, thereby obstru!ting its vagal
e##e!ts on the sinoatrial noe an in!reasing heart rate.
9ali!ylates, parti!ularly aspirin, are the treatment o# !hoi!e in rheumatoi
arthritis be!ause they e!rease in#lammation an relieve 7oint pain.
"eep, intense pain that usually worsens at night an is unrelate to
movement suggests bone pain.
%ain that #ollows prolonge or e3!essive e3er!ise an subsies with rest
suggests mus!le pain.
,he ma7or hemoynami! !hanges asso!iate with !ariogeni! sho!k are
e!rease le#t ventri!ular #un!tion an e!rease !aria! output.
&e#ore thyroie!tomy, the patient shoul be avise that he may
e3perien!e hoarseness or loss o# his voi!e #or several ays a#ter surgery.
*!!eptable averse e##e!ts o# long+term steroi use in!lue weight gain,
a!ne, heaa!hes, #atigue, an in!rease urine retention.
Cna!!eptable averse e##e!ts o# long+term steroi use are i00iness on
rising, nausea, vomiting, thirst, an pain.
*#ter a !raniotomy, nursing !are in!lues maintaining normal intra!ranial
pressure, maintaining !erebral per#usion pressure, an preventing in7ury
relate to !erebral an !ellular is!hemia.
=oli! a!i an vitamin &'( are essential #or nu!leoprotein synthesis an
re bloo !ell maturation.
Immeiately a#ter intra!ranial surgery, nursing !are in!lues not giving
the patient anything by mouth until the gag an !ough re#le3es return,
monitoring vital signs an assessing the level o# !ons!iousness (L>-) #or
signs o# in!reasing intra!ranial pressure, an aministering analgesi!s that
on6t mask the L>-.
-hest physiotherapy in!lues postural rainage, !hest per!ussion an
vibration, an !oughing an eep+breathing e3er!ises.
-ushing6s synrome results #rom e3!essive levels o# areno!orti!al
hormones an is mani#este by #at pas on the #a!e (moon #a!e) an over
the upper ba!k (bu##alo hump), a!ne, moo swings, hirsutism, amenorrhea,
an e!rease libio.
,o prevent an aisonian !risis when is!ontinuing long+term prenisone
("eltasone) therapy, the nurse shoul taper the ose slowly to allow #or
monitoring o# isease #lare+ups an #or the return o# hypothalami!+pituitary+
arenal #un!tion.
%ulsus parao3us is a pulse that be!omes weak uring inspiration an
strong uring e3piration. It may be a sign o# !aria! tamponae.
9ubstan!es that are e3pelle through portals o# e3it in!lue saliva,
mu!us, #e!es, urine, vomitus, bloo, an vaginal an penile is!harges.
* mi!roorganism may be transmitte ire!tly, by !onta!t with an in#e!te
boy or roplets, or inire!tly, by !onta!t with !ontaminate air, soil, water,
or #luis.
* postmenopausal woman who re!eives estrogen therapy is at an
in!rease risk #or gallblaer isease an breast !an!er.
,he appro3imate o3ygen !on!entrations elivere by a nasal !annula are
as #ollowsG ' L H (4E, ( L H (1E, 3 L H 3(E, 4 LH 3;E, an 5 L H 42E.
-arinal #eatures o# iabetes insipius in!lue polyipsia (e3!essive thirst)
an polyuria (in!rease urination to 5 L/(4 hours).
* patient with low spe!i#i! gravity ('.22' to '.225) may have an
in!rease esire #or !ol water.
"iabeti! !oma !an o!!ur when the bloo glu!ose level rops below ;2
mg/l.
=or a patient with heart #ailure, the nurse shoul elevate the hea o# the
be 1D to '(D ((2 to 32 !m), provie a besie !ommoe, an aminister
!aria! gly!osies an iureti!s as pres!ribe.
,he primary reason to treat strepto!o!!al sore throat with antibioti!s is to
prote!t the heart valves an prevent rheumati! #ever.
* patient with a nasal #ra!ture may lose !ons!iousness uring reu!tion.
8oarseness an !hange in the voi!e are !ommonly the #irst signs o#
laryngeal !an!er.
,he lungs, !olon, an re!tum are among the most !ommon !an!er sites.
,he most !ommon preoperative problem in elerly patients is lower+than+
normal total bloo volume.
/annitol (>smitrol), an osmoti! iureti!, is aministere to reu!e
intrao!ular or intra!ranial pressure.
:hen a stroke is suspe!te, the nurse shoul pla!e the patient on the
a##e!te sie to promote lung e3pansion on the una##e!te sie.
=or a patient who has ha !hest surgery, the nurse shoul re!ommen
sitting upright an per#orming !oughing an eep+breathing e3er!ises. ,hese
a!tions promote e3pansion o# the lungs, removal o# se!retions, an optimal
pulmonary #un!tioning.
"uring every sleep !y!le, the sleeper passes through #our stages o#
nonrapi+eye+movement sleep an one stage o# rapi+eye+movement sleep.
* patient who is taking !al!i#eiol (-alerol) shoul avoi !on!omitant use
o# preparations that !ontain vitamin ".
* patient shoul begin an en a (4+hour urine !olle!tion perio with an
empty blaer. =or e3ample, i# the physi!ian orers urine to be !olle!te
#rom 2122 ,hursay to 2122 =riay, the urine voie at 2122 ,hursay
shoul be is!are an the urine voie at 2122 =riay shoul be retaine.
In a patient who is re!eiving igo3in (Lano3in), a low potassium level
in!reases the risk o# igo3in to3i!ity.
&loo urea nitrogen values normally range #rom '2 to (2 mg/l.
=lura0epam ("almane) to3i!ity is mani#este by !on#usion, hallu!inations,
an ata3ia.
* silent myo!arial in#ar!tion is one that has no symptoms.
*verse rea!tions to verapamil (Isoptin) in!lue i00iness, heaa!he,
!onstipation, hypotension, an atrioventri!ular !onu!tion isturban!es. ,he
rug also may in!rease the serum igo3in level.
:hen a re!tal tube is use to relieve #latulen!e or enhan!e peristalsis, it
shoul be inserte #or no longer than (2 minutes.
Pellowish green is!harge on a woun ressing ini!ates in#e!tion an
shoul be !ulture.
9i!kle !ell !risis !an !ause severe abominal, thora!i!, mus!ular, an
bone pain along with pain#ul swelling o# so#t tissue in the hans an #eet.
>ral !aniiasis (thrush) is !hara!teri0e by !ream+!olore or bluish white
pat!hes on the oral mu!ous membrane.
,reatment #or a patient with !ysti! #ibrosis may in!lue rug therapy,
e3er!ises to improve breathing an posture, e3er!ises to #a!ilitate
mobili0ation o# pulmonary se!retions, a high+salt iet, an pan!reati!
en0yme supplements with sna!ks an meals.
%an!reati! !an!er may !ause weight loss, 7auni!e, an intermittent ull+
to+severe epigastri! pain.
/etastasis is the sprea o# !an!er #rom one organ or boy part to another
through the lymphati! system, !ir!ulation system, or !erebrospinal #lui.
,he management o# pulmonary eema #o!uses on opening the airways,
supporting ventilation an per#usion, improving !aria! #un!tioning, reu!ing
preloa, an reu!ing patient an3iety.
=a!tors that !ontribute to the eath o# patients with *l0heimer6s isease
in!lue in#e!tion, malnutrition, an ehyration.
8ogkin6s isease is !hara!teri0e by painless, progressive enlargement
o# !ervi!al lymph noes an other lymphoi tissue as a result o# proli#eration
o# 5ee+9ternberg !ells, histio!ytes, an eosinophils.
8untington6s isease (!horea) is a hereitary isease !hara!teri0e by
egeneration in the !erebral !orte3 an basal ganglia.
* patient with 8untington6s isease may e3hibit sui!ial ieation.
*t is!harge, an amputee shoul be able to emonstrate proper stump
!are an per#orm stump+toughening e3er!ises.
*!ute tubular ne!rosis is the most !ommon !ause o# a!ute renal #ailure.
-ommon !ompli!ations o# i!e water lavage are vomiting an aspiration.
=oos high in vitamin " in!lue #orti#ie milk, #ish, liver, liver oil, herring,
an egg yolk.
=or a pelvi! e3amination, the patient shoul be in the lithotomy position,
with the butto!ks e3tening (TD (;.4 !m) past the en o# the e3amination
table.
I# a patient !an6t assume the lithotomy position #or a pelvi! e3amination,
she may lie on her le#t sie.
* male e3aminer shoul have a #emale assistant present uring a vaginal
e3amination #or the patient6s emotional !om#ort an the e3aminer6s legal
prote!tion.
-ervi!al se!retions are !lear an stret!hy be#ore ovulation an white an
opaque a#ter ovulation. ,hey6re normally oorless an on6t irritate the
mu!osa.
* patient with an ileostomy shouln6t eat !orn be!ause it may obstru!t the
opening o# the pou!h.
Liver ys#un!tion a##e!ts the metabolism o# !ertain rugs.
Eema that a!!ompanies burns an malnutrition is !ause by e!rease
osmoti! pressure in the !apillaries.
8yponatremia is most likely to o!!ur as a !ompli!ation o# nasogastri!
su!tioning.
In a man who has !omplete spinal !or separation at 94, ere!tion an
e7a!ulation aren6t possible.
,he early signs o# pulmonary eema (yspnea on e3ertion an !oughing)
re#le!t interstitial #lui a!!umulation an e!rease ventilation an alveolar
per#usion.
/ethylprenisolone (9olu+/erol) is a #irst+line rug use to !ontrol
eema a#ter spinal !or trauma.
=or the patient who is re!overing #rom an intra!ranial blee, the nurse
shoul maintain a quiet, rest#ul environment #or the #irst #ew ays.
Ieurosyphilis is asso!iate with wiesprea amage to the !entral
nervous system, in!luing general paresis, personality !hanges, slapping
gait, an blinness.
* woman who has ha a spinal !or in7ury !an still be!ome pregnant.
In a patient who has ha a stroke, the most serious !ompli!ation is
in!reasing intra!ranial pressure.
* patient with an intra!ranial hemorrhage shoul unergo arteriography
to ienti#y the site o# the bleeing.
=a!tors that a##e!t the a!tion o# rugs in!lue absorption, istribution,
metabolism, an e3!retion.
&e#ore pres!ribing a rug #or a woman o# !hilbearing age, the pres!riber
shoul ask #or the ate o# her last menstrual perio an ask i# she may be
pregnant.
*!iosis may !ause insulin resistan!e.
* patient with glu!ose+;+phosphate ehyrogenase e#i!ien!y may have
a!ute hemolyti! anemia when given a sul#onamie.
,he #ive basi! a!tivities o# the igestive system are ingestion, movement
o# #oo, igestion, absorption, an e#e!ation.
9igns an symptoms o# a!ute pan!reatitis in!lue epigastri! pain,
vomiting, bluish is!oloration o# the le#t #lank ()rey ,urner6s sign), bluish
is!oloration o# the periumbili!al area (-ullen6s sign), low+grae #ever,
ta!hy!aria, an hypotension.
* patient with a gastri! ul!er may have gnawing or burning epigastri!
pain.
,o test the #irst !ranial nerve (ol#a!tory nerve), the nurse shoul ask the
patient to !lose his eyes, o!!lue one nostril, an ienti#y a nonirritating
substan!e (su!h as peppermint or !innamon) by smell. ,hen the nurse
shoul repeat the test with the patient6s other nostril o!!lue.
9alk an 9abin introu!e the oral polio va!!ine.
* patient with a isease o# the !erebellum or posterior !olumn has an
ata3i! gait that6s !hara!teri0e by staggering an inability to remain steay
when staning with the #eet together.
In trauma patients, improve out!ome is ire!tly relate to early
resus!itation, aggressive management o# sho!k, an appropriate e#initive
!are.
,o !he!k #or leakage o# !erebrospinal #lui, the nurse shoul inspe!t the
patient6s nose an ears. I# the patient !an sit up, the nurse shoul observe
him #or leakage as the patient leans #orwar.
Lo!ke+in synrome is !omplete paralysis as a result o# brain stem
amage. >nly the eyes !an be move voluntarily.
Ie!k isse!tion, or surgi!al removal o# the !ervi!al lymph noes, is
per#orme to prevent the sprea o# malignant tumors o# the hea an ne!k.
* patient with !hole!ystitis typi!ally has right epigastri! pain that may
raiate to the right s!apula or shouler? nausea? an vomiting, espe!ially
a#ter eating a heavy meal.
*tropine is use preoperatively to reu!e se!retions.
9erum !al!ium levels are normally 4.5 to 5.5 mEq/L.
9uppressor , !ells regulate overall immune response.
9erum levels o# aspartate aminotrans#erase an alanine aminotrans#erase
show whether the liver is aequately eto3i#ying rugs.
9erum soium levels are normally '35 to '45 mEq/L.
9erum potassium levels are normally 3.5 to 5.2 mEq/L.
* patient who is taking prenisone ("eltasone) shoul !onsume a salt+
restri!te iet that6s ri!h in potassium an protein.
:hen per#orming !ontinuous ambulatory peritoneal ialysis, the nurse
must use sterile te!hnique when hanling the !atheter, sen a peritoneal
#lui sample #or !ulture an sensitivity testing every (4 hours, an report
signs o# in#e!tion an #lui imbalan!e.
:hen working with patients who have a!quire immunoe#i!ien!y
synrome, the nurse shoul wear goggles an a mask only i# bloo or
another boy #lui !oul splash onto the nurse6s #a!e.
&loo spills that are in#e!te with human immunoe#i!ien!y virus shoul
be !leane up with a 'G'2 solution o# soium hypo!hlorite 5.(5E (househol
blea!h).
5aynau6s phenomenon is intermittent is!hemi! atta!ks in the #ingers or
toes. It !auses severe pallor an sometimes paresthesia an pain.
Intussus!eption (prolapse o# one bowel segment into the lumen o#
another) !auses suen epigastri! pain, sausage+shape abominal swelling,
passage o# mu!us an bloo through the re!tum, sho!k, an hypotension.
&en!e Sones protein o!!urs almost e3!lusively in the urine o# patients who
have multiple myeloma.
)au!her6s isease is an autosomal isorer that6s !hara!teri0e by
abnormal a!!umulation o# glu!o!erebrosies (lipi substan!es that !ontain
glu!ose) in mono!ytes an ma!ro!ytes. It has three #ormsG ,ype ' is the
ault #orm, type ( is the in#antile #orm, an type 3 is the 7uvenile #orm.
* patient with !olon obstru!tion may have lower abominal pain,
!onstipation, in!reasing istention, an vomiting.
-ol!hi!ine (-olsalie) relieves in#lammation an is use to treat gout.
9ome people have gout as a result o# hyperuri!emia be!ause they !an6t
metaboli0e an e3!rete purines normally.
* normal sperm !ount is (2 to '52 million/ml.
* #irst+egree burn involves the stratum !orneum layer o# the epiermis
an !auses pain an reness.
9heehan6s synrome is hypopituitarism !ause by a pituitary in#ar!t a#ter
postpartum sho!k an hemorrhage.
:hen !aring #or a patient who has ha an asthma atta!k, the nurse
shoul pla!e the patient in =owler6s or semi+=owler6s position.
In elerly patients, the in!ien!e o# non!omplian!e with pres!ribe rug
therapy is high. /any elerly patients have iminishe visual a!uity, hearing
loss, or #orget#ulness, or nee to take multiple rugs.
,uber!ulosis is a reportable !ommuni!able isease that6s !ause by
in#e!tion with /y!oba!terium tuber!ulosis (an a!i+#ast ba!illus).
=or right+sie !aria! !atheteri0ation, the physi!ian passes a multilumen
!atheter through the superior or in#erior vena !ava.
*#ter a #ra!ture, bone healing o!!urs in these stagesG hematoma
#ormation, !ellular proli#eration an !allus #ormation, an ossi#i!ation an
remoeling.
* patient who is s!heule #or positron emission tomography shoul avoi
al!ohol, toba!!o, an !a##eine #or (4 hours be#ore the test.
In a stroke, e!rease o3ygen estroys brain !ells.
* patient with glau!oma shouln6t re!eive atropine sul#ate be!ause it
in!reases intrao!ular pressure.
,he nurse shoul instru!t a patient who is hyperventilating to breathe into
a paper bag.
"uring intermittent positive+pressure breathing, the patient shoul bite
own on the mouthpie!e, breathe normally, an let the ma!hine o the
work. *#ter inspiration, the patient shoul hol his breath #or 3 or 4 se!ons
an e3hale !ompletely through the mouthpie!e.
=le3ion !ontra!tures o# the hips may o!!ur in a patient who sits in a
wheel!hair #or a long time.
Iystagmus is rapi hori0ontal or rotating eye movement.
*#ter myelography, the patient shoul remain re!umbent #or (4 hours.
,he treatment o# sprains an strains !onsists o# applying i!e immeiately
an elevating the arm or leg above heart level.
*n anti!holinesterase agent shouln6t be pres!ribe #or a patient who is
taking morphine be!ause it !an potentiate the e##e!t o# morphine an !ause
respiratory epression.
/yopia is nearsighteness. 8yperopia an presbyopia are two types o#
#arsighteness.
,he most e##e!tive !ontra!eptive metho is one that the woman sele!ts
#or hersel# an uses !onsistently.
,o per#orm :eber6s test #or bone !onu!tion, a vibrating tuning #ork is
pla!e on top o# the patient6s hea at miline. ,he patient shoul per!eive
the soun equally in both ears. In a patient who has !onu!tive hearing loss,
the soun is hear in (laterali0es to) the ear that has !onu!tive loss.
In the 5inne test, bone !onu!tion is teste by pla!ing a vibrating tuning
#ork on the mastoi pro!ess o# the temporal bone an air !onu!tion is
teste by holing the vibrating tuning #ork TD ('.3 !m) #rom the e3ternal
auitory meatus. ,hese tests are alternate, at i##erent #requen!ies, until
the tuning #ork is no longer hear at one position.
*#ter an amputation, the stump may shrink be!ause o# mus!le atrophy
an e!rease sub!utaneous #at.
* patient who has eep vein thrombosis is given heparin #or A to '2 ays,
#ollowe by '( weeks o# war#arin (-oumain) therapy.
*#ter pneumone!tomy, the patient shoul be positione on the operative
sie or on his ba!k, with his hea slightly elevate.
,o reu!e the possibility o# #ormation o# new emboli or e3pansion o#
e3isting emboli, a patient with eep vein thrombosis shoul re!eive heparin.
*theros!lerosis is the most !ommon !ause o# !oronary artery isease. It
usually involves the aorta an the #emoral, !oronary, an !erebral arteries.
%ulmonary embolism is a potentially #atal !ompli!ation o# eep vein
thrombosis.
-hest pain is the most !ommon symptom o# pulmonary embolism.
,he nurse shoul in#orm a patient who is taking phena0opyriine
(%yriium) that this rug !olors urine orange or re.
%neumothora3 is a serious !ompli!ation o# !entral venous line pla!ement?
it6s !ause by inavertent lung pun!ture.
%neumo!ystis !arinii pneumonia isn6t !onsiere !ontagious be!ause it
only a##e!ts patients who have a suppresse immune system.
,o enhan!e rug absorption, the patient shoul take regular erythromy!in
tablets with a #ull glass o# water ' hour be#ore or ( hours a#ter a meal or
shoul take enteri!+!oate tablets with #oo. ,he patient shoul avoi taking
either type o# tablet with #ruit 7ui!e.
,rismus, a sign o# tetanus (lo!k7aw), !auses pain#ul spasms o# the
masti!atory mus!les, i##i!ulty opening the mouth, ne!k rigiity an
sti##ness, an ysphagia.
,he nurse shoul pla!e the patient in an upright position #or
thora!entesis. I# this isn6t possible, the nurse shoul position the patient on
the una##e!te sie.
I# gravity #low is use, the nurse shoul hang a bloo bag 3R (' m) above
the level o# the planne venipun!ture site.
,he nurse shoul pla!e a patient who has a !lose !hest rainage system
in the semi+=owler position.
I# bloo isn6t trans#use within 32 minutes, the nurse shoul return it to
the bloo bank be!ause the re#rigeration #a!ilities on a nursing unit are
inaequate #or storing bloo prou!ts.
&loo that6s is!olore an !ontains gas bubbles is !ontaminate with
ba!teria an shouln6t be trans#use. =i#ty per!ent o# patients who re!eive
!ontaminate bloo ie.
=or massive, rapi bloo trans#usions an #or e3!hange trans#usions in
neonates, bloo shoul be warme to B1.A@ = (3A@ -).
* !hest tube permits air an #lui to rain #rom the pleural spa!e.
* hanhel resus!itation bag is an in#latable evi!e that !an be atta!he
to a #a!e mask or an enotra!heal or tra!heostomy tube. It allows manual
elivery o# o3ygen to the lungs o# a patient who !an6t breathe inepenently.
/e!hani!al ventilation arti#i!ially !ontrols or assists respiration.
,he nurse shoul en!ourage a patient who has a !lose !hest rainage
system to !ough #requently an breathe eeply to help rain the pleural
spa!e an e3pan the lungs.
,ra!heal su!tion removes se!retions #rom the tra!hea an bron!hi with a
su!tion !atheter.
"uring !olostomy irrigation, the irrigation bag shoul be hung '1D (45.A
!m) above the stoma.
,he water use #or !olostomy irrigation shoul be '22@ to '25@ = (3A.1@
to 42.;@ -).
*n arterial embolism may !ause pain, loss o# sensory nerves, pallor,
!oolness, paralysis, pulselessness, or paresthesia in the a##e!te arm or leg.
5espiratory alkalosis results #rom !onitions that !ause hyperventilation
an reu!e the !arbon io3ie level in the arterial bloo.
/ineral oil is !ontraini!ate in a patient with appeni!itis, a!ute surgi!al
abomen, #e!al impa!tion, or intestinal obstru!tion.
:hen using a P+type aministration set to trans#use pa!ke re bloo
!ells (5&-s), the nurse !an a normal saline solution to the bag to ilute
the 5&-s an make them less vis!ous.
*utotrans#usion is !olle!tion, #iltration, an rein#usion o# the patient6s own
bloo.
%repare I.$. solutions #all into three general !ategoriesG isotoni!,
hypotoni!, an hypertoni!. Isotoni! solutions have a solute !on!entration
that6s similar to boy #luis? aing them to plasma oesn6t !hange its
osmolarity. 8ypotoni! solutions have a lower osmoti! pressure than boy
#luis? aing them to plasma e!reases its osmolarity. 8ypertoni! solutions
have a higher osmoti! pressure than boy #luis? aing them to plasma
in!reases its osmolarity.
9tress in!ontinen!e is involuntary leakage o# urine triggere by a suen
physi!al strain, su!h as a !ough, snee0e, or qui!k movement.
"e!rease renal #un!tion makes an elerly patient more sus!eptible to the
evelopment o# renal !al!uli.
,he nurse shoul !onsier using shorter neeles to in7e!t rugs in elerly
patients be!ause these patients e3perien!e sub!utaneous tissue
reistribution an loss in areas, su!h as the butto!ks an eltoi mus!les.
Crge in!ontinen!e is the inability to suppress a suen urge to urinate.
,otal in!ontinen!e is !ontinuous, un!ontrollable leakage o# urine as a
result o# the blaer6s inability to retain urine.
%rotein, vitamin, an mineral nees usually remain !onstant as a person
ages, but !alori! requirements e!rease.
=our valves keep bloo #lowing in one ire!tion in the heartG two
atrioventri!ular valves (tri!uspi an mitral) an two semilunar valves
(pulmoni! an aorti!).
*n elerly patient6s height may e!rease be!ause o# narrowing o# the
intervertebral spa!es an e3aggerate spinal !urvature.
-onstipation most !ommonly o!!urs when the urge to e#e!ate is
suppresse an the mus!les asso!iate with bowel movements remain
!ontra!te.
)out evelops in #our stagesG asymptomati!, a!ute, inter!riti!al, an
!hroni!.
-ommon postoperative !ompli!ations in!lue hemorrhage, in#e!tion,
hypovolemia, septi!emia, septi! sho!k, atele!tasis, pneumonia,
thrombophlebitis, an pulmonary embolism.
*n insulin pump elivers a !ontinuous in#usion o# insulin into a sele!te
sub!utaneous site, !ommonly in the abomen.
* !ommon symptom o# sali!ylate (aspirin) to3i!ity is tinnitus (ringing in
the ears).
* #rostbitten e3tremity must be thawe rapily, even i# e#initive
treatment must be elaye.
* patient with 5aynau6s isease shouln6t smoke !igarettes or other
toba!!o prou!ts.
5aynau6s isease is a primary arteriospasti! isorer that has no known
!ause. 5aynau6s phenomenon, however, is !ause by another isorer su!h
as s!leroerma.
,o remove a #oreign boy #rom the eye, the nurse shoul irrigate the eye
with sterile normal saline solution.
:hen irrigating the eye, the nurse shoul ire!t the solution towar the
lower !on7un!tival sa!.
Emergen!y !are #or a !orneal in7ury !ause by a !austi! substan!e is
#lushing the eye with !opious amounts o# water #or (2 to 32 minutes.
"ebriement is me!hani!al, !hemi!al, or surgi!al removal o# ne!roti!
tissue #rom a woun.
9evere pain a#ter !atara!t surgery ini!ates bleeing in the eye.
* bivalve !ast is !ut into anterior an posterior portions to allow skin
inspe!tion.
*#ter ear irrigation, the nurse shoul pla!e the patient on the a##e!te sie
to permit gravity to rain #lui that remains in the ear.
I# a patient with an inwelling !atheter has abominal is!om#ort, the
nurse shoul assess #or blaer istention, whi!h may be !ause by !atheter
blo!kage.
-ontinuous blaer irrigation helps prevent urinary tra!t obstru!tion by
#lushing out small bloo !lots that #orm a#ter prostate or blaer surgery.
,he nurse shoul remove an inwelling !atheter when blaer
e!ompression is no longer neee, when the !atheter is obstru!te, or
when the patient !an resume voiing. ,he longer a !atheter remains in
pla!e, the greater the risk o# urinary tra!t in#e!tion.
In an ault, the e3tent o# a burn in7ury is etermine by using the 5ule o#
IinesG the hea an ne!k are !ounte as BE? ea!h arm, as BE? ea!h leg,
as '1E? the ba!k o# the trunk, as '1E? the #ront o# the trunk, as '1E? an
the perineum, as 'E.
* eep partial+thi!kness burn a##e!ts the epiermis an ermis.
In a patient who is having an asthma atta!k, nursing interventions in!lue
aministering o3ygen an bron!hoilators as pres!ribe, pla!ing the patient
in the semi+=owler position, en!ouraging iaphragmati! breathing, an
helping the patient to rela3.
%rostate !an!er is usually #atal i# bone metastasis o!!urs.
* stri!t vegetarian nees vitamin &'( supplements be!ause animals an
animal prou!ts are the only sour!e o# this vitamin.
5egular insulin is the only type o# insulin that !an be mi3e with other
types o# insulin an !an be given I.$.
I# a patient pulls out the outer tra!heostomy tube, the nurse shoul hol
the tra!heostomy open with a surgi!al ilator until the physi!ian provies
appropriate !are.
,he meulla oblongata is the part o# the brain that !ontrols the
respiratory !enter.
=or an un!ons!ious patient, the nurse shoul per#orm passive range+o#+
motion e3er!ises every ( to 4 hours.
* time+release rug isn6t re!ommene #or use in a patient who has an
ileostomy be!ause it releases the rug at i##erent rates along the )I tra!t.
,he nurse isn6t require to wear gloves when applying nitrogly!erin paste?
however, she shoul wash her hans a#ter applying this rug.
&e#ore e3!retory urography, a patient6s #lui intake is usually restri!te
a#ter minight.
* soium polystyrene sul#onate (.aye3alate) enema, whi!h e3!hanges
soium ions #or potassium ions, is use to e!rease the potassium level in a
patient who has hyperkalemia.
I# the !olor o# a stoma is mu!h lighter than when previously assesse,
e!rease !ir!ulation to the stoma shoul be suspe!te.
/assage is !ontraini!ate in a leg with a bloo !lot be!ause it may
isloge the !lot.
,he #irst pla!e a nurse !an ete!t 7auni!e in an ault is in the s!lera.
Sauni!e is !ause by e3!essive levels o# !on7ugate or un!on7ugate
bilirubin in the bloo.
/yriati! rugs are use primarily to ilate the pupils #or intrao!ular
e3aminations.
*#ter eye surgery, the patient shoul be pla!e on the una##e!te sie.
:hen assigning tasks to a li!ense pra!ti!al nurse, the registere nurse
shoul elegate tasks that are !onsiere besie nursing !are, su!h as
taking vital signs, !hanging simple ressings, an giving baths.
"eep !al# pain on orsi#le3ion o# the #oot is a positive 8omans6 sign, whi!h
suggests venous thrombosis or thrombophlebitis.
Cltra+short+a!ting barbiturates, su!h as thiopental (%entothal), are use
as in7e!tion anestheti!s when a short uration o# anesthesia is neee su!h
as outpatient surgery.
*tropine sul#ate may be use as a preanestheti! rug to reu!e se!retions
an minimi0e vagal re#le3es.
=or a patient with in#e!tious mononu!leosis, the nursing !are plan shoul
emphasi0e stri!t be rest uring the a!ute #ebrile stage to ensure aequate
rest.
"uring the a!ute phase o# in#e!tious mononu!leosis, the patient shoul
!urtail a!tivities to minimi0e the possibility o# rupturing the enlarge spleen.
"aily appli!ation o# a long+a!ting, transermal nitrogly!erin pat!h is a
!onvenient, e##e!tive way to prevent !hroni! angina.
,he nurse must wear a !ap, gloves, a gown, an a mask when proviing
woun !are to a patient with thir+egree burns.
,he nurse shoul e3pe!t to aminister an analgesi! be#ore bathing a burn
patient.
,he passage o# bla!k, tarry #e!es (melena) is a !ommon sign o# lower )I
bleeing, but also may o!!ur in patients who have upper )I bleeing.
* patient who has a gastri! ul!er shoul avoi taking aspirin an aspirin+
!ontaining prou!ts be!ause they !an irritate the gastri! mu!osa.
:hile aministering !hemotherapy agents with an I.$. line, the nurse
shoul is!ontinue the in#usion at the #irst sign o# e3travasation.
* low+#iber iet may !ontribute to the evelopment o# hemorrhois.
* patient who has abominal pain shouln6t re!eive an analgesi! until the
!ause o# the pain is etermine.
I# surgery requires hair removal, the re!ommenation o# the -enters #or
"isease -ontrol an %revention is that a epilatory be use to avoi skin
abrasions an !uts.
=or nasotra!heal su!tioning, the nurse shoul set wall su!tion at 52 to B5
mm 8g #or an in#ant, B5 to ''5 mm 8g #or a !hil, or 12 to '(2 mm 8g #or
an ault.
*#ter a myo!arial in#ar!tion, a !hange in pulse rate an rhythm may
signal the onset o# #atal arrhythmias.
,reatment o# epista3is in!lues nasal pa!king, i!e pa!ks, !autery with
silver nitrate, an pressure on the nares.
%alliative treatment relieves or reu!es the intensity o# un!om#ortable
symptoms, but oesn6t !ure the !ausative isorer.
%la!ing a postoperative patient in an upright position too qui!kly may
!ause hypotension.
$erapamil (-alan) an iltia0em (-ari0em) slow the in#low o# !al!ium to
the heart, thereby e!reasing the risk o# supraventri!ular ta!hy!aria.
*#ter !ariopulmonary bypass gra#t, the patient will per#orm turning,
!oughing, eep breathing, an woun splinting, an will use assistive
breathing evi!es.
* patient who is e3pose to hepatitis & shoul re!eive 2.2; ml/kg I./. o#
immune globulin within A( hours a#ter e3posure an a repeat ose at (1
ays a#ter e3posure.
,he nurse shoul avise a patient who is unergoing raiation therapy not
to remove the markings on the skin mae by the raiation therapist be!ause
they are lanmarks #or treatment.
,he most !ommon symptom o# osteoarthritis is 7oint pain that6s relieve
by rest, espe!ially i# the pain o!!urs a#ter e3er!ise or weight bearing.
In aults, urine volume normally ranges #rom 122 to (,222 ml/ay an
averages between ',(22 an ',522 ml/ay.
"ire!tly applie moist heat so#tens !rusts an e3uates, penetrates
eeper than ry heat, oesn6t ry the skin, an is usually more !om#ortable
#or the patient.
,etra!y!lines are selom !onsiere rugs o# !hoi!e #or most !ommon
ba!terial in#e!tions be!ause their overuse has le to the emergen!e o#
tetra!y!line+resistant ba!teria.
&e!ause light egraes nitroprussie (Iitropress), the rug must be
shiele #rom light. =or e3ample, an I.$. bag that !ontains nitroprussie
soium shoul be wrappe in #oil.
-ephalosporins shoul be use !autiously in patients who are allergi! to
peni!illin. ,hese patients are more sus!eptible to hypersensitivity rea!tions.
I# !hlorampheni!ol an peni!illin must be aministere !on!omitantly, the
nurse shoul give the peni!illin ' or more hours be#ore the !hlorampheni!ol
to avoi a reu!tion in peni!illin6s ba!teri!ial a!tivity.
,he erythro!yte seimentation rate measures the istan!e an spee at
whi!h erythro!ytes in whole bloo #all in a verti!al tube in ' hour. ,he rate
at whi!h they #all to the bottom o# the tube !orrespons to the egree o#
in#lammation.
:hen tea!hing a patient with myasthenia gravis about pyriostigmine
(/estinon) therapy, the nurse shoul stress the importan!e o# taking the
rug e3a!tly as pres!ribe, on time, an in evenly spa!e oses to prevent a
relapse an ma3imi0e the e##e!t o# the rug.
I# an antibioti! must be aministere into a peripheral heparin lo!k, the
nurse shoul #lush the site with normal saline solution a#ter the in#usion to
maintain I.$. paten!y.
,he nurse shoul instru!t a patient with angina to take a nitrogly!erin
tablet be#ore anti!ipate stress or e3er!ise or, i# the angina is no!turnal, at
betime.
*rterial bloo gas analysis evaluates gas e3!hange in the lungs (alveolar
ventilation) by measuring the partial pressures o# o3ygen an !arbon io3ie
an the p8 o# an arterial sample.
,he normal serum magnesium level ranges #rom '.5 to (.5 mEq/L.
%atient preparation #or a total !holesterol test in!lues an overnight #ast
an abstinen!e #rom al!ohol #or (4 hours be#ore the test.
,he #asting plasma glu!ose test measures glu!ose levels a#ter a '(+ to '4+
hour #ast.
Iormal bloo p8 ranges #rom A.35 to A.45. * bloo p8 higher than A.45
ini!ates alkalemia? one lower than A.35 ini!ates a!iemia.
"uring an a!i per#usion test, a small amount o# weak hyro!hlori! a!i
solution is in#use with a nasoesophageal tube. * positive test result (pain
a#ter in#usion) suggests re#lu3 esophagitis.
Iormally, the partial pressure o# arterial !arbon io3ie (%a->() ranges
#rom 35 to 45 mm 8g. * %a->( greater than 45 mm 8g ini!ates a!iemia
as a result o# hypoventilation? one less than 35 mm 8g ini!ates alkalemia
as a result o# hyperventilation.
5e !ell ini!es ai in the iagnosis an !lassi#i!ation o# anemia.
Iormally, the partial pressure o# arterial o3ygen (%ao () ranges #rom 12
to '22 mm 8g. * %ao ( o# 52 to 12 mm 8g ini!ates respiratory
insu##i!ien!y. * %ao ( o# less than 52 mm 8g ini!ates respiratory #ailure.
,he white bloo !ell (:&-) i##erential evaluates :&- istribution an
morphology an provies more spe!i#i! in#ormation about a patient6s
immune system than the :&- !ount.
*n e3er!ise stress test (treamill test, e3er!ise ele!tro!ariogram)
!ontinues until the patient rea!hes a preetermine target heart rate or
e3perien!es !hest pain, #atigue, or other signs o# e3er!ise intoleran!e.
*lterable risk #a!tors #or !oronary artery isease in!lue !igarette
smoking, hypertension, high !holesterol or trigly!erie levels, an iabetes.
,he meiastinum is the spa!e between the lungs that !ontains the heart,
esophagus, tra!hea, an other stru!tures.
/a7or !ompli!ations o# a!ute myo!arial in#ar!tion in!lue arrhythmias,
a!ute heart #ailure, !ariogeni! sho!k, thromboembolism, an le#t ventri!ular
rupture.
,he sinoatrial noe is a !luster o# hunres o# !ells lo!ate in the right
atrial wall, near the opening o# the superior vena !ava.
=or one+person !ariopulmonary resus!itation, the ratio o# !ompressions
to ventilations is '5G(.
=or two+person !ariopulmonary resus!itation, the ratio o# !ompressions
to ventilations is 5G'.
* patient who has pulseless ventri!ular ta!hy!aria is a !aniate #or
!arioversion.
E!ho!ariography, a noninvasive test that ire!ts ultra+high+#requen!y
soun waves through the !hest wall an into the heart, evaluates !aria!
stru!ture an #un!tion an !an show valve e#ormities, tumors, septal
e#e!ts, peri!arial e##usion, an hypertrophi! !ariomyopathy.
*ta3ia is impaire ability to !oorinate movements. It6s !ause by a
!erebellar or spinal !or lesion.
>n an ele!tro!ariogram strip, ea!h small blo!k on the hori0ontal a3is
represents 2.24 se!on. Ea!h large blo!k (!ompose o# #ive small blo!ks)
represents 2.( se!on.
9tarling6s law states that the #or!e o# !ontra!tion o# ea!h heartbeat
epens on the length o# the mus!le #ibers o# the heart wall.

,he therapeuti! bloo level #or igo3in is 2.5 to (.5 ng/ml.
%an!relipase (%an!rease) is use to treat !ysti! #ibrosis an !hroni!
pan!reatitis.
,reatment #or mil to moerate vari!ose veins in!lues antiembolism
sto!kings an an e3er!ise program that in!lues walking to minimi0e venous
pooling.
*n into3i!ate patient isn6t !onsiere !ompetent to re#use require
mei!al treatment an shouln6t be allowe to !he!k out o# a hospital
against mei!al avi!e.
,he primary i##eren!e between the pain o# angina an that o# a
myo!arial in#ar!tion is its uration.
)yne!omastia is e3!essive mammary glan evelopment an in!rease
breast si0e in boys an men.
-lassi! symptoms o# )raves6 isease are an enlarge thyroi,
nervousness, heat intoleran!e, weight loss espite in!rease appetite,
sweating, iarrhea, tremor, an palpitations.
)enerali0e malaise is a !ommon symptom o# viral an ba!terial
in#e!tions an epressive isorers.
$itamin - an protein are the most important nutrients #or woun
healing.
* patient who has portal hypertension shoul re!eive vitamin . to
promote a!tive thrombin #ormation by the liver. ,hrombin reu!es the risk o#
bleeing.
,he nurse shoul aminister a seative !autiously to a patient with
!irrhosis be!ause the amage liver !an6t metaboli0e rugs e##e!tively.
&eta+hemolyti! strepto!o!!al in#e!tions shoul be treate aggressively to
prevent glomerulonephritis, rheumati! #ever, an other !ompli!ations.
,he most !ommon noso!omial in#e!tion is a urinary tra!t in#e!tion.
,he nurse shoul implement stri!t isolation pre!autions to prote!t a
patient with a thir+egree burn that6s in#e!te by 9taphylo!o!!us aureus.
* patient who is unergoing e3ternal raiation therapy shouln6t apply
!ream or lotion to the treatment site.
,he most !ommon vas!ular !ompli!ation o# iabetes mellitus is
atheros!lerosis.
Insulin e#i!ien!y may !ause hypergly!emia.
9igns o# %arkinson6s isease in!lue rooling, a masklike e3pression, an
a propulsive gait.
I.$. !holangiography is !ontraini!ate in a patient with hyperthyroiism,
severe renal or hepati! amage, tuber!ulosis, or ioine hypersensitivity.
/irrors shoul be remove #rom the room o# a patient who has is#iguring
wouns su!h as #a!ial burns.
* patient who has gouty arthritis shoul in!rease #lui intake to prevent
!al!uli #ormation.
*n3iety is the most !ommon !ause o# !hest pain.
* patient who is #ollowing a low+salt iet shoul avoi !anne vegetables.
&ananas are a goo sour!e o# potassium an shoul be in!lue in a low+
salt iet #or patients who are taking a loop iureti! su!h as #urosemie
(Lasi3).
,he nurse shoul en!ourage a patient who is at risk #or pneumonia to turn
#requently, !ough, an breathe eeply. ,hese a!tions mobili0e pulmonary
se!retions, promote alveolar gas e3!hange, an help prevent atele!tasis.
,he nurse shoul noti#y the physi!ian whenever a patient6s bloo pressure
rea!hes '12/'22 mm 8g.
&u!k6s tra!tion is use to immobili0e an reu!e spasms in a #ra!ture
hip.
=or a patient with a #ra!ture hip, the nurse shoul assess
neuro!ir!ulatory status every ( hours.
:hen !aring #or a patient with a #ra!ture hip, the nurse shoul use
pillows or a tro!hanter roll to maintain abu!tion.
>rthopnea is a symptom o# le#t+sie heart #ailure.
*lthough a #iberglass !ast is more urable an ries more qui!kly than a
plaster !ast, it typi!ally !auses skin irritation.
In an immobili0e patient, the ma7or !ir!ulatory !ompli!ation is pulmonary
embolism.
,o relieve eema in a #ra!ture limb, the patient shoul keep the limb
elevate.
I.$. antibioti!s are the treatment o# !hoi!e #or a patient with
osteomyelitis.
&lue ye in !imetiine (,agamet) !an !ause a #alse+positive result on a
#e!al o!!ult bloo test su!h as a 8emo!!ult test.
,he nurse shoul suspe!t eler abuse i# wouns are in!onsistent with the
patient6s history, multiple wouns are present, or wouns are in i##erent
stages o# healing.
Immeiately a#ter amputation, patient !are in!lues monitoring rainage
#rom the stump, positioning the a##e!te limb, assisting with e3er!ises
pres!ribe by a physi!al therapist, an wrapping an !onitioning the stump.
* patient who is prone to !onstipation shoul in!rease his bulk intake by
eating whole+grain !ereals an #resh #ruits an vegetables.
In the pelvi! e3amination o# a se3ual assault vi!tim, the spe!ulum shoul
be lubri!ate with water. -ommer!ial lubri!ants retar sperm motility an
inter#ere with spe!imen !olle!tion an analysis.
=or a terminally ill patient, physi!al !om#ort is the top priority in nursing
!are.
"orsi#le3ion o# the #oot provies immeiate relie# o# leg !ramps.
*#ter !aria! surgery, the patient shoul limit aily soium intake to ( g
an aily !holesterol intake to 322 mg.
&leeing a#ter inter!ourse is an early sign o# !ervi!al !an!er.
>ral antiiabeti! agents, su!h as !hlorpropamie ("iabinese) an
tolbutamie (>rinase), stimulate insulin release #rom beta !ells in the islets
o# Langerhans o# the pan!reas.
:hen visiting a patient who has a raiation implant, #amily members an
#riens must limit their stay to '2 minutes. $isitors an nurses who are
pregnant are restri!te #rom entering the room.
-ommon !auses o# vaginal in#e!tion in!lue using an antibioti!, an oral
!ontra!eptive, or a !orti!osteroi? wearing tight+#itting panty hose? an
having se3ual inter!ourse with an in#e!te partner.
* patient with a raiation implant shoul remain in isolation until the
implant is remove. ,o minimi0e raiation e3posure, whi!h in!reases with
time, the nurse shoul !are#ully plan the time spent with the patient.
*mong !ultural groups, Iative *meri!ans have the lowest in!ien!e o#
!an!er.
,he kineys #ilter bloo, sele!tively reabsorb substan!es that are neee
to maintain the !onstan!y o# boy #lui, an e3!rete metaboli! wastes.
,o prevent straining uring e#e!ation, o!usate (-ola!e) is the la3ative
o# !hoi!e #or patients who are re!overing #rom a myo!arial in#ar!tion, re!tal
or !aria! surgery, or postpartum !onstipation.
*#ter prostate surgery, a patient6s primary sour!es o# pain are blaer
spasms an irritation in the area aroun the !atheter.
,o3oplasmosis is more likely to a##e!t a pregnant !at owner than other
pregnant women be!ause !at #e!es in the litter bo3 harbor the in#e!ting
organism.
)oo #oo sour!es o# #oli! a!i in!lue green lea#y vegetables, liver, an
legumes.
,he )lasgow -oma 9!ale evaluates verbal, eye, an motor responses to
etermine the patient6s level o# !ons!iousness.
,he nurse shoul pla!e an un!ons!ious patient in low =owler6s position #or
intermittent nasogastri! tube #eeings.
LaUnne!6s (al!oholi!) !irrhosis is the most !ommon type o# !irrhosis.
In e!orti!ate posturing, the patient6s arms are au!te an #le3e, with
the wrists an #ingers #le3e on the !hest. ,he legs are e3tene sti##ly an
rotate internally, with plantar #le3ion o# the #eet.
-aniates #or surgery shoul re!eive nothing by mouth #rom minight o#
the ay be#ore surgery unless !leare by a physi!ian.
/eperiine ("emerol) is an e##e!tive analgesi! to relieve the pain o#
nephrolithiasis (urinary !al!uli).
*n in7ure patient with thrombo!ytopenia is at risk #or li#e+threatening
internal an e3ternal hemorrhage.
,he ,renelenburg test is use to !he!k #or unilateral hip islo!ation.
*s soon as possible a#ter eath, the patient shoul be pla!e in the supine
position, with the arms at the sies an the hea on a pillow.
$as!ular resistan!e epens on bloo vis!osity, vessel length an, most
important, insie vessel iameter.
* below+the+knee amputation leaves the knee inta!t #or prosthesis
appli!ation an allows a more normal gait than above+the+knee amputation.
-erebrospinal #lui #lows through an prote!ts the #our ventri!les o# the
brain, the subara!hnoi spa!e, an the spinal !anal.
9oium regulates e3tra!ellular osmolality.
,he heart an brain !an maintain bloo !ir!ulation in the early stages o#
sho!k.
*#ter limb amputation, nar!oti! analgesi!s may not relieve Lphantom
limbM pain.
* patient who re!eives multiple bloo trans#usions is at risk #or
hypo!al!emia.
9yphilis initially !auses painless !han!res (small, #lui+#ille lesions) on
the genitals an sometimes on other parts o# the boy.
E3posure to a raioa!tive sour!e is !ontrolle by time (limiting time spent
with the patient), istan!e (#rom the patient), an shiel (a lea apron).
Sauni!e is a sign o# ys#un!tion, not a isease.
9evere 7auni!e !an !ause brain stem ys#un!tion i# the un!on7ugate
bilirubin level in bloo is elevate to (2 to (5 mg/l.
,he patient shoul take !imetiine (,agamet) with meals to help ensure a
!onsistent therapeuti! e##e!t.
:hen !aring #or a patient with 7auni!e, the nurse shoul relieve pruritus
by proviing a soothing lotion or a baking soa bath an shoul prevent
in7ury by keeping the patient6s #ingernails short.
,ype & hepatitis, whi!h is usually transmitte parenterally, also !an be
sprea through !onta!t with human se!retions an #e!es.
Insulin is a naturally o!!urring hormone that6s se!rete by the beta !ells
o# the islets o# Langerhans in the pan!reas in response to a rise in the bloo
glu!ose level.
"iabetes mellitus is a !hroni! eno!rine isorer that6s !hara!teri0e by
insulin e#i!ien!y or resistan!e to insulin by boy tissues.
* iagnosis o# iabetes mellitus is base on the !lassi! symptoms
(polyuria, polyphagia, weight loss, an polyipsia) an a ranom bloo
glu!ose level o# more than (22 mg/l or a #asting plasma glu!ose level o#
more than '42 mg/l when teste on two separate o!!asions.
* patient with nonFinsulin+epenent (type () iabetes mellitus prou!es
some insulin an normally oesn6t nee e3ogenous insulin supplementation.
/ost patients with this type o# iabetes respon well to oral antiiabeti!
agents, whi!h stimulate the pan!reas to in!rease the synthesis an release
o# insulin.
* patient with insulin+epenent (type ') iabetes mellitus !an6t prou!e
enogenous insulin an requires e3ogenous insulin aministration to meet
the boy6s nees.
5api+a!ting insulins are !lear? intermeiate+ an long+a!ting insulins are
turbi (!louy).
5api+a!ting insulins begin to a!t in 32 to ;2 minutes, rea!h a peak
!on!entration in ( to '2 hours, an have a uration o# a!tion o# 5 to ';
hours.
,he best times to test a iabeti! patient6s glu!ose level are be#ore ea!h
meal an at betime.
Intermeiate+a!ting insulins begin to a!t in ' to ( hours, rea!h a peak
!on!entration in 4 to '5 hours, an have a uration o# a!tion o# (( to (1
hours.
Long+a!ting insulins begin to a!t in 4 to 1 hours, rea!h a peak
!on!entration in '2 to 32 hours, an have a uration o# a!tion o# 3; hours or
more.
I# the results o# a non#asting glu!ose test show above+normal glu!ose
levels a#ter glu!ose aministration, but the patient has normal plasma
glu!ose levels otherwise, the patient has impaire glu!ose toleran!e.
Insulin requirements are in!rease by growth, pregnan!y, in!rease #oo
intake, stress, surgery, in#e!tion, illness, in!rease insulin antiboies, an
some rugs.
Insulin requirements are e!rease by hypothyroiism, e!rease #oo
intake, e3er!ise, an some rugs.
8ypogly!emia o!!urs when the bloo glu!ose level is less than 52 mg/l.
*n insulin+resistant patient is one who requires more than (22 units o#
insulin aily.
8ypogly!emia may o!!ur ' to 3 hours a#ter the aministration o# a rapi+
a!ting insulin, 4 to '1 hours a#ter the aministration o# an intermeiate+
a!ting insulin, an '1 to 32 hours a#ter the aministration o# a long+a!ting
insulin.
:hen the bloo glu!ose level e!reases rapily, the patient may
e3perien!e sweating, tremors, pallor, ta!hy!aria, an palpitations.
>b7e!tive signs o# hypogly!emia in!lue slurre spee!h, la!k o#
!oorination, staggere gait, sei0ures, an possibly, !oma.
* !ons!ious patient who has hypogly!emia shoul re!eive sugar in an
easily igeste #orm, su!h as orange 7ui!e, !any, or lump sugar.
*n un!ons!ious patient who has hypogly!emia shoul re!eive an 9.-. or
I./. in7e!tion o# glu!agon as pres!ribe by a physi!ian or 52E e3trose by
I.$. in7e!tion.
* patient with iabetes mellitus shoul inspe!t his #eet aily #or !alluses,
!orns, an blisters. 8e shoul also use warm water to wash his #eet an trim
his toenails straight a!ross to prevent ingrown toenails.
,he early stage o# ketoa!iosis !auses polyuria, polyipsia, anore3ia,
mus!le !ramps, an vomiting. ,he late stage !auses .ussmaul6s
respirations, sweet breath oor, an stupor or !oma.
*n allergen is a substan!e that !an !ause a hypersensitivity rea!tion.
* !orre!tive lens #or nearsighteness is !on!ave.
-hroni! untreate hypothyroiism or abrupt withrawal o# thyroi
mei!ation may lea to my3eema !oma.
9igns an symptoms o# my3eema !oma are lethargy, stupor, e!rease
level o# !ons!iousness, ry skin an hair, elaye eep tenon re#le3es,
progressive respiratory !enter epression an !erebral hypo3ia, weight gain,
hypothermia, an hypogly!emia.
Iearsighteness o!!urs when the #o!al point o# a ray o# light #rom an
ob7e!t that6s (2R (; m) away #alls in #ront o# the retina.
=arsighteness o!!urs when the #o!al point o# a ray o# light #rom an ob7e!t
that6s (2R away #alls behin the retina.
* !orre!tive lens #or #arsighteness is !onve3.
5e#ra!tion is !lini!al measurement o# the error in eye #o!using.
*hesions are bans o# granulation an s!ar tissue that evelop in some
patients a#ter a surgi!al in!ision.
,he nurse shoul moisten an eye pat!h #or an un!ons!ious patient
be!ause a ry pat!h may irritate the !ornea.
* patient who has ha eye surgery shouln6t ben over, !omb his hair
vigorously, or engage in a!tivity that in!reases intrao!ular pressure.
:hen !aring #or a patient who has a penetrating eye in7ury, the nurse
shoul pat!h both eyes loosely with sterile gau0e, aminister an oral
antibioti! (in high oses) an tetanus in7e!tion as pres!ribe, an re#er the
patient to an ophthalmologist #or #ollow+up.
9igns an symptoms o# !olore!tal !an!er in!lue !hanges in bowel habits,
re!tal bleeing, abominal pain, anore3ia, weight loss, malaise, anemia, an
!onstipation or iarrhea.
:hen !limbing stairs with !rut!hes, the patient shoul lea with the
uninvolve leg an #ollow with the !rut!hes an involve leg.
:hen es!ening stairs with !rut!hes, the patient shoul lea with the
!rut!hes an the involve leg an #ollow with the uninvolve leg.
:hen surgery requires eyelash trimming, the nurse shoul apply
petroleum 7elly to the s!issor blaes so that the eyelashes will ahere to
them.
%ain a#ter a !orneal transplant may ini!ate that the ressing has been
applie too tightly, the gra#t has slippe, or the eye is hemorrhaging.
* patient with retinal eta!hment may report #loating spots, #lashes o#
light, an a sensation o# a veil or !urtain !oming own.
Immeiate postoperative !are #or a patient with retinal eta!hment
in!lues maintaining the eye pat!h an shiel in pla!e over the a##e!te area
an observing the area #or rainage? maintaining the patient in the position
spe!i#ie by the ophthalmologist (usually, lying on his abomen, with his
hea parallel to the #loor an turne to the sie)? avoiing bumping the
patient6s hea or be? an en!ouraging eep breathing, but not !oughing.
* patient with a !atara!t may have vision isturban!es, su!h as image
istortion, light glaring, an graual loss o# vision.
:hen talking to a hearing+impaire patient who !an lip+rea, the nurse
shoul #a!e the patient, speak slowly an enun!iate !learly, point to ob7e!ts
as neee, an avoi !hewing gum.
-lini!al mani#estations o# venous stasis ul!er in!lue hemosierin eposits
(visible in #air+skinne iniviuals)? ry, !ra!ke skin? an in#e!tion.
,he #luores!ent treponemal antiboy absorption test is a spe!i#i! serologi!
test #or syphilis.
,o reu!e #ever, the nurse may give the patient a sponge bath with tepi
water (12@ to B3@ = N(;.A@ to 33.B@ -O).
:hen !ommuni!ating with a patient who has ha a stroke, the nurse
shoul allow ample time #or the patient to speak an respon, #a!e the
patient6s una##e!te sie, avoi talking qui!kly, give visual !lues, supplement
spee!h with gestures, an give instru!tions !onsistently.
,he ma7or !ompli!ation o# &ell6s palsy is keratitis (!orneal in#lammation),
whi!h results #rom in!omplete eye !losure on the a##e!te sie.
Immunosuppressants are use to !ombat tissue re7e!tion an help !ontrol
autoimmune isorers.
*#ter a unilateral stroke, a patient may be able to propel a wheel!hair by
using a heel+to+toe movement with the una##e!te leg an turning the wheel
with the una##e!te han.
=irst+morning urine is the most !on!entrate an most likely to show
abnormalities. It shoul be re#rigerate to retar ba!terial growth or, #or
mi!ros!opi! e3amination, shoul be sent to the laboratory immeiately.
* patient who is re!overing #rom a stroke shoul align his arms an legs
!orre!tly, wear high+top sneakers to prevent #ootrop an !ontra!ture, an
use an egg !rate, #lotation, or pulsating mattress to help prevent pressure
ul!ers.
*#ter a #ra!ture o# the arm or leg, the bone may show !omplete union
(normal healing), elaye union (healing that takes longer than e3pe!te),
or nonunion (#ailure to heal).
,he most !ommon !ompli!ation o# a hip #ra!ture is thromboembolism,
whi!h may o!!lue an artery an !ause the area it supplies to be!ome !ol
an !yanoti!.
-hloral hyrate suppositories shoul be re#rigerate.
-ast appli!ation usually requires two persons? it shouln6t be attempte
alone.
* plaster !ast rea!hes ma3imum strength in 41 hours? a syntheti! !ast,
within 32 minutes be!ause it oesn6t require rying.
9evere pain ini!ates the evelopment o# a pressure ul!er within a !ast?
the pain e!reases signi#i!antly a#ter the ul!er evelops.
Ini!ations o# !ir!ulatory inter#eren!e are abnormal skin !oolness,
!yanosis, an rubor or pallor.
"uring the postoperative phase, in!reasing pulse rate an e!reasing
bloo pressure may ini!ate hemorrhage an impening sho!k.
>rthopei! surgi!al wouns blee more than other surgi!al wouns. ,he
nurse !an e3pe!t (22 to 522 ml o# rainage uring the #irst (4 hours an
less than 32 ml ea!h 1 hours #or the ne3t 41 hours.
* patient who has ha hip surgery shouln6t au!t or #le3 the a##e!te
hip be!ause #le3ion greater than B2 egrees may !ause islo!ation.
,he 8oyer li#t, a hyrauli! evi!e, allows two persons to li#t an move a
nonambulatory patient sa#ely.
* patient with !arpal tunnel synrome, a !omple3 o# symptoms !ause by
!ompression o# the meian nerve in the !arpal tunnel, usually has weakness,
pain, burning, numbness, or tingling in one or both hans.
,he nurse shoul instru!t a patient who has ha heatstroke to wear light+
!olore, loose+#itting !lothing when e3pose to the sun? rest #requently? an
rink plenty o# #luis.
* !ons!ious patient with heat e3haustion or heatstroke shoul re!eive a
solution o# T teaspoon o# salt in '(2 ml o# water every '5 minutes #or '
hour.
*n I.$. line inserte uring an emergen!y or outsie the hospital setting
shoul be !hange within (4 hours.
*#ter a tepi bath, the nurse shoul ry the patient thoroughly to prevent
!hills.
,he nurse shoul take the patient6s temperature 32 minutes a#ter
!ompleting a tepi bath.
9hower or bath water shouln6t e3!ee '25@ = (42.;@ -).
"ilatation an !urettage is wiening o# the !ervi!al !anal with a ilator
an s!raping o# the uterus with a !urette.
:hen not in use, all !entral venous !atheters must be !appe with
aaptors a#ter #lushing.
-are a#ter ilatation an !urettage !onsists o# be rest #or ' ay, mil
analgesi!s #or pain, an use o# a sterile pa #or as long as bleeing persists.
I# a patient #eels #aint uring a bath or shower, the nurse shoul turn o##
the water, !over the patient, lower the patient6s hea, an summon help.
* patient who is taking oral !ontra!eptives shouln6t smoke be!ause
smoking !an intensi#y the rug6s averse !ariovas!ular e##e!t.
,he use o# so#t restraints requires a physi!ian6s orer an assessment an
o!umentation o# the patient an a##e!te limbs, a!!oring to #a!ility poli!y.
* vest restraint shoul be use !autiously in a patient with heart #ailure or
a respiratory isorer. ,he restraint !an tighten with movement, #urther
limiting respiratory #un!tion. ,o ensure patient sa#ety, the least amount o#
restraint shoul be use.
I# a piggyba!k system be!omes isloge, the nurse shoul repla!e the
entire piggyba!k system with the appropriate solution an rug, as
pres!ribe.
,he nurse shouln6t se!ure a restraint to a be6s sie rails be!ause they
might be lowere inavertently an !ause patient in7ury or is!om#ort.
,he nurse shoul assess a patient who has limb restraints every 32
minutes to ete!t signs o# impaire !ir!ulation.
,he -enters #or "isease -ontrol an %revention re!ommens using a
neeleless system #or piggyba!king an I.$. rug into the main I.$. line.
I# a gown is require, the nurse shoul put it on when she enters the
patient6s room an is!ar it when she leaves.
:hen !hanging the ressing o# a patient who is in isolation, the nurse
shoul wear two pairs o# gloves.
* isposable bepan an urinal shoul remain in the room o# a patient
who is in isolation an be is!are on is!harge or at the en o# the
isolation perio.
/y!oses (#ungal in#e!tions) may be systemi! or eep (a##e!ting the
internal organs), sub!utaneous (involving the skin), or super#i!ial (growing
on the outer layer o# skin an hair).
,he night be#ore a sputum spe!imen is to be !olle!te by e3pe!toration,
the patient shoul in!rease #lui intake to promote sputum prou!tion.
* sample o# #e!es #or an ova an parasite stuy shoul be !olle!te
ire!tly into a waterproo# !ontainer, !overe with a li, an sent to the
laboratory immeiately. I# the patient is berien, the sample !an be
!olle!te into a !lean, ry bepan an then trans#erre with a tongue
epressor into a !ontainer.
:hen obtaining a sputum spe!imen #or testing, the nurse shoul instru!t
the patient to rinse his mouth with !lean water, !ough eeply #rom his !hest,
an e3pe!torate into a sterile !ontainer.
,onometry allows inire!t measurement o# intrao!ular pressure an ais
in early ete!tion o# glau!oma.
%ulmonary #un!tion tests (a series o# measurements that evaluate
ventilatory #un!tion through spirometri! measurements) help to iagnose
pulmonary ys#un!tion.
*#ter a liver biopsy, the patient shoul lie on the right sie to !ompress
the biopsy site an e!rease the possibility o# bleeing.
* patient who has !irrhosis shoul #ollow a iet that restri!ts soium, but
provies protein an vitamins (espe!ially &, -, an ., an #olate).
I# '( hours o# gastri! su!tion on6t relieve bowel obstru!tion, surgery is
ini!ate.
,he nurse !an pun!ture a ni#eipine (%ro!aria) !apsule with a neele,
withraw its liqui, an instill it into the bu!!al pou!h.
:hen aministering whole bloo or pa!ke re bloo !ells (5&-s), the
nurse shoul use a '; to (2) neele or !annula to avoi 5&- hemolysis.
8irsutism is e3!essive boy hair in a mas!uline istribution.
>ne unit o# whole bloo or pa!ke re bloo !ells is aministere over (
to 4 hours.
9!urvy is asso!iate with vitamin - e#i!ien!y.
* vitamin is an organi! !ompoun that usually !an6t be synthesi0e by the
boy an is neee in metaboli! pro!esses.
%ulmonary embolism !an be !ause when thromboembolism o# #at, bloo,
bone marrow, or amnioti! #lui obstru!ts the pulmonary artery.
*#ter ma3illo#a!ial surgery, a patient whose manible an ma3illa have
been wire together shoul keep a pair o# s!issors or wire !utters reaily
available so that he !an !ut the wires an prevent aspiration i# vomiting
o!!urs.
5api instillation o# #lui uring !oloni! irrigation !an !ause abominal
!ramping.
* !ollaborative relationship between health !are workers helps shorten
the hospital stay an in!reases patient satis#a!tion.
=or elerly patients in a health !are #a!ility, prei!table ha0ars in!lue
nighttime !on#usion (sunowning), #ra!tures #rom #alling, immobility+inu!e
pressure ul!ers, prolonge !onvales!en!e, an loss o# home an support
systems.
5espiratory tra!t in#e!tions, espe!ially viral in#e!tions, !an trigger asthma
atta!ks.
>3ygen therapy is use in severe asthma atta!ks to prevent or treat
hypo3emia.
"uring an asthma atta!k, the patient may pre#er nasal prongs to a $enturi
mask be!ause o# the mask6s smothering e##e!t.
-hroni! obstru!tive pulmonary isease usually evelops over a perio o#
years. In B5E o# patients, it results #rom smoking.
*n early sign o# !hroni! obstru!tive pulmonary isease (->%") is slowing
o# #or!e e3piration. * healthy person !an empty the lungs in less than 4
se!ons? a patient with ->%" may take ; to '2 se!ons.
-hroni! obstru!tive pulmonary isease eventually leas to stru!tural
!hanges in the lungs, in!luing overistene alveoli an hyperin#late
lungs.
-ellulitis !auses lo!ali0e heat, reness, swelling an, o!!asionally, #ever,
!hills, an malaise.
$enous stasis may pre!ipitate thrombophlebitis.
,reatment o# thrombophlebitis in!lues leg elevation, heat appli!ation,
an possibly, anti!oagulant therapy.
* su!tioning ma!hine shoul remain at the besie o# a patient who has
ha ma3illo#a!ial surgery.
=or a berien patient with heart #ailure, the nurse shoul !he!k #or
eema in the sa!ral area.
In passive range+o#+motion e3er!ises, the therapist moves the patient6s
7oints through as #ull a range o# motion as possible to improve or maintain
7oint mobility an help prevent !ontra!tures.
In resistan!e e3er!ises, whi!h allow mus!le length to !hange, the patient
per#orms e3er!ises against resistan!e applie by the therapist.
In isometri! e3er!ises, the patient !ontra!ts mus!les against stable
resistan!e, but without 7oint movement. /us!le length remains the same,
but strength an tone may in!rease.
Impetigo is a !ontagious, super#i!ial, vesi!opustular skin in#e!tion.
%reisposing #a!tors in!lue poor hygiene, anemia, malnutrition, an a warm
!limate.
*#ter !ariopulmonary resus!itation (-%5) begins, it shouln6t be
interrupte, e3!ept when the aministrator is alone an must summon help.
In this !ase, the aministrator shoul per#orm -%5 #or ' minute be#ore
!alling #or help.
,he tongue is the most !ommon airway obstru!tion in an un!ons!ious
patient.
=or ault !ariopulmonary resus!itation, the !hest !ompression rate is 12
to '22 times per minute.
* patient with ul!ers shoul avoi betime sna!ks be!ause #oo may
stimulate no!turnal se!retions.
In angioplasty, a bloo vessel is ilate with a balloon !atheter that6s
inserte through the skin an the vessel6s lumen to the narrowe area. >n!e
in pla!e, the balloon is in#late to #latten plaque against the vessel wall.
* #ull liqui iet supplies nutrients, #luis, an !alories in simple, easily
igeste #oos, su!h as apple 7ui!e, !ream o# wheat, milk, !o##ee, straine
!ream soup, high+protein gelatin, !ranberry 7ui!e, !ustar, an i!e !ream.
It6s pres!ribe #or patients who !an6t tolerate a regular iet.
* puree iet meets the patient6s nutritional nees without in!luing #oos
that are i##i!ult to !hew or swallow. =oo is blene to a semisoli
!onsisten!y.
* so#t, or light, iet is spe!i#i!ally esigne #or patients who have i##i!ulty
!hewing or tolerating a regular iet. It6s nutritionally aequate an !onsists
o# #oos su!h as orange 7ui!e, !ream o# wheat, s!ramble eggs, enri!he
toast, !ream o# !hi!ken soup, wheat brea, #ruit !o!ktail, an mushroom
soup.
* regular iet is provie #or patients who on6t require ietary
moi#i!ation.
* blan iet restri!ts #oos that !ause gastri! irritation or prou!e a!i
se!retion without proviing a neutrali0ing e##e!t.
* !lear liqui iet provies #lui an a graual return to a regular iet.
,his type o# iet is e#i!ient in all nutrients an shoul be #ollowe #or only a
short perio.
%atients with a gastri! ul!er shoul avoi al!ohol, !a##einate beverages,
aspirin, an spi!y #oos.
In a!tive assistan!e e3er!ises, the patient per#orms e3er!ises with the
therapist6s help.
%eni!illinase is an en0yme prou!e by !ertain ba!teria. It !onverts
peni!illin into an ina!tive prou!t, in!reasing the ba!teria6s resistan!e to the
antibioti!.
&attle6s sign is a bluish is!oloration behin the ear in some patients who
sustain a basilar skull #ra!ture.
-ra!kles are nonmusi!al !li!king or rattling noises that are hear uring
aus!ultation o# abnormal breath souns. ,hey are !ause by air passing
through #lui+#ille airways.
*ntibioti!s aren6t e##e!tive against viruses, proto0oa, or parasites.
/ost peni!illins an !ephalosporins prou!e their antibioti! e##e!ts by !ell
wall inhibition.
:hen assessing a patient with an inguinal hernia, the nurse shoul
suspe!t strangulation i# the patient reports severe pain, nausea, an
vomiting.
%himosis is tightness o# the prepu!e o# the penis that prevents retra!tion
o# the #oreskin over the glans.
*minogly!osies are natural antibioti!s that are e##e!tive against gram+
negative ba!teria. ,hey must be use with !aution be!ause they !an !ause
nephroto3i!ity an ototo3i!ity.
>n s!rotal e3amination, vari!o!eles an tumors on6t transilluminate, but
spermato!eles an hyro!eles o.
* horeolum (eyeli stye) is an in#e!tion o# one or more seba!eous glans
o# the eyeli.
* !hala0ion is an eyeli mass that6s !ause by !hroni! in#lammation o# the
meibomian glan.
"uring ophthalmos!opi! e3amination, the absen!e o# the re re#le3
ini!ates a lens opa!ity (!atara!t) or a eta!he retina.
5espiratory a!iosis is asso!iate with !onitions su!h as rug overose,
)uillain+&arrK synrome, myasthenia gravis, !hroni! obstru!tive pulmonary
isease, pi!kwi!kian synrome, an kyphos!oliosis. &ullets
5espiratory alkalosis is asso!iate with !onitions su!h as high #ever,
severe hypo3ia, asthma, an pulmonary embolism.
/etaboli! a!iosis is asso!iate with su!h !onitions as renal #ailure,
iarrhea, iabeti! ketosis, an la!ti! ketosis, an with high oses o#
a!eta0olamie ("iamo3).
)astre!tomy is surgi!al e3!ision o# all or part o# the stoma!h to remove a
!hroni! pepti! ul!er, stop hemorrhage in a per#orate ul!er, or remove a
malignant tumor.
/etaboli! alkalosis is asso!iate with nasogastri! su!tioning, e3!essive
use o# iureti!s, an steroi therapy.
$itiligo (a benign, a!quire skin isease) is marke by stark white skin
pat!hes that are !ause by the estru!tion an loss o# pigment !ells.
>verose or a!!iental overingestion o# isul#iram (*ntabuse) shoul be
treate with gastri! aspiration or lavage an supportive therapy.
,he !auses o# abominal istention are represente by the si3 =6sG #latus,
#e!es, #etus, #lui, #at, an #atal (malignant) neoplasm.
* positive /urphy6s sign ini!ates !hole!ystitis.
9igns o# appeni!itis in!lue right abominal pain, abominal rigiity an
reboun tenerness, nausea, an anore3ia.
*s!ites !an be ete!te when more than 522 ml o# #lui has !olle!te in
the intraperitoneal spa!e.
=or a patient with organi! brain synrome or a senile isease, the ieal
environment is stable an limits !on#usion.
In a patient with organi! brain synrome, memory loss usually a##e!ts all
spheres, but begins with re!ent memory loss.
"uring !aria! !atheteri0ation, the patient may e3perien!e a thuing
sensation in the !hest, a strong esire to !ough, an a transient #eeling o#
heat, usually in the #a!e, as a result o# in7e!tion o# the !ontrast meium.
9light bubbling in the su!tion !olumn o# a thora!i! rainage system, su!h
as a %leur+eva! unit, ini!ates that the system is working properly. * la!k o#
bubbling in the su!tion !hamber ini!ates inaequate su!tion.
Iutritional e#i!ien!y is a !ommon #ining in people who have a long
history o# al!ohol abuse.
In the patient with vari!ose veins, grauate !ompression elasti!
sto!kings (32 to 42 mm 8g) may be pres!ribe to promote venous return.
Ionviral hepatitis usually results #rom e3posure to !ertain !hemi!als or
rugs.
9ubstantial elevation o# the serum transaminase level is a symptom o#
a!ute hepatitis.
Iormal !aria! output is 4 to ; L/minute, with a stroke volume o# ;2 to
A2 ml.
E3!essive vomiting or removal o# the stoma!h !ontents through su!tion
!an e!rease the potassium level an lea to hypokalemia.
*s a heparin antagonist, protamine is an antiote #or heparin overose.
I# a patient has a positive rea!tion to a tuber!ulin skin test, su!h as the
puri#ie protein erivative test, the nurse shoul suspe!t !urrent or past
e3posure. ,he nurse shoul ask the patient about a history o# tuber!ulosis
(,&) an the presen!e o# early signs an symptoms o# ,&, su!h as low+grae
#ever, weight loss, night sweats, #atigue, an anore3ia.
9igns an symptoms o# a!ute rheumati! #ever in!lue !horea, #ever,
!aritis, migratory polyarthritis, erythema marginatum (rash), an
sub!utaneous noules.
&e#ore unergoing any invasive ental pro!eure, the patient who has a
history o# rheumati! #ever shoul re!eive prophyla!ti! peni!illin therapy. ,his
therapy helps to prevent !ontamination o# the bloo with oral ba!teria,
whi!h !oul migrate to the heart valves.
*#ter a myo!arial in#ar!tion, most patients !an resume se3ual a!tivity
when they !an !limb two #lights o# stairs without #atigue or yspnea.
Elerly patients are sus!eptible to orthostati! hypotension be!ause the
barore!eptors be!ome less sensitive to position !hanges as people age.
=or the patient with suspe!te renal or urethral !al!uli, the nurse shoul
strain the urine to etermine whether !al!uli have been passe.
,he nurse shoul pla!e the patient with as!ites in the semi+=owler
position be!ause it permits ma3imum lung e3pansion.
=or the patient who has ingeste poison, the nurse shoul save the
vomitus #or analysis.
,he earliest signs o# respiratory istress are in!rease respiratory rate
an in!rease pulse rate.
In aults, gastroenteritis is !ommonly sel#+limiting an !auses iarrhea,
abominal is!om#ort, nausea, an vomiting.
-aria! output equals stroke volume multiplie by the heart rate per
minute.
In patients with a!ute meningitis, the !erebrospinal #lui protein level is
elevate.
:hen a patient is suspe!te o# having #oo poisoning, the nurse shoul
noti#y publi! health authorities so that they !an interview patients an #oo
hanlers an take samples o# the suspe!te !ontaminate #oo.
,he patient who is re!eiving a potassium+wasting iureti! shoul eat
potassium+ri!h #oos.
* patient with !hroni! obstru!tive pulmonary isease shoul re!eive low+
level o3ygen aministration by nasal !annula (( to 3 L/minute) to avoi
inter#ering with the hypo3i! rive.
In metaboli! a!iosis, the patient may have .ussmaul6s respirations
be!ause the rate an epth o# respirations in!rease to Lblow o##M e3!ess
!arboni! a!is.
In women, gonorrhea a##e!ts the vagina an #allopian tubes.
*#ter traumati! amputation, the greatest threats to the patient are bloo
loss an hypovolemi! sho!k. Initial interventions shoul !ontrol bleeing an
repla!e #lui an bloo as neee.
Epinephrine is a sympathomimeti! rug that a!ts primarily on alpha,
beta', an beta( re!eptors, !ausing vaso!onstri!tion.
Epinephrine6s averse e##e!ts in!lue yspnea, ta!hy!aria, palpitations,
heaa!hes, an hypertension.
* !arinal sign o# pan!reatitis is an elevate serum amylase level.
8igh !oloni! irrigation is use to stimulate peristalsis an reu!e
#latulen!e.
&leeing is the most !ommon postoperative problem.
,he patient !an !ontrol some !olostomy oors by avoiing su!h #oos as
#ish, eggs, onions, beans, an !abbage an relate vegetables.
:hen paralysis or !oma impairs or erases the !orneal re#le3, #requent eye
!are is per#orme to keep the e3pose !ornea moist, preventing ul!eration
an in#lammation.
Interventions #or the patient with a!quire immunoe#i!ien!y synrome
in!lue treating e3isting in#e!tions an !an!ers, reu!ing the risk o#
opportunisti! in#e!tions, maintaining aequate nutrition an hyration, an
proviing emotional support to the patient an #amily.
9igns an symptoms o# !hlamyial in#e!tion are urinary #requen!y? thin,
white vaginal or urethral is!harge? an !ervi!al in#lammation.
-hlamyial in#e!tion is the most prevalent se3ually transmitte isease in
the Cnite 9tates.
,he pituitary glan is lo!ate in the sella tur!i!a o# the sphenoi bone in
the !ranial !avity.
/yasthenia gravis is a neuromus!ular isorer that6s !hara!teri0e by
impulse isturban!es at the myoneural 7un!tion.
/yasthenia gravis, whi!h usually a##e!ts young women, !auses e3treme
mus!le weakness an #atigability, i##i!ulty !hewing an talking, strabismus,
an ptosis.
8ypothermia is a li#e+threatening isorer in whi!h the boy6s !ore
temperature rops below B5@ = (35@ -).
9igns an symptoms o# hypopituitarism in aults may in!lue gonaal
#ailure, iabetes insipius, hypothyroiism, an areno!orti!al insu##i!ien!y.
5eiter6s synrome !auses a tria o# symptomsG arthritis, !on7un!tivitis,
an urethritis.
=or patients who have ha a partial gastre!tomy, a !arbohyrate+
restri!te iet in!lues #oos that are high in protein an #ats an restri!ts
#oos that are high in !arbohyrates. 8igh+!arbohyrate #oos are igeste
qui!kly an are reaily emptie #rom the stoma!h into the uoenum,
!ausing iarrhea an umping synrome.
* woman o# !hilbearing age who is unergoing !hemotherapy shoul be
en!ourage to use a !ontra!eptive be!ause o# the risk o# #etal amage i# she
be!omes pregnant.
%erni!ious anemia is vitamin &'( e#i!ien!y that6s !ause by a la!k o#
intrinsi! #a!tor, whi!h is prou!e by the gastri! mu!osal parietal !ells.
,o per#orm purse+lip breathing, the patient inhales through the nose an
e3hales slowly an evenly against purse lips while !ontra!ting the
abominal mus!les.
* patient who is unergoing !hemotherapy shoul !onsume a high+
!alorie, high+protein iet.
*verse e##e!ts o# !hemotherapy in!lue bone marrow epression, whi!h
!auses anemia, leukopenia, an thrombo!ytopenia? )I epithelial !ell
irritation, whi!h !auses )I ul!eration, bleeing, an vomiting? an
estru!tion o# hair #olli!les an skin, whi!h !auses alope!ia an ermatitis.
,he hemoglobin ele!trophoresis test i##erentiates between si!kle !ell trait
an si!kle !ell anemia.
,he antibioti!s erythromy!in, !linamy!in, an tetra!y!line a!t by
inhibiting protein synthesis in sus!eptible organisms.
,he nurse aministers o3ygen as pres!ribe to the patient with heart
#ailure to help over!ome hypo3ia an yspnea.
9igns an symptoms o# small+bowel obstru!tion in!lue e!rease or
absent bowel souns, abominal istention, e!rease #latus, an pro7e!tile
vomiting.
,he nurse shoul use both hans when ventilating a patient with a
manual resus!itation bag. >ne han !an eliver only 422 !! o# air? two
hans !an eliver ',222 !! o# air.
"osages o# methyl3anthine agents, su!h as theophylline (,heo+"ur) an
aminophylline (*minophyllin), shoul be iniviuali0e base on serum rug
level, patient response, an averse rea!tions.
,he patient shoul apply a transermal s!opolamine pat!h (,ranserm+
9!op) at least 4 hours be#ore its antiemeti! a!tion is neee.
Early ini!ations o# gangrene are eema, pain, reness, arkening o# the
tissue, an !olness in the a##e!te boy part.
Ipe!a! syrup is the emeti! o# !hoi!e be!ause o# its e##e!tiveness in
eva!uating the stoma!h an relatively low in!ien!e o# averse rea!tions.
>ral iron (#errous sul#ate) may !ause green to bla!k #e!es.
%oly!ythemia vera !auses pruritus, pain#ul #ingers an toes,
hyperuri!emia, plethora (reish purple skin an mu!osa), weakness, an
easy #atigability.
5heumati! #ever is usually pre!ee by a group * beta+hemolyti!
strepto!o!!al in#e!tion, su!h as s!arlet #ever, otitis meia, strepto!o!!al
throat in#e!tion, impetigo, or tonsillitis.
* thyroi storm, or !risis, is an e3treme #orm o# hyperthyroiism. It6s
!hara!teri0e by hyperpyre3ia with a temperature o# up to '2;@ = (4'.'@ -),
iarrhea, ehyration, ta!hy!aria o# up to (22 beats/minute, arrhythmias,
e3treme irritability, hypotension, an elirium. It may lea to !oma, sho!k,
an eath.
,arive yskinesia, an averse rea!tion to long+term use o# antipsy!hoti!
rugs, !auses involuntary repetitive movements o# the tongue, lips,
e3tremities, an trunk.
*sthma is bron!ho!onstri!tion in response to allergens, su!h as #oo,
pollen, an rugs? irritants, su!h as smoke an paint #umes? in#e!tions?
weather !hanges? e3er!ise? or gastroesophageal re#lu3. In the Cnite 9tates,
about 5E o# !hilren have !hroni! asthma.
&loo !ultures help ienti#y the !ause o# eno!aritis. *n in!rease white
bloo !ell !ount suggests ba!terial in#e!tion.
In a patient who has a!ute aorti! isse!tion, the nursing priority is to
maintain the mean arterial pressure between ;2 an ;5 mm 8g. *
vasoilator su!h as nitroprussie (Iitropress) may be neee to a!hieve this
goal.
=or a patient with heart #ailure, one o# the most important nursing
iagnoses is e!rease !aria! output relate to altere myo!arial
!ontra!tility, in!rease preloa an a#terloa, an altere rate, rhythm, or
ele!tri!al !onu!tion.
=or a patient re!eiving peritoneal ialysis, the nurse must monitor boy
weight an bloo urea nitrogen, !reatinine, an ele!trolyte levels.
*ngiotensin+!onverting en0yme inhibitors, su!h as !aptopril (-apoten)
an enalapril ($asote!), e!rease bloo pressure by inter#ering with the
renin+angiotensin+alosterone system.
* patient who has stable ventri!ular ta!hy!aria has a bloo pressure an
is !ons!ious? there#ore, the patient6s !aria! output is being maintaine, an
the nurse must monitor the patient6s vital signs !ontinuously.
*ngiotensin+!onverting en0yme inhibitors inhibit the en0yme that !onverts
angiotensin I into angiotensin II, whi!h is a potent vaso!onstri!tor. ,hrough
this a!tion, they reu!e peripheral arterial resistan!e an bloo pressure.
In a patient who is re!eiving a iureti!, the nurse shoul monitor serum
ele!trolyte levels, !he!k vital signs, an observe #or orthostati! hypotension.
&reast sel#+e3amination is one o# the most important health habits to
tea!h a woman. It shoul be per#orme ' week a#ter the menstrual perio
be!ause that6s when hormonal e##e!ts, whi!h !an !ause breast lumps an
tenerness, are reu!e.
%ostmenopausal women shoul !hoose a regular time ea!h month to
per#orm breast sel#+e3amination (#or e3ample, on the same ay o# the
month as the woman6s birthay).
,he i##eren!e between a!ute an !hroni! arterial isease is that the
a!ute isease pro!ess is li#e+threatening.
:hen preparing the patient #or !hest tube removal, the nurse shoul
e3plain that removal may !ause pain or a burning or pulling sensation.
Essential hypertensive renal isease is !ommonly !hara!teri0e by
progressive renal impairment.
/ean arterial pressure (/*%) is !al!ulate using the #ollowing #ormula,
where 9 H systoli! pressure an " H iastoli! pressureG /*% H N(" V () W
9O X 3
9ymptoms o# supine hypotension synrome are i00iness, light+
heaeness, nausea, an vomiting.
*n immuno!ompromise patient is at risk #or .aposi6s sar!oma.
"oll6s eye movement is the normal lag between hea movement an eye
movement.
,hir spa!ing o# #lui o!!urs when #lui shi#ts #rom the intravas!ular spa!e
to the interstitial spa!e an remains there.
-hroni! pain is any pain that lasts longer than ; months. *!ute pain lasts
less than ; months.
,he me!hanism o# a!tion o# a phenothia0ine erivative is to blo!k
opamine re!eptors in the brain.
%atients shouln6t take bisa!oyl, anta!is, an airy prou!ts all at the
same time.
*vise the patient who is taking igo3in to avoi #oos that are high in
#iber, su!h as bran !ereal an prunes.
* patient who is taking iureti!s shoul avoi #oos that !ontain
monosoium glutamate be!ause it !an !ause tightening o# the !hest an
#lushing o# the #a!e.
=urosemie (Lasi3) shoul be taken ' hour be#ore meals.
* patient who is taking griseo#ulvin ()risovin =%) shoul maintain a high+
#at iet, whi!h enhan!es the se!retion o# bile.
%atients shoul take oral iron prou!ts with !itrus rinks to enhan!e
absorption.
Isonia0i shoul be taken on an empty stoma!h, with a #ull glass o# water.
=oos that are high in protein e!rease the absorption o# levoopa.
* patient who is taking tetra!y!line shouln6t take iron supplements or
anta!is.
* patient who is taking war#arin (-oumain) shoul avoi #oos that are
high in vitamin ., su!h as liver an green lea#y vegetables.
,he normal value #or !holesterol is less than (22 mg/l. ,he normal value
#or low+ensity lipoproteins is ;2 to '12 mg/l? #or high+ensity lipoproteins,
it6s 32 to 12 mg/l.
,he normal !aria! output #or an ault who weighs '55 lb (A2.3 kg) is 5
to ; L/minute.
* pulmonary artery pressure !atheter (9wan+)an0) measures the
pressure in the !aria! !hambers.
9evere !hest pain that6s aggravate by breathing an is es!ribe as
Lsharp,M Lstabbing,M or Lkni#elikeM is !onsistent with peri!aritis.
:ater+hammer pulse is a pulse that6s lou an bouning an rises an
#alls rapily. It !an be !ause by emotional e3!itement or aorti!
insu##i!ien!y.
%athologi! splitting o# 9( is normally hear between inspiration an
e3piration. It o!!urs in right bunle+bran!h blo!k.
%ink, #rothy sputum is asso!iate with pulmonary eema. =rank
hemoptysis may be asso!iate with pulmonary embolism.
*n aorti! aneurysm !an be hear 7ust over the umbili!al area an !an be
ete!te as an abominal pulsation (bruit).
8eart murmurs are grae a!!oring to the #ollowing systemG grae ' is
#aint an is hear a#ter the e3aminer Ltunes inM? grae ( is hear
immeiately? grae 3 is moerately lou? grae 4 is lou? grae 5 is very
lou, but is hear only with a stethos!ope? an grae ; is very lou an is
hear without a stethos!ope.
-lot #ormation uring !aria! !atheteri0ation is minimi0e by the
aministration o# 4,222 to 5,222 units o# heparin.
/ost !ompli!ations that arise #rom !aria! !atheteri0ation are asso!iate
with the pun!ture site.
*llergi! symptoms asso!iate with ioine+base !ontrast meia use in
!aria! !atheteri0ation in!lue urti!aria, nausea an vomiting, an #lushing.
,o ensure that bloo #low hasn6t been !ompromise, the nurse shoul
mark the peripheral pulses istal to the !utown site to ai in lo!ating the
pulses a#ter the pro!eure.
,he e3tremity use #or the !utown site shoul remain straight #or 4 to ;
hours. I# an ante!ubital vessel was use, an armboar is neee. I# a
#emoral artery was use, the patient shoul remain on be rest #or ; to '(
hours.
I# a patient e3perien!es numbness or tingling in the e3tremity a#ter a
!utown, the physi!ian shoul be noti#ie immeiately.
*#ter !aria! !atheteri0ation, #lui intake shoul be en!ourage to ai in
#lushing the !ontrast meium through the kineys.
In a patient who is unergoing pulmonary artery !atheteri0ation, risks
in!lue pulmonary artery in#ar!tion, pulmonary embolism, in7ury to the heart
valves, an in7ury to the myo!arium.
%ulmonary artery wege pressure is a ire!t ini!ator o# le#t ventri!ular
pressure.
%ulmonary artery wege pressure greater than '1 to (2 mm 8g ini!ates
in!rease le#t ventri!ular pressure, as seen in le#t+sie heart #ailure.
:hen measuring pulmonary artery wege pressure, the nurse shoul
pla!e the patient in a supine position, with the hea o# the be elevate no
more than (5 egrees.
%ulmonary artery pressure, whi!h ini!ates right an le#t ventri!ular
pressure, is taken with the balloon e#late.
%ulmonary artery systoli! pressure is the peak pressure generate by the
right ventri!le. %ulmonary artery iastoli! pressure is the lowest pressure in
the pulmonary artery.
Iormal ault pulmonary artery systoli! pressure is '5 to (5 mm 8g.
Iormal ault pulmonary artery iastoli! pressure is 1 to '( mm 8g.
,he normal o3ygen saturation o# venous bloo is A5E.
-entral venous pressure is the amount o# pressure in the superior vena
!ava an the right atrium.
Iormal ault !entral venous pressure is ( to 1 mm 8g, or 3 to '2 !m
8(>.
* e!rease in !entral venous pressure ini!ates a #all in !ir!ulating #lui
volume, as seen in sho!k.
*n in!rease in !entral venous pressure is asso!iate with an in!rease in
!ir!ulating volume, as seen in renal #ailure.
In a patient who is on a ventilator, !entral venous pressure shoul be
taken at the en o# the e3piratory !y!le.
,o ensure an a!!urate baseline !entral venous pressure reaing, the 0ero
point o# the transu!er must be at the level o# the right atrium.
* bloo pressure reaing obtaine through intra+arterial pressure
monitoring may be '2 mm 8g higher than one obtaine with a bloo
pressure !u##.
In /Yn!keberg6s s!lerosis, !al!ium eposits #orm in the meial layer o# the
arterial walls.
,he symptoms asso!iate with !oronary artery isease usually on6t
appear until plaque has narrowe the vessels by at least A5E.
9ymptoms o# !oronary artery isease appear only when there is an
imbalan!e between the eman #or o3ygenate bloo an its availability.
%er!utaneous transluminal !oronary angioplasty is an invasive pro!eure
in whi!h a balloon+tippe !atheter is inserte into a blo!ke artery. :hen
the balloon is in#late, it opens the artery by !ompressing plaque against the
artery6s intimal layer.
&e#ore per!utaneous transluminal !oronary angioplasty is per#orme, an
anti!oagulant (su!h as aspirin) is usually aministere to the patient. "uring
the pro!eure, the patient is given heparin, a !al!ium agonist, or
nitrogly!erin to reu!e the risk o# !oronary artery spasms.
"uring !oronary artery bypass gra#t surgery, a blo!ke !oronary artery is
bypasse by using the saphenous vein #rom the patient6s thigh or lower leg.
:hen a vein is use to bypass an artery, the vein is reverse so that the
valves on6t inter#ere with bloo #low.
"uring a !oronary artery bypass gra#t pro!eure, the patient6s heart is
stoppe to allow the surgeon to sew the new vessel in pla!e. &loo #low to
the boy is maintaine with a !ariopulmonary bypass.
"uring an anginal atta!k, the !ells o# the heart !onvert to anaerobi!
metabolism, whi!h prou!es la!ti! a!i as a waste prou!t. *s the level o#
la!ti! a!i in!reases, pain evelops.
%ain that6s es!ribe as LsharpM or Lkni#elikeM is not !onsistent with angina
pe!toris.
*nginal pain typi!ally lasts #or 5 minutes? however, atta!ks asso!iate
with a heavy meal or e3treme emotional istress may last '5 to (2 minutes.
* pattern o# Le3ertion+pain+rest+relie#M is !onsistent with stable angina.
Cnlike stable angina, unstable angina !an o!!ur without e3ertion an is
!onsiere a pre!ursor to a myo!arial in#ar!tion.
* patient who is s!heule #or a stress ele!tro!ariogram shoul noti#y
the sta## i# he has taken nitrates. I# he has, the test must be res!heule.
E3er!ise equipment, su!h as a treamill or an e3er!ise bike, is use #or a
stress ele!tro!ariogram. *!tivity is in!rease until the patient rea!hes 15E
o# his ma3imum heart rate.
In patients who take nitrogly!erin #or a long time, toleran!e o#ten
evelops an reu!es the e##e!tiveness o# nitrates. * '(+hour rug+#ree
perio is usually maintaine at night.
&eta+arenergi! blo!kers, su!h as propranolol (Ineral), reu!e the
workloa on the heart, thereby e!reasing o3ygen eman. ,hey also slow
the heart rate.
-al!ium !hannel blo!kers in!lue ni#eipine (%ro!aria), whi!h is use to
treat angina? verapamil (-alan, Isoptin), whi!h is use primarily as an
antiarrhythmi!? an iltia0em (-ari0em), whi!h !ombines the e##e!ts o#
ni#eipine an verapamil without the averse e##e!ts.
* patient who has anginal pain that raiates or worsens an oesn6t
subsie shoul be evaluate at an emergen!y mei!al #a!ility.
-aria! !ells !an withstan (2 minutes o# is!hemia be#ore !ell eath
o!!urs.
"uring a myo!arial in#ar!tion, the most !ommon site o# in7ury is the
anterior wall o# the le#t ventri!le, near the ape3.
*#ter a myo!arial in#ar!tion, the in#ar!te tissue !auses signi#i!ant Q+
wave !hanges on an ele!tro!ariogram. ,hese !hanges remain evient even
a#ter the myo!arium heals.
,he level o# -.+/&, an isoen0yme spe!i#i! to the heart, in!reases 4 to ;
hours a#ter a myo!arial in#ar!tion an peaks at '( to '1 hours. It returns to
normal in 3 to 4 ays.
%atients who survive a myo!arial in#ar!tion an have no other
!ariovas!ular pathology usually require ; to '( weeks #or a #ull re!overy.
*#ter a myo!arial in#ar!tion, the patient is at greatest risk #or suen
eath uring the #irst (4 hours.
*#ter a myo!arial in#ar!tion, the #irst ; hours is the !ru!ial perio #or
salvaging the myo!arium.
*#ter a myo!arial in#ar!tion, i# the patient !onsistently has more than
three premature ventri!ular !ontra!tions per minute, the physi!ian shoul be
noti#ie.
*#ter a myo!arial in#ar!tion, in!reasing vas!ular resistan!e through the
use o# vasopressors, su!h as opamine an levarterenol, !an raise bloo
pressure.
-lini!al mani#estations o# heart #ailure in!lue istene ne!k veins,
weight gain, orthopnea, !ra!kles, an enlarge liver.
5isk #a!tors asso!iate with embolism are in!rease bloo vis!osity,
e!rease !ir!ulation, prolonge be rest, an in!rease bloo !oagulability.
*ntiembolism sto!kings shoul be worn aroun the !lo!k, but shoul be
remove twi!e a ay #or 32 minutes so that skin !are !an be per#orme.
&e#ore the nurse puts antiembolism sto!kings ba!k on the patient, the
patient shoul lie with his #eet elevate ;D ('5.( !m) #or (2 minutes.
"ressler6s synrome is known as late peri!aritis be!ause it o!!urs
appro3imately ; weeks to ; months a#ter a myo!arial in#ar!tion. It !auses
peri!arial pain an a #ever that lasts longer than ' week.
In phase I a#ter a myo!arial in#ar!tion, #or the #irst (4 hours, the patient
is kept on a !lear liqui iet an be rest with the use o# a besie
!ommoe.
In phase I a#ter a myo!arial in#ar!tion, on the se!on ay, the patient
gets out o# be an spens '5 to (2 minutes in a !hair. ,he number o# times
that the patient goes to the !hair an the length o# time he spens in the
!hair are in!rease epening on his enuran!e. In phase II, the length o#
time that the patient spens out o# be an the istan!e to the !hair are
in!rease.
*#ter trans#er #rom the !aria! !are unit, the post+myo!arial in#ar!tion
patient is allowe to walk the halls as his enuran!e in!reases.
9e3ual inter!ourse with a known partner usually !an be resume 4 to 1
weeks a#ter a myo!arial in#ar!tion.
* patient uner !aria! !are shoul avoi rinking al!oholi! beverages or
eating be#ore engaging in se3ual inter!ourse.
,he ambulation goal #or a post+myo!arial in#ar!tion patient is ( miles in
;2 minutes.
* post+myo!arial in#ar!tion patient who oesn6t have a strenuous 7ob
may be able to return to work #ull+time in 1 or B weeks.
9troke volume is the amount o# bloo e7e!te #rom the heart with ea!h
heartbeat.
*#terloa is the #or!e that the ventri!le must e3ert uring systole to e7e!t
the stroke volume.
,he three+point position (with the patient upright an leaning #orwar,
with the hans on the knees) is !hara!teristi! o# orthopnea, as seen in le#t+
sie heart #ailure.
%aro3ysmal no!turnal yspnea ini!ates a severe #orm o# pulmonary
!ongestion in whi!h the patient awakens in the mile o# the night with a
#eeling o# being su##o!ate.
-lini!al mani#estations o# pulmonary eema in!lue breathlessness, nasal
#laring, use o# a!!essory mus!les to breath, an #rothy sputum.
* late sign o# heart #ailure is e!rease !aria! output that !auses
e!rease bloo #low to the kineys an results in oliguria.
* late sign o# heart #ailure is anasar!a (generali0e eema).
"epenent eema is an early sign o# right+sie heart #ailure. It6s seen in
the legs, where in!rease !apillary hyrostati! pressure overwhelms plasma
protein, !ausing a shi#t o# #lui #rom the !apillary bes to the interstitial
spa!es.
"epenent eema, whi!h is most noti!eable at the en o# the ay, usually
starts in the #eet an ankles an !ontinues upwar.
=or the re!umbent patient, eema is usually seen in the presa!ral area.
9igns o# urinary tra!t in#e!tion in!lue #requen!y, urgen!y, an ysuria.
In tertiary+intention healing, woun !losure is elaye be!ause o#
in#e!tion or eema.
* patient who has ha supratentorial surgery shoul have the hea o# the
be elevate 32 egrees.
*n a!i+ash iet a!ii#ies urine.
$itamin - an !ranberry 7ui!e a!ii#y urine.
* patient who takes probene!i (-olbenemi) #or gout shoul be
instru!te to take the rug with #oo.
I# woun ehis!en!e is suspe!te, the nurse shoul instru!t the patient to
lie own an shoul e3amine the woun an monitor the vital signs.
*bnormal #inings shoul be reporte to the physi!ian.
Zoster immune globulin is aministere to stimulate immunity to
vari!ella.
,he most !ommon symptoms asso!iate with !ompartmental synrome
are pain that6s not relieve by analgesi!s, loss o# movement, loss o#
sensation, pain with passive movement, an la!k o# pulse.
,o help relieve mus!le spasms in a patient who has multiple s!lerosis, the
nurse shoul aminister ba!lo#en (Lioresal) as orere? give the patient a
warm, soothing bath? an tea!h the patient progressive rela3ation
te!hniques.
* patient who has a !ervi!al in7ury an impairment at -5 shoul be able
to li#t his shoulers an elbows partially, but has no sensation below the
!lavi!le.
* patient who has !ervi!al in7ury an impairment at -; shoul be able to
li#t his shoulers, elbows, an wrists partially, but has no sensation below
the !lavi!le, e3!ept a small amount in the arms an thumb.
* patient who has !ervi!al in7ury an impairment at -A shoul be able to
li#t his shoulers, elbows, wrists, an hans partially, but has no sensation
below the mi!hest.
In7uries to the spinal !or at -3 an above may be #atal as a result o# loss
o# innervation to the iaphragm an inter!ostal mus!les.
9igns o# meningeal irritation seen in meningitis in!lue nu!hal rigiity, a
positive &ru0inski6s sign, an a positive .ernig6s sign.
Laboratory values that show pneumomeningitis in!lue an elevate
!erebrospinal #lui (-9=) protein level (more than '22 mg/l), a e!rease
-9= glu!ose level (42 mg/l), an an in!rease white bloo !ell !ount.
&e#ore unergoing magneti! resonan!e imaging, the patient shoul
remove all ob7e!ts !ontaining metal, su!h as wat!hes, unerwire bras, an
7ewelry.
Csually #oo an mei!ine aren6t restri!te be#ore magneti! resonan!e
imaging.
%atients who are unergoing magneti! resonan!e imaging shoul know
that they !an ask questions uring the pro!eure? however, they may be
aske to lie still at !ertain times.
I# a !ontrast meium is use uring magneti! resonan!e imaging, the
patient may e3perien!e iuresis as the meium is #lushe #rom the boy.
,he ,0an!k test is use to !on#irm herpes genitalis.
8epatitis - is sprea primarily through bloo (#or e3ample, uring
trans#usion or in people who work with bloo prou!ts), personal !onta!t
an, possibly, the #e!al+oral route.
,he best metho #or soaking an open, in#e!te, raining woun is to use a
hot+moist ressing.
9putum !ulture is the !on#irmation test #or tuber!ulosi
s.
"e3amethasone ("e!aron) is a steroial anti+in#lammatory that6s use to
treat arenal insu##i!ien!y.
9igns o# in!rease intra!ranial pressure in!lue alteration in level o#
!ons!iousness, restlessness, irritability, an pupillary !hanges.
,he patient who has a lower limb amputation shoul be instru!te to
assume a prone position at least twi!e a ay.
"uring the #irst (4 hours a#ter amputation, the resiual limb is elevate
on a pillow. *#ter that time, the limb is pla!e #lat to reu!e the risk o# hip
#le3ion !ontra!tures.
* tourniquet shoul be in #ull view at the besie o# the patient who has
an amputation.
*n emergen!y tra!heostomy set shoul be kept at the besie o# a
patient who is suspe!te o# having epiglottitis.
5o!ky /ountain spotte #ever is sprea through the bite o# a ti!k
harboring the 5i!kettsia organism.
* patient who has a!quire immunoe#i!ien!y synrome shouln6t share
ra0ors or toothbrushes with others, but there are no spe!ial pre!autions #or
innerware or launry servi!es.
&e!ause anti#ungal !reams may stain !lothing, patients who use them
shoul use sanitary napkins.
*n anti#ungal !ream shoul be inserte high in the vagina at betime.
* patient who is having a sei0ure usually requires prote!tion #rom the
environment only? however, anyone who nees airway management shoul
be turne on his sie.
9tatus epilepti!us is treate with I.$. iphenylhyantoin.
* 3enogra#t is a skin gra#t #rom an animal.
,he antiote #or magnesium sul#ate is !al!ium glu!onate '2E.
*llergi! rea!tions to a bloo trans#usion are #lushing, whee0ing, urti!aria,
an rash.
* patient who has a history o# basal !ell !ar!inoma shoul avoi sun
e3posure.
:hen potent, nitrogly!erin !auses a slight stinging sensation uner the
tongue.
* patient who appears to be L#ighting the ventilatorM is holing his breath
or breathing out on an inspiratory !y!le.
*n antineoplasti! rug that6s use to treat breast !an!er is tamo3i#en
(Iolvae3).
*verse e##e!ts o# vin!ristine (>n!ovin) are alope!ia, nausea, an
vomiting.
In!rease urine output is an ini!ation that a hypertensive !risis is
normali0ing.
I# a patient who is re!eiving I.$. !hemotherapy has pain at the insertion
site, the nurse shoul stop the I.$. in#usion immeiately.
E3travasation is leakage o# #lui into surrouning tissue #rom a vein that6s
being use #or I.$. therapy.
-lini!al signs o# prostate !an!er are ribbling, hesitan!y, an e!rease
urinary #or!e.
-aria! gly!osies in!rease !aria! !ontra!tility.
*verse e##e!ts o# !aria! gly!osies in!lue heaa!he, hypotension,
nausea an vomiting, an yellow+green halos aroun lights.
* , tube shoul be !lampe uring patient meals to ai in #at igestion.
* , tube usually remains in pla!e #or '2 ays.
"uring a vertigo atta!k, a patient who has /Kni[re6s isease shoul be
instru!te to lie own on his sie with his eyes !lose.
:hen maintaining a Sa!kson+%ratt rainage system, the nurse shoul
squee0e the reservoir an e3pel the air be#ore re!apping the system.
,he most !ommon symptom asso!iate with sleep apnea is snoring.
8istamine is release uring an in#lammatory response.
:hen ealing with a patient who has a severe spee!h impeiment, the
nurse shoul minimi0e ba!kgroun noise an avoi interrupting the patient.
=ever an night sweats, hallmark signs o# tuber!ulosis, may not be
present in elerly patients who have the isease.
* suitable ressing #or woun ebriement is wet+to+ry.
"rinking warm milk at betime ais sleeping be!ause o# the natural
seative e##e!t o# the amino a!i tryptophan.
,he initial step in promoting sleep in a hospitali0e patient is to minimi0e
environmental stimulation.
&e#ore moving a patient, the nurse shoul assess how mu!h e3ertion the
patient is permitte, the patient6s physi!al ability, an his ability to
unerstan instru!tion as well as her own strength an ability to move the
patient.
* patient who is in a restraint shoul be !he!ke every 32 minutes an
the restraint loosene every ( hours to permit range o# motion e3er!ises #or
the e3tremities.
*ntibioti!s that are given #our times a ay shoul be given at ; a.m., '(
p.m., ; p.m., an '( a.m. to minimi0e isruption o# sleep.
9unowner synrome is seen in patients who be!ome more !on#use
towar the evening. ,o !ounter this tenen!y, the nurse shoul turn a light
on.
=or the patient who has somnambulism, the primary goal is to prevent
in7ury by proviing a sa#e environment.
=or the patient who has somnambulism, the primary goal is to prevent
in7ury by proviing a sa#e environment.
Ialo3one (Iar!an) shoul be kept at the besie o# the patient who is
re!eiving patient+!ontrolle analgesia.
8ypnoti! rugs e!rease rapi eye movement sleep, but in!rease the
overall amount o# sleep.
* suen wave o# overwhelming sleepiness is a symptom o# nar!olepsy.
* iabeti! patient shoul be instru!te to buy shoes in the a#ternoon
be!ause #eet are usually largest at that time o# ay.
I# surgery is s!heule late in the a#ternoon, the surgeon may approve a
light break#ast.
* hearing ai is usually le#t in pla!e uring surgery to permit
!ommuni!ation with the patient. ,he operating room team shoul be noti#ie
o# its presen!e.
,he nurse shoul monitor the patient #or !entral nervous system
epression #or (4 hours a#ter the aministration o# nitrous o3ie.
In the postanesthesia !are unit, the proper position o# an ault is with the
hea to the sie an the !hin e3tene upwar. ,he 9ims6 position also !an
be use unless !ontraini!ate.
*#ter a patient is amitte to the postanesthesia !are unit, the #irst a!tion
is to assess the paten!y o# the airway.
I# a patient is amitte to the postanesthesia !are unit without the
pharyngeal re#le3, he6s positione on his sie. ,he nurse stays at the besie
until the gag re#le3 returns.
In the postanesthesia !are unit, the patient6s vital signs are taken every
'5 minutes routinely, or more o#ten i# ini!ate, until the patient is stable.
In the postanesthesia !are unit, the , tube shoul be un!lampe an
atta!he to a rainage system.
*#ter the patient re!eives anesthesia, the nurse must observe him #or a
rop in bloo pressure or evien!e o# labore breathing.
I# a patient begins to go into sho!k uring the postanesthesia assessment,
the nurse shoul aminister o3ygen, pla!e the patient in the ,renelenburg
position, an in!rease the I.$. #lui rate a!!oring to the physi!ian6s orer or
the poli!y o# the postanesthesia !are unit.
,ypes o# benign tumors in!lue my3oma, #ibroma, lipoma, osteoma, an
!honroma.
/alignant tumors in!lue sar!oma, basal !ell !ar!inoma, #ibrosar!oma,
osteosar!oma, my3osar!oma, !honrosar!oma, an aeno!ar!inoma.
=or a !an!er patient, palliative surgery is per#orme to reu!e pain,
relieve airway obstru!tion, relieve )I obstru!tion, prevent hemorrhage,
relieve pressure on the brain an spinal !or, rain abs!esses, an remove
or rain in#e!te tumors.
* patient who is unergoing raiation implant therapy shoul be kept in a
private room to reu!e the risk o# e3posure to others, in!luing nursing
personnel.
*#ter total knee repla!ement surgery, the knee shoul be kept in
ma3imum e3tension #or 3 ays.
%artial weight bearing is allowe appro3imately ' week a#ter total knee
repla!ement. :eight bearing to the point o# pain is allowe at ( weeks.
97Ygren6s synrome is a !hroni! in#lammatory isorer asso!iate with a
e!rease in salivation an la!rimation. -lini!al mani#estations in!lue
ryness o# the mouth, eyes, an vagina.
Iormal values o# !erebrospinal #lui in!lue the #ollowingG protein level,
'5 to 45 mg/'22 ml? #asting glu!ose, 52 to 12 mg/'22 ml? re bloo !ell
!ount, 2? white bloo !ell !ount, 2 to 5/\lG p8, A.3? potassium ion value, (.B
mmol/L? !hlorie, '(2 to '32 mEq/L.
,he #ollowing mnemoni! evi!e !an be use to ienti#y whether a !ranial
nerve is a motor nerveG I 9ome ] II 9ay ] III /arry ] I$ /oney, ] $ but ] $I
/y ] $II &rother ] $II 9ays ] I< &a ] < &usiness ] <I /arry ] <II /oney.
,o interpret the mnemoni! evi!eG I# the wor begins with an 9, it6s a
sensory nerve? i# it starts with an /, it6s a motor nerve? an i# it starts with a
&, it6s both a sensory an a motor nerve.
,he )lasgow -oma 9!ale evaluates level o# !ons!iousness, pupil rea!tion,
an motor a!tivity. * s!ore between 3 an '5 is possible.
:hen assessing a patient6s pupils, the nurse shoul remember that
aniso!oria, unequal pupils o# ' mm or larger, o!!urs in appro3imately 'AE
o# the population.
8omonymous hemianopsia is a visual e#e!t in whi!h the patient sees
only one+hal# o# the visual #iel with ea!h eye. ,here#ore, the patient sees
only one+hal# o# a normal visual #iel.
%assive range+o#+motion e3er!ises are !ommonly starte (4 hours a#ter a
stroke. ,hey6re per#orme #our times per ay.
In treating a patient with a transient is!hemi! atta!k, the goal o# mei!al
management is to prevent a stroke. ,he patient is aministere
antihypertensive rugs, antiplatelet rugs or aspirin an, in some !ases,
war#arin (-oumain).
* patient who has an intraperitoneal shunt shoul be observe #or
in!rease abominal girth.
"igestion o# !arbohyrates begins in the mouth.
"igestion o# #ats begins in the stoma!h, but o!!urs preominantly in the
small intestine.
"ietary sour!es o# magnesium are #ish, grains, an nuts.
* rough estimate o# serum osmolarity is twi!e the serum soium level.
In etermining a!iFbase problems, the nurse shoul #irst note the p8. I#
it6s above A.45, it6s a problem o# alkalosis? i# it6s below A.35, it6s a problem
o# a!iosis. ,he nurse shoul ne3t look at the partial pressure o# arterial
!arbon io3ie (%a->(). ,his is the respiratory ini!ator. I# the p8 ini!ates
a!iosis an the %a->( ini!ates a!iosis as well (greater than 45 mm 8g),
then there6s a mat!h, an the sour!e o# the problem is respiration. It6s !alle
respiratory a!iosis. I# the p8 ini!ates alkalosis an the %a->( also
ini!ates alkalosis (less than 35 mm 8g), then there6s a mat!h, an the
sour!e o# the problem is respiration. ,his is !alle respiratory alkalosis. I# the
%a->( is normal, then the nurse shoul look at the bi!arbonate (8->3F),
whi!h is the metaboli! ini!ator, an note whether it6s a!ii! (less than ((
mEq/L) or alkaline (greater than (; mEq/L). "etermine whi!h value the p8
mat!hes? it will etermine whether the problem is metaboli! a!iosis or
metaboli! alkalosis. I# both the %a->( an 8->3F are abnormal, then the
boy is !ompensating. I# the p8 has returne to normal, the boy is in #ull
!ompensation.
,he ,ensilon (erophonium !hlorie) test is use to !on#irm myasthenia
gravis.
* masklike #a!ial e3pression is a sign o# myasthenia gravis an
%arkinson6s isease.
*lbumin is a !olloi that ais in maintaining #lui within the vas!ular
system. I# albumin were #iltere out through the kineys an into the urine,
eema woul o!!ur.
Eema !ause by water an trauma oesn6t !ause pitting.
"ehyration is water loss only? #lui volume e#i!it in!lues all #luis in
the boy.
,he primary a!tion o# an oil retention enema is to lubri!ate the !olon. ,he
se!onary a!tion is so#tening the #e!es.
* patient who uses a walker shoul be instru!te to move the walker
appro3imately '(D (32.5 !m) to the #ront an then avan!e into the walker.
&raykinesia is a sign o# %arkinson6s isease.
Lorosis is ba!kwar ar!hing !urvature o# the spine.
.yphosis is #orwar !urvature o# the spine.
In a patient with anore3ia nervosa, a positive response to therapy is
sustaine weight gain.
,he rug in ialysate is heparin.
*n autogra#t is a gra#t that6s remove #rom one area o# the boy #or
transplantation to another.
9igns o# !ervi!al !an!er in!lue mimenses bleeing an post!oital
bleeing.
*#ter prostate!tomy, a !atheter is inserte to irrigate the blaer an
keep urine straw+!olore or light pink, to put ire!t pressure on the
operative sie, an to maintain a patent urethra.
I# a raiation implant be!omes isloge, but remains in the patient, the
nurse shoul noti#y the physi!ian.
,he best metho to reu!e the risk #or atele!tasis is to en!ourage the
patient to walk.
*tele!tasis usually o!!urs (4 to 41 hours a#ter surgery.
%atients who are at the greatest risk #or atele!tasis are those who have
ha high abominal surgery, su!h as !hole!yste!tomy.
* persistent e!rease in o3ygen to the kineys !auses erythropoiesis.
5hon!hi an !ra!kles ini!ate ine##e!tive airway !learan!e.
:hee0ing ini!ates bron!hospasms.
-lini!al signs an symptoms o# hypo3emia are restlessness (usually the
#irst sign), agitation, yspnea, an isorientation.
-ommon averse e##e!ts o# opiois are !onstipation an respiratory
epression.
"isuse osteoporosis is !ause by eminerali0ation o# !al!ium as a result o#
prolonge be rest.
,he best way to prevent isuse osteoporosis is to en!ourage the patient
to walk.
* !ane shoul be !arrie on the una##e!te sie an avan!e with the
a##e!te e3tremity.
9terois shouln6t be use in patients who have !hi!kenpo3 or shingles
be!ause they may !ause averse e##e!ts.
9ero!onversion o!!urs appro3imately 3 to ; months a#ter e3posure to
human immunoe#i!ien!y virus.
,herapy with the antiviral agent 0iovuine is initiate when the -"4W ,+
!ell !ount is 522 !ells/\l or less.
In a light+skinne person, .aposi6s sar!oma !auses a purplish
is!oloration o# the skin. In a ark+skinne person, the is!oloration is ark
brown to bla!k.
*#ter an esophageal balloon tamponae is in pla!e, it shoul be in#late to
(2 mm 8g.
* patient who has .aposi6s sar!oma shoul avoi a!ii! or highly
seasone #oos.
,he treatment #or oral !aniiasis is amphoteri!in & (=ungi0one) or
#lu!ona0ole ("i#lu!an).
* sign o# respiratory #ailure is vital !apa!ity o# less than '5 ml/kg an
respiratory rate o# greater than 32 breaths/minute or less than 1 breaths/
minute.
=or le#t+sie !aria! !atheteri0ation, the !atheter is threae through the
es!ening aorta, aorti! ar!h, as!ening aorta, aorti! valve, an le#t
ventri!le.
=or right+sie !aria! !atheteri0ation, the !atheter is threae through
the superior vena !ava, right atrium, right ventri!le, pulmonary artery, an
pulmonary !apillaries.
*nemia !an be ivie into #our groups a!!oring to its !auseG bloo loss,
impaire prou!tion o# re bloo !ells (5&-s), in!rease estru!tion o# 5&-s,
an nutritional e#i!ien!ies.
*spirin, ibupro#en, phenobarbital, lithium, !ol!hi!ine, lea, an
!hlorampheni!ol !an !ause aplasti! anemia.
*#ter a patient unergoes bone marrow aspiration, the nurse shoul apply
ire!t pressure to the site #or 3 to 5 minutes to reu!e the risk o# bleeing.
=resh #ro0en plasma is thawe to B1.;@ = (3A@ -) be#ore in#usion.
9igns o# thrombo!ytopenia in!lue pete!hiae, e!!hymoses, hematuria,
an gingival bleeing.
* patient who has thrombo!ytopenia shoul be taught to use a so#t
toothbrush an use an ele!tri! ra0or.
9igns o# #lui overloa in!lue in!rease !entral venous pressure,
in!rease pulse rate, istene 7ugular veins, an bouning pulse.
* patient who has leukopenia (or any other patient who is at an in!rease
risk #or in#e!tion) shoul avoi eating raw meat, #resh #ruit, an #resh
vegetables.
,o prevent a severe gra#t+versus+host rea!tion, whi!h is most !ommonly
seen in patients oler than age 32, the onor marrow is treate with
mono!lonal antiboies be#ore transplantation.
,he #our most !ommon signs o# hypogly!emia reporte by patients are
nervousness, mental isorientation, weakness, an perspiration.
%rolonge atta!ks o# hypogly!emia in a iabeti! patient !an result in brain
amage.
*!tivities that in!rease intra!ranial pressure in!lue !oughing, snee0ing,
straining to pass #e!es, bening over, an blowing the nose.
,reatment #or bleeing esophageal vari!es in!lues vasopressin,
esophageal tamponae, i!e saline lavage, an vitamin ..
8epatitis - (also known as bloo+trans#usion hepatitis) is a parenterally
transmitte #orm o# hepatitis that has a high in!ien!e o# !arrier status.
,he nurse shoul be !on!erne about #lui an ele!trolyte problems in the
patient who has as!ites, eema, e!rease urine output, or low bloo
pressure.
,he nurse shoul be !on!erne about )I bleeing, low bloo pressure,
an in!rease heart rate in a patient who is hemorrhaging.
,he nurse shoul be !on!erne about generali0e malaise, !louy urine,
purulent rainage, ta!hy!aria, an in!rease temperature in a patient who
has an in#e!tion.
In a patient who has eema or as!ites, the serum ele!trolyte level shoul
be monitore. ,he patient also shoul be weighe aily? have his abominal
girth measure with a !entimeter tape at the same lo!ation, using the
umbili!us as a !he!kpoint? have his intake an output measure? an have
his bloo pressure taken at least every 4 hours.
Enogenous sour!es o# ammonia in!lue a0otemia, )I bleeing,
!atabolism, an !onstipation.
E3ogenous sour!es o# ammonia in!lue protein, bloo trans#usion, an
amino a!is.
,he #ollowing histologi! graing system is use to !lassi#y !an!ersG grae
', well+i##erentiate? grae (, moerately well+i##erentiate? grae 3,
poorly i##erentiate? an grae 4, very poorly i##erentiate.
,he #ollowing graing system is use to !lassi#y tumorsG ,2, no evien!e
o# a primary tumor? ,I9, tumor in situ? an ,', ,(, ,3, an ,4, a!!oring to
the si0e an involvement o# the tumor? the higher the number, the greater
the involvement.
%heo!hromo!ytoma is a !ate!holamine+se!reting neoplasm o# the arenal
meulla. It !auses e3!essive prou!tion o# epinephrine an norepinephrine.
-lini!al mani#estations o# pheo!hromo!ytoma in!lue visual isturban!es,
heaa!hes, hypertension, an elevate serum glu!ose level.
,he patient shouln6t !onsume any !a##eine+!ontaining prou!ts, su!h as
!ola, !o##ee, or tea, #or at least 1 hours be#ore obtaining a (4+hour urine
sample #or vanillylmaneli! a!i.
* patient who is taking -ol&enemi (probene!i an !ol!hi!ine) #or gout
shoul in!rease his #lui intake to (,222 ml/ay.
* mioti! su!h as pilo!arpine is aministere to a patient with glau!oma to
in!rease the out#low o# aqueous humor, whi!h e!reases intrao!ular tension.
,he rug that6s most !ommonly use to treat strepto!o!!al pharyngitis
an rheumati! #ever is peni!illin.
* patient with gout shoul avoi purine+!ontaining #oos, su!h as liver
an other organ meats.
* patient who unergoes magneti! resonan!e imaging lies on a #lat
plat#orm that moves through a magneti! #iel.
Laboratory values in patients who have ba!terial meningitis in!lue
in!rease white bloo !ell !ount, in!rease protein an la!ti! a!i levels, an
e!rease glu!ose level.
/annitol is a hypertoni! osmoti! iureti! that e!reases intra!ranial
pressure.
,he best metho to ebrie a woun is to use a wet+to+ry ressing an
remove the ressing a#ter it ries.
,he greatest risk #or respiratory !ompli!ations o!!urs a#ter !hest wall
in7ury, !hest wall surgery, or upper abominal surgery.
9e!onary methos to prevent postoperative respiratory !ompli!ations
in!lue having the patient use an in!entive spirometer, turning the patient,
avising the patient to !ough an breathe eeply, an proviing hyration.
* !hara!teristi! o# allergi! inspiratory an e3piratory whee0ing is a ry,
ha!king, nonprou!tive !ough.
,he in!ubation perio #or 5o!ky /ountain spotte #ever is A to '4 ays.
/i!ona0ole (/onistat) vaginal suppository shoul be aministere with
the patient lying #lat.
,he nurse shoul pla!e the patient who is having a sei0ure on his sie.
9igns o# hip islo!ation are one leg that6s shorter than the other an one
leg that6s e3ternally rotate.
*nti!holinergi! mei!ation is aministere be#ore surgery to iminish
se!retion o# saliva an gastri! 7ui!es.
E3trapyramial synrome in a patient with %arkinson6s isease is usually
!ause by a e#i!ien!y o# opamine in the substantia nigra.
In a burn patient, the orer o# !on!ern is airway, !ir!ulation, pain, an
in#e!tion.
8yperkalemia normally o!!urs uring the hypovolemi! phase in a patient
who has a serious burn in7ury.
&la!k #e!es in the burn patient are !ommonly relate to -urling6s ul!er.
In a patient with burn in7ury, immeiate !are o# a #ull+thi!kness skin gra#t
in!lues !overing the site with a bulky ressing.
,he onor site o# a skin gra#t shoul be le#t e3pose to the air.
Leaking aroun a , tube shoul be reporte immeiately to the physi!ian.
* patient who has /Kni[re6s isease shoul !onsume a low+soium iet.
In any postoperative patient, the priority o# !on!ern is airway, breathing,
an !ir!ulation, #ollowe by sel#+!are e#i!its.
,he symptoms o# myasthenia gravis are most likely relate to nerve
egeneration.
9ymptoms o# septi! sho!k in!lue !ol, !lammy skin? hypotension? an
e!rease urine output.
Iinety+#ive per!ent o# women who have gonorrhea are asymptomati!.
*n averse sign in a patient who has a 9teinmann6s pin in the #emur
woul be erythema, eema, an pain aroun the pin site.
9igns o# !hroni! glau!oma in!lue halos aroun lights, graual loss o#
peripheral vision, an !louy vision.
9igns o# a eta!he retina in!lue a sensation o# a veil (or !urtain) in the
line o# sight.
,o3i! levels o# streptomy!in !an !ause hearing loss.
* long+term e##e!t o# rheumati! #ever is mitral valve amage.
Laboratory values note in rheumati! #ever in!lue an antistreptolysin+>
titer, the presen!e o# -+rea!tive protein, leuko!ytosis, an an in!rease
erythro!yte seimentation rate.
-rampy pain in the right lower quarant o# the abomen is a !onsistent
#ining in -rohn6s isease.
-rampy pain in the le#t lower quarant o# the abomen is a !onsistent
#ining in iverti!ulitis.
In the i!teri! phase o# hepatitis, urine is amber, #e!es are !lay+!olore,
an the skin is yellow.
9igns o# osteomyelitis in!lue pathologi! #ra!tures, shortening or
lengthening o# the bone, an pain eep in the bone.
,he laboratory test that woul best re#le!t #lui loss be!ause o# a burn
woul be hemato!rit.
* patient who has a!ute pan!reatitis shoul take nothing by mouth an
unergo gastri! su!tion to e!ompress the stoma!h.
* mist tent is use to in!rease the hyration o# se!retions.
* patient who is re!eiving levoopa shoul avoi #oos that !ontain
pyrio3ine (vitamin &;), su!h as beans, tuna, an bee# liver, be!ause this
vitamin e!reases the e##e!tiveness o# levoopa.
* patient who has a transa!tional in7ury at -3 requires positive
ventilation.
,he a!tion o# phenytoin ("ilantin) is potentiate when given with
anti!oagulants.
-erebral palsy is a nonprogressive isorer that persists throughout li#e.
* !ompli!ation o# ul!erative !olitis is per#oration.
:hen a patient who has multiple s!lerosis e3perien!es iplopia, one eye
shoul be pat!he.
* anger sign a#ter hip repla!ement is la!k o# re#le3es in the a##e!te
e3tremity.
* !lini!al mani#estation o# a rupture lumbar isk in!lues pain that
shoots own the leg an terminates in the popliteal spa!e.
,he most important nutritional nee o# the burn patient is I.$. #lui with
ele!trolytes.
,he patient who has systemi! lupus erythematosus shoul avoi
sunshine, hair spray, hair !oloring prou!ts, an usting power.
,he best position #or a patient who has low ba!k pain is sitting in a
straight+ba!ke !hair.
-lini!al signs o# ul!erative !olitis in!lue blooy, purulent, mu!oi, an
watery #e!es.
* patient who has a protein systemi! shunt must #ollow a li#elong protein+
restri!te iet.
* patient who has a hiatal hernia shoul maintain an upright position a#ter
eating.
* su!tion apparatus shoul be kept at the besie o# a patient who is at
risk #or status epilepti!us.
,he leaing !ause o# eath in the burn patient is respiratory !ompromise
an in#e!tion.
In patients who have herpes 0oster, the primary !on!ern is pain
management.
,he treatment #or 5o!ky /ountain spotte #ever is tetra!y!line.
9trawberry tongue is a sign o# s!arlet #ever.
I# a patient has hemianopsia, the nurse shoul pla!e the !all light, the
meal tray, an other items in his #iel o# vision.
,he best position #or the patient a#ter a !raniotomy is semi+=owler.
9igns o# renal trauma in!lue #lank pain, hematoma an, possibly, bloo
in the urine an e!rease urine output.
=lank pain an hematoma in the ba!k ini!ate renal hemorrhage in the
trauma patient.
Iatural iureti!s in!lue !o##ee, tea, an grape#ruit 7ui!e.
-entral venous pressure o# '1 !m 8(> ini!ates hypervolemia.
9almonellosis !an be a!quire by eating !ontaminate meat su!h as
!hi!ken, or eggs.
)oo sour!es o# magnesium in!lue #ish, nuts, an grains.
%atients who have low bloo urea nitrogen levels shoul be instru!te to
eat high+protein #oos, su!h as #ish an !hi!ken.
,he nurse shoul monitor a patient who has )uillain+&arrK synrome #or
respiratory !ompromise.
* heating pa may provie !om#ort to a patient who has pelvi!
in#lammatory isease.
*#ter supratentorial surgery, the patient shoul be pla!e in the semi+
=owler position.
,o prevent eep vein thrombosis, the patient shoul e3er!ise his legs at
least every ( hours, elevate the legs above the level o# the heart while lying
own, an ambulate with assistan!e.
*#ter bron!hos!opy, the patient6s gag re#le3 shoul be !he!ke.
In a patient with mononu!leosis, abominal pain an pain that raiates to
the le#t shouler may ini!ate a rupture spleen.
=or a skin gra#t to take, it must be autologous.
Cntreate retinal eta!hment leas to blinness.
* patient who has #ibro!ysti! breast isease shoul !onsume a iet that6s
low in !a##eine an salt.
* #oul oor at the pin site o# a patient who is in skeletal tra!tion ini!ates
in#e!tion.
* mus!le rela3ant that6s aministere with o3ygen may !ause malignant
hyperthermia an respiratory epression.
%ain that o!!urs on movement o# the !ervi3, together with ane3al
tenerness, suggests pelvi! in#lammatory isease.
,he goal o# !risis intervention is to restore the person to a pre!risis level
o# #un!tioning an orer.
Iephroti! synrome !auses proteinuria, hypoalbuminemia, an eema,
an sometimes hematuria, hypertension, an a e!rease glomerular
#iltration rate.
&owel souns may be hear over a hernia, but not over a hyro!ele.
9' is e!rease in #irst+egree heart blo!k. 9( is e!rease in aorti!
stenosis.
)as in the !olon may !ause tympany in the right upper quarant, obs!ure
liver ullness, an lea to #alsely e!rease estimates o# liver si0e.
In ata3ia !ause by loss o# position sense, vision !ompensates #or the
sensory loss. ,he patient stans well with the eyes open, but loses balan!e
when they6re !lose (positive 5omberg test result).
Inability to re!ogni0e numbers when rawn on the han with the blunt
en o# a pen suggests a lesion in the sensory !orte3.
"uring the late stage o# multiple myeloma, the patient shoul be
prote!te against pathologi!al #ra!tures as a result o# osteoporosis.
,ri!y!li! antiepressants su!h as amitriptyline (Elavil) shouln6t be
aministere to patients with narrow+angle glau!oma, benign prostati!
hypertrophy, or !oronary artery isease.
%ulmonary embolism is !hara!teri0e by a suen, sharp, stabbing pain in
the !hest? yspnea? e!rease breath souns? an !ra!kles or a pleural
#ri!tion rub on aus!ultation.
-lini!al mani#estations o# !aria! tamponae are hypotension an 7ugular
vein istention.
,o avoi #urther amage, the nurse shouln6t inu!e vomiting in a patient
who has swallowe a !orrosive !hemi!al, su!h as oven !leaner, rain
!leaner, or kerosene.
* brilliant re re#le3 e3!lues most serious e#e!ts o# the !ornea, aqueous
!hamber, lens, an vitreous !hamber.
>ral hypogly!emi! agents stimulate the islets o# Langerhans to prou!e
insulin.
,o treat woun ehis!en!e, the nurse shoul help the patient to lie in a
supine position? !over the protruing intestine with moist, sterile, normal
saline pa!ks? an !hange the pa!ks #requently to keep the area moist.
:hile a patient is re!eiving an I.$. nitrogly!erin rip, the nurse shoul
monitor his bloo pressure every '5 minutes to ete!t hypotension.
*ny type o# #lui loss !an trigger a !risis in a patient with si!kle !ell
anemia.
,he patient shoul rinse his mouth a#ter using a !orti!osteroi inhaler to
avoi steroi resiue an reu!e oral #ungal in#e!tions.
* patient with low levels o# triioothyronine an thyro3ine may have
#atigue, lethargy, !ol intoleran!e, !onstipation, an e!rease libio.
"uring a si!kle !ell !risis, treatment in!lues pain management,
hyration, an be rest.
* patient who is hyperventilating shoul rebreathe into a paper bag to
in!rease the retention o# !arbon io3ie.
-horea is a ma7or !lini!al mani#estation o# !entral nervous system
involvement !ause by rheumati! #ever.
-horea !auses !onstant 7erky, un!ontrolle movements? #igeting?
twisting? grima!ing? an loss o# bowel an blaer !ontrol.
9evere iarrhea !an !ause ele!trolyte e#i!ien!ies an metaboli! a!iosis.
,o reu!e the risk o# hyper!al!emia in a patient with metastati! bone
!an!er, the nurse shoul help the patient ambulate, promote #lui intake to
ilute urine, an limit the patient6s oral intake o# !al!ium.
%ain asso!iate with a myo!arial in#ar!tion usually is es!ribe as
LpressureM or as a LheavyM or Lsquee0ingM sensation in the misternal area.
,he patient may report that the pain #eels as though someone is staning on
his !hest or as though an elephant is sitting on his !hest.
-al!ium an phosphorus levels are elevate until hyperparathyroidism
is stabili0e.
,he pain asso!iate with !arpal tunnel synrome is !ause by entrapment
o# the meian nerve at the wrist.
%an!reati! en0yme repla!ement enhan!es the absorption o# protein.
Lamine!tomy with spinal #usion is per#orme to relieve pressure on the
spinal nerves an stabili0e the spine.
* transe!tion in7ury o# the spinal !or at any level !auses paralysis below
the level o# the lesion.
=or pulseless ventri!ular ta!hy!aria, the patient shoul be e#ibrillate
immeiately, with (22 7oules, 322 7oules, an then 3;2 7oules given in rapi
su!!ession.
%leural #ri!tion rub is hear in pleurisy, pneumonia, an plural in#ar!tion.
:hee0es are hear in emphysema, #oreign boy obstru!tion, an asthma.
5hon!hi are hear in pneumonia, emphysema, bron!hitis, an
bron!hie!tasis.
-ra!kles are hear in pulmonary eema, pneumonia, an pulmonary
#ibrosis.
,he ele!tro!ariogram o# a patient with heart #ailure shows ventri!ular
hypertrophy.
* e!rease in the potassium level e!reases the e##e!tiveness o# !aria!
gly!osies, in!reases the possibility o# igo3in to3i!ity, an !an !ause #atal
!aria! arrhythmias.
* '(+lea ele!tro!ariogram reaing shoul be obtaine uring a
myo!arial in#ar!tion or an anginal atta!k.
,he primary i##eren!e between angina an the symptoms o# a myo!arial
in#ar!tion (/I) is that angina !an be relieve by rest or nitrogly!erin
aministration. ,he symptoms o# an /I aren6t relieve with rest, an the
pain !an last 32 minutes or longer.
-al!ium !hannel blo!kers in!lue verapamil (-alan), iltia0em
hyro!hlorie (-ari0em), ni#eipine (%ro!aria), an ni!aripine
hyro!hlorie (-arene).
*#ter a myo!arial in#ar!tion, ele!tro!ariograph !hanges in!lue
elevations o# the Q wave an 9, segment.
*ntiarrhythmi! agents in!lue quiniine glu!onate (Quinaglute), lio!aine
hyro!hlorie, an pro!ainamie hyro!hlorie (%ronestyl).
*ngiotensin+!onverting en0yme inhibitors in!lue !aptopril an enalapril
maleate ($asote!).
*#ter a myo!arial in#ar!tion, the patient shoul avoi stress#ul a!tivities
an situations, su!h as e3ertion, hot or !ol temperatures, an emotional
stress.
*ntihypertensive rugs in!lue hyrala0ine hyro!hlorie (*presoline) an
methylopa (*lomet).
&oth parents must have a re!essive gene #or the o##spring to inherit the
gene.
* ominant gene is a gene that only nees to be present in one parent to
have a 52F52 !han!e o# a##e!ting ea!h o##spring.
&ron!hoilators ilate the bron!hioles an rela3 bron!hiolar smooth
mus!le.
,he primary #un!tion o# alosterone is soium reabsorption.
,he goal o# positive en+e3piratory pressure is to a!hieve aequate
arterial o3ygenation without using a to3i! level o# inspire o3ygen or
!ompromising !aria! output.
=urosemie (Lasi3) is a loop iureti!. Its onset o# a!tion is 32 to ;2
minutes, peak is a!hieve at ' to ( hours, an uration is ; to 1 hours #or
the I./. or oral route.
%regnan!y, myo!arial in#ar!tion, )I bleeing, bleeing isorers, an
hemorrhois are !ontraini!ations to manual removal o# #e!al impa!tion.
*mbulation is the best metho to prevent postoperative atele!tasis. >ther
measures in!lue in!entive spirometry an turning, !oughing, an breathing
eeply.
,he bloo urea nitrogen test an the !reatinine !learan!e test measure
how e##e!tively the kineys e3!rete these respe!tive substan!es.
,he #irst sign o# respiratory istress or !ompromise is restlessness.
,he antiote #or magnesium sul#ate overose is !al!ium glu!onate '2E.
,he antiote #or heparin overose is protamine sul#ate.
*n allergi! rea!tion to a bloo trans#usion may in!lue #lushing, urti!aria,
whee0ing, an a rash. I# the patient has any o# these signs o# a rea!tion, the
nurse shoul stop the trans#usion immeiately, keep the vein open with
normal saline, an noti#y the physi!ian.
* patient taking igo3in an #urosemie (Lasi3) shoul !all the physi!ian i#
he e3perien!es mus!le weakness.
* patient with basal !ell !ar!inoma shoul avoi e3posure to the sun
uring the hottest time o# ay (between '2 a.m. an 3 p.m.).
* !lini!al mani#estation o# a!ute pain is iaphoresis.
)arnerella vaginitis is a type o# ba!terial vaginosis that !auses a thin,
watery, milklike is!harge that has a #ishy oor.
* patient who is taking =lagyl (metronia0ole) shouln6t !onsume
al!oholi! beverages or use preparations that !ontain al!ohol be!ause they
may !ause a isul#iram+like rea!tion (#lushing, heaa!he, vomiting, an
abominal pain).
"uring the aministration o# trans!utaneous ele!tri!al nerve stimulation,
the patient #eels a tingling sensation.
In patients with glau!oma, the hea o# the be shoul be elevate in the
semi+=owler position or as orere a#ter surgery to promote rainage o#
aqueous humor.
%ostoperative !are a#ter peripheral irie!tomy in!lues aministering
rugs (sterois an !y!loplegi!s) as pres!ribe to e!rease in#lammation an
ilate the pupils.
5etinopathy re#ers to !hanges in retinal !apillaries that e!rease bloo
#low to the retina an lea to is!hemia, hemorrhage, an retinal
eta!hment.
.egel e3er!ises are re!ommene a#ter surgery to improve the tone o#
the sphin!ter an pelvi! mus!les.
>ne o# the treatments #or tri!homoniasis vaginalis is metronia0ole
(=lagyl), whi!h must be pres!ribe #or the patient an the patient6s se3ual
partner.
* !ommon symptom a#ter !atara!t laser surgery is blurre vision.
* patient with a!ute open+angle glau!oma may see halos aroun lights.
*n *sian patient with iabetes mellitus usually !an rink ginseng tea.
,o prevent otitis e3terna, the patient shoul keep the ears ry when
bathing.
%atients who re!eive prolonge high oses o# I.$. #urosemie (Lasi3)
shoul be assesse #or tinnitus an hearing loss.
,he treatment #or to3i! sho!k synrome is I.$. #lui aministration to
restore bloo volume an pressure an antibioti! therapy to eliminate
in#e!tion.
In patients with glau!oma, beta+arenergi! blo!kers #a!ilitate the out#low
o# aqueous humor.
* man who loses one testi!le shoul still be able to #ather a !hil.
Iative *meri!ans are parti!ularly sus!eptible to iabetes mellitus.
&la!ks are parti!ularly sus!eptible to hypertension.
:omen with the greatest risk #or !ervi!al !an!er are those whose mothers
ha !ervi!al !an!er, #ollowe by those whose #emale siblings ha !ervi!al
!an!er.
* postmenopausal woman shoul per#orm breast sel#+e3amination on the
same ay ea!h month, #or e3ample, on the same ay o# the month as her
birthay.
/ile+ear hearing loss usually results #rom otos!lerosis.
*#ter testi!ular surgery, the patient shoul use an i!e pa!k #or !om#ort.
* patient with !hroni! open+angle glau!oma has tunnel vision. ,he nurse
must be !are#ul to pla!e items ire!tly in #ront o# him so that he !an see
them.
-lini!al signs o# ba!terial pneumonia in!lue shaking, !hills, #ever, an a
!ough that prou!es purulent sputum.
-lini!al mani#estations o# #lail !hest in!lue parao3i!al movement o# the
involve !hest wall, yspnea, pain, an !yanosis.
5ight+sie !aria! #un!tion is assesse by evaluating !entral venous
pressure.
* patient with a pa!emaker shoul immeiately report an in!rease in the
pulse rate or a slowing o# the pulse rate o# more than 4 to 5 beats/minute.
"i00iness, #ainting, palpitation, hi!!ups, an !hest pain ini!ate
pa!emaker #ailure.
Leukemia !auses easy #atigability, generali0e malaise, an pallor.
*#ter !aria! !atheteri0ation, the pun!ture, or !utown, site shoul be
monitore #or hematoma #ormation.
.ussmaul6s breathing is asso!iate with iabeti! ketoa!iosis.
I# the nurse noti!es water in a ventilator tube, she shoul remove the
water #rom the tube an re!onne!t it.
,amo3i#en is an antineoplasti! rug that6s use to treat breast !an!er.
,he averse e##e!ts o# vin!ristine (>n!ovin) in!lue alope!ia, nausea, an
vomiting.
Emphysema is !hara!teri0e by estru!tion o# the alveoli, enlargement o#
the istal air spa!es, an breakown o# the alveolar walls.
,o keep se!retions thin, the patient who has emphysema shoul in!rease
his #lui intake to appro3imately (.5 L/ay.
,he !lini!al mani#estations o# asthma are whee0ing, yspnea, hypo3emia,
iaphoresis, an in!rease heart an respiratory rate.
E3trinsi! asthma is an antigenFantiboy rea!tion to allergens, su!h as
pollen, animal, aner, #eathers, #oos, house ust, or mites.
*#ter enos!opy is per#orme, the nurse shoul assess the patient #or
hemoptysis.
In!rease urine output is an ini!ation that a hypertensive !risis has
resolve.
*#ter rai!al maste!tomy, the patient shoul be positione with the
a##e!te arm on pillows with the han elevate an aligne with the arm.
*#ter pneumone!tomy, the patient shoul per#orm arm e3er!ises to
prevent #ro0en shouler. &ullets&ullets
Le#t+sie heart #ailure !auses !ra!kles, !oughing, ta!hy!aria, an
#atigability. (,hink o# L to remember Le#t an Lungs.) &ullets
-aria! gly!osies in!rease !ontra!tility an !aria! output.
5ight+sie heart #ailure !auses eema, istene ne!k veins, no!turia,
an weakness.
*verse e##e!ts o# !aria! gly!osies in!lue !aria! isturban!e,
heaa!he, hypotension, )I symptoms, blurre vision, an yellow+green
halos aroun lights.
* patient who is re!eiving anti!oagulant therapy shoul take
a!etaminophen (,ylenol) instea o# aspirin #or pain relie#.
*equate humii#i!ation is important a#ter larynge!tomy. *t home, the
patient !an use pans o# water or a !ool mist vapori0er, espe!ially in the
beroom.
Late symptoms o# renal !an!er in!lue hematuria, #lank pain, an a
palpable mass in the #lank.
8eparin is given sub!utaneously, usually in the lower abominal #at pa.
In a patient with si!kle !ell anemia, warm pa!ks shoul be use over the
e3tremities to relieve pain. -ol pa!ks may stimulate vaso!onstri!tion an
!ause #urther is!hemia. ,he e3tremities shoul be pla!e on pillows #or
!om#ort.
9i!kle !ell !risis !auses sepsis (#ever greater than '2(@ = N31.B@ -O,
meningeal irritation, ta!hypnea, ta!hy!aria, an hypotension) an vaso+
o!!lusive !risis (severe pain) with hypo3ia (partial pressure o# arterial
o3ygen o# less than A2 mm 8g).
*verse e##e!ts o# igo3in in!lue heaa!he, weakness, vision
isturban!es, anore3ia, an )I upset.
,o per#orm a tuber!ulosis test, a (;+gauge neele is use with a '+ml
syringe.
5espiratory #ailure o!!urs when mu!us blo!ks the alveoli or the airways o#
the lungs.
,he patient shoul be instru!te not to !ough uring thora!entesis.
,he patient shoul be instru!te not to !ough uring thora!entesis.
* patient who has thrombophlebitis shoul be pla!e in the ,renelenburg
position.
9ymptoms o# %neumo!ystis !arinii pneumonia in!lue yspnea an
nonprou!tive !ough.
,o !ountera!t vitamin &' e#i!ien!y, a patient who has perni!ious anemia
shoul eat meat an animal prou!ts.
* patient who is on a ventilator an be!omes restless shoul unergo
su!tioning.
*utologous bone marrow transplantation oesn6t !ause gra#t+versus+host
isease.
* patient who has mil thrombophlebitis is likely to have mil !ramping
on e3ertion.
I# the #irst attempt to per#orm !olostomy irrigation is unsu!!ess#ul, the
pro!eure is repeate with normal saline solution.
&reast enlargement, or gyne!omastia, is an averse e##e!t o# estrogen
therapy.
In a patient who has leukemia, a low platelet !ount may lea to
hemorrhage.
*#ter rai!al ne!k isse!tion, the immeiate !on!ern is respiratory istress
as a result o# tra!heal eema.
*#ter rai!al maste!tomy, the patient6s arm shoul be elevate to prevent
lympheema.
8ypoventilation !auses respiratory a!iosis.
,he high =owler position is the best position #or a patient who has
orthopnea.
* transient is!hemi! atta!k a##e!ts sensory an motor #un!tion an may
!ause iplopia, ysphagia, aphasia, an ata3ia.
*#ter maste!tomy, the patient shoul squee0e a ball with the han on the
a##e!te sie.
-holestyramine (Questran), whi!h is use to reu!e the serum !holesterol
level, may !ause !onstipation.
)lu!o!orti!oi, or steroi, therapy may mask the signs o# in#e!tion.
/elanoma is most !ommonly seen in light+skinne people who work or
spen time outoors.
* patient who has a pa!emaker shoul take his pulse at the same time
every ay.
* patient who has stomatitis shoul rinse his mouth with mouthwash
#requently.
*n averse e##e!t o# theophylline aministration is ta!hy!aria.
,he treatment #or laryngotra!heobron!hitis in!lues postural rainage
be#ore meals.
*#ter rai!al ne!k isse!tion, a high priority is proviing a means o#
!ommuni!ation.
* high+#at iet that in!lues re meat is a !ontributing #a!tor #or !olore!tal
!an!er.
*#ter a moi#ie rai!al maste!tomy, the patient shoul be pla!e in the
semi+=owler position, with the arm pla!e on a pillow.
.ni#elike, stabbing pain in the !hest may ini!ate pulmonary embolism.
Esophageal !an!er is asso!iate with e3!essive al!ohol !onsumption.
* patient who has pan!ytopenia an is unergoing !hemotherapy may
e3perien!e hemorrhage an in#e!tion.
* grae I tumor is en!apsulate an grows by e3pansion.
-an!er o# the pan!reas !auses anore3ia, weight loss, an 7auni!e.
%rolonge gastri! su!tioning !an !ause metaboli! alkalosis.
,o measure the amount o# resiual urine, the nurse per#orms straight
!atheteri0ation a#ter the patient vois.
"e3amethasone ("e!aron) is a steroial anti+in#lammatory agent that6s
use to treat brain tumors.
Long+term reu!tion in the elivery o# o3ygen to the kineys !auses an
in!rease in erythropoiesis.
* patient who subsists on !anne #oos an !anne #ish is at risk #or
soium imbalan!e (hypernatremia).
-lini!al signs an symptoms o# hypo3ia in!lue !on#usion, iaphoresis,
!hanges in bloo pressure, ta!hy!aria, an ta!hypnea.
5e meat !an !ause a #alse+positive result on #e!al o!!ult bloo test.
-arbon mono3ie repla!es hemoglobin in the re bloo !ells, e!reasing
the amount o# o3ygen in the tissue.
*lkaline urine !an result in urinary tra!t in#e!tion.
&laer retraining is e##e!tive i# it lengthens the intervals between
urination.
-heilosis is !ause by ribo#lavin e#i!ien!y.
,he !on!entration o# o3ygen in inspire air is reu!e at high altitues. *s
a result, yspnea may o!!ur on e3ertion.
* patient who is re!eiving enteri! #eeing shoul be assesse #or
abominal istention.
,hiamine e#i!ien!y !auses neuropathy.
* patient who has abominal istention as a result o# #latus !an be treate
with a !arminative enema (8arris #lush).
%erni!ious anemia is !ause by a e#i!ien!y o# vitamin &'(, or !obalamin.
*#ter a barium enema, the patient is given a la3ative.
,he appropriate I.$. #lui to !orre!t a hypovolemi!, or #lui volume, e#i!it
is normal saline solution.
9erum albumin e#i!ien!y !ommonly o!!urs a#ter burn in7ury.
&e#ore giving a gastrostomy #eeing, the nurse shoul inspe!t the
patient6s stoma.
,he most !ommon intestinal ba!teria ienti#ie in urinary tra!t in#e!tion is
Es!heri!hia !oli.
8yponatremia may o!!ur in a patient who has a high #ever an rinks
only water.
=oli! a!i e#i!ien!y !auses mus!le weakness as a result o# hypo3emia.
"ehyration !auses in!rease respiration an heart rate, #ollowe by
irritability an #ussiness.
)lu!o!orti!ois !an !ause an ele!trolyte imbalan!e.
* e!rease in potassium level e!reases the e##e!tiveness o# !aria!
gly!osies, in!reases possible igo3in to3i!ity, an !an !ause #atal !aria!
arrhythmias.
"iuresis !an !ause e!rease absorption o# vitamins *, ", E, an ..
%rotein epletion !auses a e!rease in lympho!yte !ount.
,o prevent paraphimosis a#ter the insertion o# a =oley !atheter, the nurse
shoul repla!e the prepu!e.
Loop iureti!s, su!h as #urosemie (Lasi3), e!rease plasma levels o#
potassium an soium.
*#ter pyelography, the patient shoul rink plenty o# #luis to promote the
e3!retion o# ye.
%otassium shoul be taken with #oo an #luis.
%roper measurement o# a nasogastri! tube is #rom the !orner o# the
mouth to the ear lobe to the tip o# the sternum.
=ull agonist analgesi!s in!lue morphine, !oeine, meperiine ("emerol),
propo3yphene ("arvon), an hyromorphone ("ilaui).
&uprenorphine (&uprene3) is a partial agonist analgesi!.
%oor skin turgor is a !lini!al mani#estation o# iabetes insipius.
* patient who has *ison6s isease an is re!eiving !orti!osteroi
therapy may be at risk #or in#e!tion.
,o assess a patient #or hemorrhage a#ter a thyroie!tomy, the nurse
shoul roll the patient onto his sie to e3amine the sies an ba!k o# the
ne!k.
* patient who is re!eiving hormone therapy #or hypothyroiism shoul
take the rug at the same time ea!h ay.
8yperproteinemia may !ontribute to the evelopment o# hepati!
en!ephalopathy.
,o minimi0e bleeing in a patient who has liver ys#un!tion, small+gauge
neeles are use #or in7e!tions.
* patient who has !irrhosis o# the liver an as!ites shoul #ollow a low+
soium iet.
&e#ore an e3!retory urography, the nurse must ask the patient whether
he6s allergi! to ioine or shell#ish.
* bu##alo hump is an abnormal istribution o# aipose tissue that o!!urs in
-ushing6s synrome.
Levothyro3ine (9ynthroi) is use as repla!ement therapy in
hypothyroiism.
Levothyro3ine (9ynthroi) treats, but oesn6t !ure, hypothyroiism an
must be taken #or the patient6s li#etime. It shouln6t be taken with #oo
be!ause #oo may inter#ere with its absorption.
Imipramine (,o#ranil) with !on!omitant use o# barbiturates may result in
enhan!e -I9 epression.
* patient who is re!eiving levothyro3ine (9ynthroi) therapy shoul report
ta!hy!aria to the physi!ian.
,he signs an symptoms o# hyperkalemia in!lue mus!le weakness,
hypotension, shallow respiration, apathy, an anore3ia.
In a patient with well+!ontrolle iabetes, the (+hour postpranial bloo
sugar level may be '3B mg/l.
* patient who has iabetes mellitus shoul wash his #eet aily in warm
water an ry them !are#ully, espe!ially between the toes.
*!ute pan!reatitis !auses !onstant epigastri! abominal pain that raiates
to the ba!k an #lank an is more intense in the supine position.
"iabeti! neuropathy is a long+term !ompli!ation o# iabetes mellitus.
%ortal vein hypertension is asso!iate with liver !irrhosis.
*#ter thyroie!tomy, the nurse shoul assess the patient #or laryngeal
amage mani#este by hoarseness.
,he patient with hypoparathyroiism has hypo!al!emia.
* patient who has !hroni! pan!reatitis shoul !onsume a blan, low+#at
iet.
* patient with hepatitis * shoul be on enteri! pre!autions to prevent the
sprea o# hepatitis *.
,he patient who has liver isease is likely to have 7auni!e, whi!h is
!ause by an in!rease bilirubin level.
*n averse e##e!t o# phenytoin ("ilantin) aministration is hyperplasia o#
the gingiva.
8ematemesis is a !lini!al sign o# esophageal vari!es.
=at estru!tion is the !hemi!al pro!ess that !auses ketones to appear in
urine.
,he glu!ose toleran!e test is the e#initive iagnosti! test #or iabetes.
*tele!tasis an ehis!en!e are postoperative !onitions asso!iate with
removal o# the gallblaer.
*#ter liver biopsy, the patient shoul be positione on his right sie, with
a pillow pla!e unerneath the liver borer.
-ategori0e
&ullets
Lugol6s solution is use to evas!ulari0e the glan be#ore thyroie!tomy.
-hole!ystitis !auses low+grae #ever, nausea an vomiting, guaring o#
the right upper quarant, an biliary pain that raiates to the right s!apula.
Early symptoms o# liver !irrhosis in!lue #atigue, anore3ia, eema o# the
ankles in the evening, epista3is, an bleeing gums.
,he !lini!al mani#estations o# iabetes insipius in!lue polyipsia,
polyuria, spe!i#i! gravity o# '.22' to '.225, an high serum osmolality.
,he !lini!al mani#estations o# iabetes insipius in!lue polyipsia,
polyuria, spe!i#i! gravity o# '.22' to '.225, an high serum osmolality.
8ypertension is a sign o# re7e!tion o# a transplante kiney.
La!tulose is use to prevent an treat portal+systemi! en!ephalopathy.
E3tra!orporeal an intra!orporeal sho!k wave lithotripsy is the use o#
sho!k waves to per#orm noninvasive estru!tion o# biliary stones. It6s
ini!ate in the treatment o# symptomati! high+risk patients who have #ew
non!al!i#ie !holesterol stones.
"e!rease !ons!iousness is a !lini!al sign o# an in!rease ammonia level
in a patient with kiney #ailure or !irrhosis o# the liver.
,he pain mei!ation that6s given to patients who have a!ute pan!reatitis
is meperiine ("emerol).
%ro!hlorpera0ine (-ompa0ine), me!li0ine, an trimethoben0amie (,igan)
are use to treat the nausea an vomiting !ause by !hole!ystitis.
>bese women are more sus!eptible to gallstones than any other group.
/etaboli! a!iosis is a !ommon #ining in a!ute renal #ailure.
=or a patient who has a!ute pan!reatitis, the most important nursing
intervention is to maintain his #lui an ele!trolyte balan!e.
*#ter thyroie!tomy, the patient is monitore #or hypo!al!emia.
In en+stage !irrhosis o# the liver, the patient6s ammonia level is elevate.
In a patient who has liver !irrhosis, abominal girth is measure with the
superior ilia! !rest use as a lanmark.
,he symptoms o# *l0heimer6s isease have an insiious onset.
=ra!ture o# the skull in the area o# the !erebellum may !ause ata3ia an
inability to !oorinate movement.
9erum !reatinine is the laboratory test that provies the most spe!i#i!
ini!ation o# kiney isease.
* patient who has bilateral arenale!tomy must take !ortisone #or the rest
o# his li#e.
%ortal vein hypertension !auses esophageal vari!es.
9igns an symptoms o# hypo3ia in!lue ta!hy!aria, shortness o# breath,
!yanosis, an mottle skin.
,he three types o# embolism are air, #at, an thrombus.
*sso!iations #or patients who have ha laryngeal !an!er in!lue the Lost
-or -lub an the Iew $oi!e -lub.
&e#ore is!harge, a patient who has ha a total larynge!tomy must be
able to per#orm tra!heostomy !are an su!tioning an use alternative means
o# !ommuni!ation.
,he universal bloo onor is > negative.
,he universal bloo re!ipient is *& positive.
/u!us in a !olostomy bag ini!ates that the !olon is beginning to
#un!tion.
*#ter a vase!tomy, the patient is !onsiere sterile i# he has no sperm
!ells.
=atigue is an averse e##e!t o# raiation therapy.
,o prevent umping synrome, the patient6s !onsumption o# high+
!arbohyrate #oos an liquis shoul be limite.
-ryopre!ipitate !ontains #a!tors $III an <III an #ibrinogen an is use
to treat hemophilia.
Insomnia is the most !ommon sleep isorer.
&ru3ism is grining o# the teeth uring sleep.
Elerly patients are at risk #or osteoporosis be!ause o# age+relate bone
eminerali0ation.
,he !lini!al mani#estations o# lo!al in#e!tion in an e3tremity are
tenerness, loss o# use o# the e3tremity, erythema, eema, an warmth.
-lini!al mani#estations o# systemi! in#e!tion in!lue #ever an swollen
lymph noes.
*n immobile patient is preispose to thrombus #ormation be!ause o#
in!rease bloo stasis.
Crea is the !hie# en prou!t o# amino a!i metabolism.
/orphine an other opiois relieve pain by bining to the nerve !ells in
the orsal horn o# the spinal !or.
,ri!homonas an -ania in#e!tions !an be a!quire nonse3ually.
%resby!usis is progressive sensorineural hearing loss that o!!urs as part
o# the aging pro!ess.