ABC S OF PASSING LOCAL BOARD EXAM

ABC S OF PASSING LOCAL BOARD EXAM

(ADDITIONAL BULLETS FOR MS)

Abdominal aortic aneurysm

Main problem :Local distention / outpouching of the artery wall usually in the thoracic or abdominal area

Initial manifestation :Initially asymptomatic; pulsating abdominal mass is a common sign, backache and auscultation of bruit are common manifestations ; abdominal or back pain

Laboratory Data : Elevated BUN and creatinine levels MRI, CT scan and X-ray. UTZ is the best test to confirm AAA

Nursing Diagnosis : Altered tissue perfusion

Nursing Interventions : Avoid abdominal palpation, prepare patient for surgery

Monitor for possible rupture preoperatively(signs of shock)

Monitor MIO and laboratory studies

Administer medications to decrease hypertension and control pain

Monitor peripheral pulses postoperatively

Acne Vulgaris

Inflammatory disease of sebaceous follicles due to blockage of sebaceous glands

Initial manifestation : Closed comedones( whiteheads ), open comedones ( blackheads)

Nursing Diagnosis : Body image disturbance

Nursing Interventions : Instruct patient to wash face gently with mild soap 1-2 times daily. Instruct patient to use benzoyl peroxide and never squeeze pimples

Use of Isotretinoin ( Accutane ) for treatment can cause birth defects. Instruct patient to use contraceptives during the entire duration of the therapy unitl a month thereafter. Avoid exposure to sunlight and use sunblock when using these medications.

Acromegaly

oversecretion of growth hormone(anterior pituitary), long lasting stimulation affecting skeletal growth in adult by enlarging certain bones and tissues

Initial manifestation : coarse facial features, increased shoe size, increased intracranial pressure due to tumor headache and blindness

Laboratory Data : elevated serum human growth hormone and blood sugar levels

Priority Nursing Diagnosis : body image disturbance

Nursing Interventions :

provide emotional support

prepare client for surgery and deligently monitor VS and Neurologic Status post-op

Monitor for signs and symptoms of diabetes

octreotide ( Sandostatin) to decrease GH

Acute gastroenteritis ( AGE ) / Diarrhea

Increase in fluid , frequency and volume of stool usually associated with rotavirus, clostridium deficile, salmonella

Initial manifestation : Frequent watery stool

Laboratory Data : Decrease in Na and K, (+) blood cultures usually for salmonella, rotavirus and clostridium defficile

Nursing Diagnosis : Fluid and electrolyte imbalance

Nursing Interventions :

Priority ; fluid replacement

Remember : fluid loss is more critical in younger patients because they have higher body fluid percentage.

Monitor the patients fluid status, weight is a critical indicator of fluid loss, 1 gram of weight equals 1 ml of body fluid.

Initially offer oral rehydration solution such as pedialyte then progress to non-carbonated drinks ( Gatorade) limit apple juice since it can cause diarrhea. BRAT diet

Acquired Immune Deficiency Syndrome ( AIDS)

Slow degeneration of the immune system( defect in T- cell mediated immunity caused by the HIV) with the development of opportunistic infections, malignancies and frequent impairment of the central nervous system

Initial Manifestation : Flu- like symptoms occur 2-4 weeks after infection

Laboratory Data :

Diagnosis of AIDS is based on laboratory evidence of HIV infection coexisting with one or more indicator diseases such as Pneumocyctis carinii Pneumonia , Kaposis Sarcoma( most common malignancy), Cytomegalovirus , Candidal infection ,Herpes Simplex Virus or AIDS dementia

HIV (+) on ELISA, confirmed by Western Blot

HIV antibodies are detectable by routine tests, 3-6 months after infection so instruct the patient to have an initial test 3-6 months after exposure. Patients who are initially negative should have a retest 12 weeks or less since a possible exposure

CD4 lymphocytes , 200 / cu .mm

Priority Nursing Diagnosis : Risk for infection

Nursing Interventions :

Instruct patient to practice safe sex, avoid needle sharing.Maintain Satndard Precautions Monitor for opportunistic infections.Monitor respiratory status and laboratory values.Maintain diet/nutrition

Use 10 % household bleaching solution to cleanse areas with blood stains from an HIV (+) patient

Assess the patient for signs and symptoms of dementia like incoordination.

Addisons Disease

Adrenal hypofunction usually due to autoimmune disease

Initial Manifestation :Hypotension; bronze skin pigmentation is a common sign

Laboratory Data : Hyponatremia, hyperkalemia, hypoglycemia

Nursing Diagnosis : Fluid volume deficit

Nursing Interventions :

Monitor fluid and electrolyte balance

Explain the need for lifelong medications of glucocorticoids and mineralocorticoids

Maintain high sodium, low potassium diet

Advice patient to avoid infection , trauma or stress, it increases the risk for addisonian crisis( IV hydrocortisone and saline soln for addisonian crisis)

Anemia , aplastic

Main Problem : Bone marrow hypoplasia or aplasia resulting in pancytopenia( decreased WBC, RBC and platelets)

Initial manifestation abnormal bleeding( purpura , petechiae, ecchymosis,epistaxis , melena and dyspnea)

Laboratory data: decreased WBC , RBC and Platelet Count

Nursing diagnosis: risk for infection; risk for injury

Interventions: prepare the patient for bone marrow transplant

Assess for signs and symptoms of bleeding

Anemia , folic acid deficiency

Main Problem : Depletion of folate, which results to progressive anemia

Initial manifestation: fatigue

Laboratory data: decreased folate levels

Nursing diagnosis: activity intolerance

Interventions: teach patient to increase sources of folic acid in the diet like: green vegetables ( asparagus, broccoli and spinach), yeast , liver , organ meats and fresh fruits.

Avoid overcooking of vegetables

Teach the patient regarding oral folic acid replacement

Anemia , iron deficiency

Main Problem : Decreased oxygen carrying capacity of the blood. The condition is usually associated with nutritional deficiency of iron

Initial manifestation: easy fatigability; poor sucking ( infants) chubby but pale babies ( milk babies)]

Laboratory data : decreased Hgb and Hct, microcytic, hypocromic RBCs

Nursing Diagnosis:Activity intolerance

Interventions: Instruct patient to have frequent rest periods

Increase iron in the diet( organ meat , egg yolk) milk is a poor source of iron

Administer oral iron supplements as ordered

Anemia , Pernicious

Main Problem : Reduced vitamin B 12 Absorption due to the absence of the intrinsic factor usually related to gastrectomy and atrophy of the gastric mucosa

Initial manifestation : Fatigue ; beefy red tongue or glossitis a common sign

Laboratory Data : Schillings test reveals low value urinary excretion of ingested vitamin B12 < 10% in 24 hours

Nursing Diagnosis : Activity Intolerance

Nursing interventions : Teach patient monthly IM Vit B12 injections for life.

Inform patient to report tingling sensation in the lower extremities indicating complication peripheral neuropathy

ANAPHYLAXIS

Main Problem : Dramatic widespread acute atopic/allergic reaction which causes vascular collapse

Initial manifestation : Sudden onset of rapidly progressive urticaria , respiratory distress and hypotension which can lead to shock

Diagnostic data : Skin testing to determine allergen

Nursing Diagnosis : Risk for altered airway clearance related to bronchial edema

Nursing Intervention : Observe for respiratory complications (laryngeal edema ), watch out for signs and symptoms of shock.

Maintain airway patency prepare suction and intubation set

Early stages no loss of consciousness epinephrine IM with loss of consciousness epinephrine IV

CPR for cardiac arrest

After emergency give antihistamines [diphenhydramine(Benadryl) ] and corticosteroids

Prevent recurrence by avoiding exposure to known allergens

1) A major nursing responsibility prior to initial administration of antibiotics specifically penicillin and sulfa drugs is :

a) Skin testing

b) Assessing for sensitivity to iodine

c) Assessing for food allergies

d) Suction equipment at bedside

Answer : a - antibiotic therapy is done after negative skin test results to prevent occurrence of hypersensitivity reactions

Aphasia

Main problem an acquired disorder of communication resulting from brain damage.Speech difficulty /change usually caused by right sided hemiplegia(left brain involvement)

Initial manifestations :

Expressive Aphasia difficulty expressing self in understandable speech

Receptive Aphasia does not comprehend spoken or written word

Global Aphasia combination of both

Nursing Diagnosis : Impaired Verbal Communication

Interventions : Give the patient enough time to speak and respond and speak clearly and slowly while facing patient

Provide visual cues like pictures and gestures when talking to the patient ( verbal and non-verbal)

Approach on the visually unaffected side

Arrythmias

Main Problem : Abnormal electrical conduction or automaticity changes in the heart rate or rhythm which affects cardiac output and blood pressure

Initial manifestation : Hypotension and deteriorating level of consciousness

Diagnostic Data : ECG tracing reveals the following:

Atrial Fibrillation- irregular atrial rhythm > 400 beats / min. indiscernible PR interval and no P waves

Ventricular Tachycardia- ECG shows rate of 140 220 bpm, wide and bizarre QRS complex and no P waves

Ventricular fibrillation - ECG shows rapid and chaotic ventricular rhythm, wide and irregular QRS complexes and no visible P waves.

Premature Ventricular Contractions- irregular intervals between QRS complexes

Asystole no atrial or ventricular rate

Nursing Diagnosis : Ineffective tissue perfusion: cardiopulmonary

Decreased cardiac output

Nursing Interventions : Watch out for hypotension and decreased urine output

Assist with measures to treat underlying cause ( electrolyte replacement , oxygen therapy and pulmonary care)

Hook on cardiac monitor and assess Level of consciousness, RR, PR , BP and fluid and electrolyte balance

Perform ACLS measures

Early defibrillation for VT and VF

Cardioversion for atrial dysrhythmias

Administer antiarrythmics (Lidocaine,Inderal,Cordarone)

for arrythmias and PVCs

hypotension common side effect

Perform CPR and intubation prn

prepare patient for possible pacemaker insertion

1) In a patient on antidysrhythmic drug therapy , the following intervention is necessary to monitor for the common side effect of the drug:

a) Use of infusion pump for continous administration

b) Ensure IV remains patent and check insertion site

c) Check BP regularly

d) Administer slowly and at a prescribed rate

Answer : c major side effect of anti arrthmics is hypotension

Angina Pectoris

Main Problem _ Insufficient coronary blood flow results to inadequate oxygen supply causing intermittent chest pain

Initial Manifestation : squeezing , burning , pressing , chocking , aching or bursting left sternal chest pain lasting not more than 20 minutes. The patient often says , It feels like gas or heartburn or indigestion .

Laboratory Data : ECG reveals ST segment depression

Nursing Diagnosis : Pain

Administer nitroglycerine sublingually to relieve the pain. Teach the patient that a burning sensation under the tongue after nitroglyvcerine indicates that the drug is potent. The drug may also cause facial flushing or headache

Prepare patient for PTCA ( percutaneous Transluminal Coronary Angioplasty ) by informing the patient that a balloon tipped catheter will be introduced through a guide wire into a coronary vessel .

Appendicitis

MAIN PROBLEM : Inflammation of the appendix due to obstruction of the intestinal lumen

Initial manifestation : right lower quadrant abdominal pain with rebound tenderness. Lessenignof pain indicates rupture of the appendix

Laboratory Data : Elevated WBC and urinalysis negative for UTI ( ruled out )

Nursing Diagnosis : Pain and Potential for injury

Interventions : Place patient in any position of comfort if appendix has not yet ruptured , if it is ruptured place patient in high fowlers position to prevent upward spread of infection. Administer antibiotics as ordered . Avoid applying hot compress on the RLQ . No analgesics , antispasmodics and enema during observation phase.

Prepare patient for appendectomy and teach post op interventions/responsibilities.

Arthritis , gouty

Main Problem : Metabolic disorder of uric acid formation and excretion

Initial manifestation : Initially asymptomatic . A common sign is dusky red hot swollen joint(inflamed painful), usually the big toe. Pathognomonic : Formation of Tophi

Laboratory Data : Elevated urate crystals in synovial fluids and elevated serum uric acid

Nursing Diagnosis : Pain

Interventions :

Teach patient to Maintain purine restricted diet

( avoid organ meats , alcohol , legumes, sardines). Increase oral fluid intake

Avoid aspirin and diuretics as these interfere with uric acid excretion. Alkalanize urine fruit, vegetables and milk.

Use bed cradle to prevent linen from coming in contact with the inflamed joint which aggravates the pain

Common Complication : Uric Acid Kidney stone formation

Encourage compliance to anti gout medications:

Allopurinol- blocks formation of uric acid, Colchicine analgesic and anti-inflammatory, Probenecid reduces uric acid

Sulfinpyrazone reduces uric acid in the blood

Arthritis , osteo

Degeneration of the articular cartilage in the joints

Initial Manifestation : Pain and swelling in a weight bearing joint, usually aggravated by activity

Laboratory Data : X ray

Nursing Diagnosis : Pain

Interventions : Priority : Minimize Discomfort Implement:

W- eight control

H- ot compress or ice packs

A spirin use

T runk assistive devices cane

Arthritis , Rheumatoid

Main Problem : systemic recurrent inflammation of the synovial lining of the joints, usually upper extremities.More common in women

Initial manifestation : Morning stiffness relieved by warm bath or soaks

Laboratory Data : elevated ESR and (+) rheumatoid factor

Nursing Diagnosis : Pain related to joint inflammation

Interventions : Teach patient to take aspirin regularly as ordered even in the absence of symptoms , instruct the patient that tinnitus is a side effect of aspirin. Apply moist heat for 15 30 minutes to reduce muscle spasm. Use ice packs during acute phase to decrease pain

Asthma

Main Problem : Abnormal Bronchial hyperactivity to certain substances and conditions

Initial manifestation : dyspnea and wheezing(asymptomatic between attacks)

Laboratory data : PFTs during attacks show decreased forced expiratory volumes , elevated immunoglobulin E , ABG reveals respiratory Acidosis, peak flow levels below normal

Nursing diagnosis : Ineffective Breathing Pattern related to bronchospasm

Interventions :

Assess precipitating factor and eradicate these sources

Instruct patient to avoid 3 Es ( exercise specially in cold weather, environmental factors like dust , emotional factors )

Position patient in orthopneic position and encourage patient to do pursed lip breathing

Administer medications Bronchodilators and corticosteroids usually via nebulization

Autonomic dysreflexia

Main Problem : Exaggerated autonomic responses to local stimuli below the level of the spinal cord injury. Occurs in clients with lesions above T6 after spinal shock has subsided

Initial manifestation : Pounding headache or severe hypertension

Nursing Diagnosis : Urinary retention related to effects of spinal cord injury

Interventions :

Catheterize the patient to prevent bladder distention. Relieve fecal impaction and pressure on skin which can precipitate attacks .

Place patient in sitting position to help lower blood pressure . Administer antihypertensives

Benign prostatic hypertrophy

Main Problem : enlargement of the prostate gland resulting to narrowing of urethral opening

Initial manifestation : decreased force and amount of urine

Laboratory data :elevated Ph of prostatic fluid

rectal examination shows enlarged prostate

Cystoscopy shows enlarged prostate gland, obstructed urine flow and urinary stasis

Nursing Diagnosis: Altered bladder elimination related to enlarged prostate

Interventions : Force fluids

Pre-op assess understanding of procedure and anticipated postoperative course. Explain TURP ( Transurethral Resection Prostatectomy) will not involve any incision. Post op assess for pain , discomfort and complications ( bleeding and infections )

Monitor continous bladder irrigations

Bleeding Esophageal Varices

Main Problem : bleeding of dilated veins in the lower esophagus

Initial manifestation : Hematemesis

Nursing Diagnosis : Fluid Volume Deficit

Interventions : Monitor the pateints airway

Assist with the insertion of Sengstaken Blakemore Tube ( keep a pair of scissors at the bedside, this is used to cut the port of the tube leading the balloon, to deflate it, in case aspiration occurs)

Bronchiectasis

Main Problem : Chronic abnormal dilation of bronchi and destruction of bronchial walls leading to multiple respiratory complications

Initial Manifestation : Chronic cough that produces copious, foul smelling, mucopurulent secretions, possibly totaling several cupfuls daily

Laboratory Data : Bronchoscopy helps identify source

chest x-ray shows peribronchial thickening,

areas of atelectasis and scattered cystic changes

Pulmonary Function tests detect decreased volumes

Nursing Diagnosis : Ineffective airway clearance related to secretions

Impaired gas exchange related to alveolar exudate

Nursing Interventions :Assess respiratory status and level of consciousness to detect early signs of hypoxia and decompensation

Administer antibiotics as necessary

Teach and perform Respiratory Physiotherapy - deep breathing and coughing, postural drainage and chest percussion(done early morning and before bedtime)

Teach importance of quitting smoking and avoidance of milk products

1) Priority nursing diagnosis for patient with bronchiectasis is:

a) Altered breathing pattern

b) Potential for infection

c) Knowledge deficit

d) Ineffective airway clearance

Answer: d - copious, foul smelling, mucopurulent secretions, possibly totaling several cupfuls daily

Buergers disease ( thromboangitis Obliterans )

Main Problem : Vasculitis of the small and medium sized veins and arteries usually in the lower extremities. It is more common in men and in smokers

Initial manifestation : Pain is an outstanding symptom, intermittent claudication is a common problem

Laboratory Data : leg arteriography reveals inflammatory lesions

Nursing Diagnosis : Altered peripheral Tissue Perfussion

Interventions : Instruct patient to stop smoking and administer calcium channel blockers and peripheral vasodilators as ordered.

Burns

Main Problem : Traumatic injury caused by thermal , electrical , chemical or radioactive agents

Initial Manifestations : 1st Degree pinkish skin with pain

2nd degree reddish with painful blisters

3rd degree eschar , charred , painless

Laboratory Data : Hyperglycemia , anemia

Nursing Diagnosis : Decrerased cardiac output related to fluid shifts

Interventions :

On strict MIO .

Administer fluids as ordered during acute phase by fluid replacement calculations using body weight multiplied by BSA burned based on rule of nines. of the total volume to be infused on the first 8 hours then the remaining infused in the next 16 hours.

Maintain a high calorie , high protein diet

Treat pain with IV narcotics, provide tetanus prophylaxis and topical antimicrobial therapy. Institute reverse isolation in severe cases. Administer pain medications prior to ROM ,ambulation and whirlpool therapy

Cancer , Bladder

Main Problem : Presence of malignant cells in the bladder

Initial Manifestation : Painless hematuria

Laboratory data : Elevated Acid Phosphatase

Nursing Diagnosis: Altered urinary Elimination

Interventions : Prepare patient for surgery and chemotherapy

Encourage patient to verbalize fears

Cancer Breast

Main Problem : Presence of malignant tumors usually in the upper outer quadrant of the left breast. It is associated with nulliparity or having the first child after age 35

Initial manifestation : skin dimpling and edema(peau d orange .Painless mass most common sign

Laboratory Data : Mammography reveals the presence of non palpable lesion. Baseline mammography should be made between age 35 40 . Q2 years 40 50 years old if w/o predisposition ;yearly for high risk women;yearly after age 50.

Nursing Diagnosis : Knowledge deficit of breast cancer and mastectomy

Interventions : Prepare patient for chemotherapy , radiation and surgery. Teach patient how to perform Self Breast examinations. Done monthly , a week after menstruation since the breast are less tender at this time. The best position is lying down with pillow under shoulder of breast being examined.

Inform the patient that Mammography will involve placing the breasts between two X-ray plates. Avoid use of deodorant ,lotions or powder

In post mastectomy patient elevate affected arm to prevent lympedema and to avoid activities that increase infection like gardening and sewing. No BP taking , venipuncture and constrictive clothing on the affected arm

Cancer , Cervix

Main Problem : presence of malignant cells in the cervix associated with multiple sexual partners and history of sexually transmitted disease

Initial manifestation : initially asymptomatic , postcoital bleeding is common manifestation

Laboratory data : pap smear reveals presence of malignant cells

Nursing Diagnosis : Knowledge deficit of cervical cancer and chemotherapy

Interventions : Instruct patient to avoid douching and sexual intercourse 24 hours before Paps Smear

Stress the importance of lifelong follow up visits to detect response to treatment.

Prepare patient for chemotherapy , radiation and surgery

Cancer , Esophagus

Main Problem : Malignant tumor in the esophagus related to alcoholism and smoking

Initial manifestation : Dysphagia presenting symptom

Laboratory Data : Barium Swallow with fluoroscopy reveals large masses. CT scans may be employed to evaluate extent of tumor

Nursing Diagnosis : Altered Nutrition

Interventions : Prepare patient for surgery , radiation therapy and chemotherapy. Administer antacids and analgesics as ordered

Prepare patient for tube or gastroctomy feedings and short course hyperalimentation

Post operatively instruct patient to avoid overeating raw fruits and vegetables

Cancer ,Larynx

Main Problem : presence of malignant cells in the larynx associated with smoking and alcoholism

Initial Manifestations : Hoarseness or voice change, tickling sensation in the throat

Laboratory data : Laryngoscopy and Biopsy reveals malignant cells

Nursing Diagnosis : Knowledge deficit of laryngeal cancer

Interventions : Prepare patient for radiation , chemotherapy and surgery . teach patient to avoid cold air

Instruct patient that swimming is not recommended post laryngectomy.

Institute alternative modes of communication

Cancer , Ovary

Main Problem : Gynecologic cancer associated with high fat diet and nulliparity

Initial Manifestation : Initial asymptomatic , vague abdominal discomfort like indigestion is a common symptom

Laboratory data : laparoscopy and Ultrasound reveals the presence of mass

Nursing Diagnosis : Pain

Interventions : Prepare patient for surgery and chemotherapy

Assist the patient to cope with change in body image

Institute effective pharmacologic and non pharmacologic pain management

Cancer , Prostate

Main Problem : Malignant tumor in the prostate gland

Initial Manifestation : Decreased size and force of urinary stream

Laboratory data : Elevated Prostate Specific Antigen ( PSA ) , elevated acid phosphatase

Nursing Diagnosis : Pain related to tumor metastases to bone

Interventions : Support patient undergoing radiation therapy

Inform the patient that radical prostatectomy, which involves the removal of the entire prostate gland, may cause impotence

Cancer , colon( colorectal Ca)

Primary or metastatic malignant tumor of the colon or rectum which infiltrate causing obstruction, ulceration and hemorrhage.

Change in bowel habits, character of stools, diarrhea and constipation- fecal oozing ( melena or hematochezia)

Barium enema locates mass, sigmoidoscopy / colonoscopy identifies and locates mass, positive for fecal occult blood and positive biopsy for Ca cells

Altered bowel elimination

Assess GI status, fluid and electrolyte studies, monitor for bleeding , infection and electrolyte imbalance

Provide post-chemotherapeutic and post radiation therapy nursing care

Provide adequate nutrition and administer antiemetics and anti - diarrheals

Prepare for surgery and Teach ostomy self care

Administer TPN as ordered

1) Among the following diagnostic results ,which is more suggestive of colorectal cancer?

a) Painless hematuria

b) Presence of occult blood in stool

c) Increased level of acid phosphatase

d) Indigestion

Answer: b lab test suggestive of colorectal cancer includes fecal occult blood and positive biopsy for Ca cells

Cancer , lung ( Bronchogenic Ca )

Development of a neoplasm in the respiratory tract(squamous cell-slow growing; large and small oat cell fast growing).Presence of malignant tumor in the epithelium of the respiratory tract usually related to smoking or exposure to asbestosis

Chronic,nagging cough ( smokers cough)

Sputum cytology positive for cancer cells

CXR shows a lesion or mass

Bronchoscopy confirms a positive biopsy

Impaired gas exchange

Impaired breathing pattern

Monitor respiratory status and pulse oximetry

Check for cyanosis suggesting respiratory failure and increase in sputum production indicates infection

Provide adequate pain control

Increase oral fluid intake and IVF as ordered

Provide increased CHON, high caloric diet( TPN or enteral,prn)

Perform and teach Respiratory Physiotherapy

Provide rest periods and mouth care

Prepare patient for surgery and chemotherapy

Elevate head of bed to prevent fluid collection in the upper body

1) All the following except one are diagnostic procedures done to confirm bronchogenic cancer:

a) Sputum cytology

b) Chest X- ray

c) Bronchoscopy

d) Pulmonary angiography

Answer : d - pulmonary angiography is the rapid injection of radiopaque dye into the pulmonary circulation useful in determining the site of pulmonary embolism, sputum cytology, CXRay and bronchoscopy are tests done to confirm lung cancer.

Cancer, Skin

Malignant primary tumor of the skin mainly caused by prolonged exposure to the sun or other carcinogenic agents

Squamous cell carcinoma- small red nodular lesion that begins as an erythematous macule or plaque

Skin biopsy shows positive cytology

Impaired skin integrity

Assess lesion and monitor skin punch test site for bleeding

Pre and post chemotherapy or radiation therapy nursing care

Teach patient to avoid contact with chemical irritants.

Use sunblock and layered clothing when outdoors

1) Nursing interventions for patients undergoing radiation therapy include all of the following except:

a) Monitoring the punch test site for bleeding

b) Teach patient to avoid contact with chemical irritants

c) Using sunblock when outdoors

d) Using layered clothing when sun exposure is possible

Answer : a - skin punch test / skin biopsy is a diagnostic procedure to confirm the presence of skin cancer

Cancer , Testicular

Main Problem : Malignancy in the testes usually associated with cryptorchidism

Initial manifestations Painless swelling and enlargement of the testes , accompanied by sensation of heaviness in the scrotum

Laboratory data : Elevated HCG and alpha feto protein

Nursing Diagnosis : Knowledge deficit

Interventions : Prepare patient for surgery and chemotherapy

Teach patient about testicular self examination .It should be done once a month while having warm bath or standing in front of mirror. Suspect cancer when spongy upon palpation

Cardiogenic shock

Main Problem : Extensive damage of the left ventricle due to Myocardial Infarction

Initial manifestation : decreased systolic pressure

Laboratory Data : Elevated BUN , creatinine and liver enzymes

Nursing diagnosis : Altered cardiac Output ( decreased related to impaired contractility of the heart

Interventions : Monitor BP , MIO and weight . Evaluate serum electrolytes for hyponatremia and hypokalemia

Cataract

Main Problem : Opacity of the lens usually associated with aging , prolonged intake of steroids and chromosomal aberrations

Initial manifestation : painless blurring of vision

Laboratory data : Slit lamp test reveals milky white color of the pupils

Nursing diagnosis : potential for injury related to visual loss

Interventions : Prepare patient for surgery

Postoperatively instruct patient to avoid activities that requires bending, report sudden eye pain, this indicates hemorrhage and increased IOP.

Avoid lifting and rapid head movements

Position in fowlers position or instruct patient to lie down on the unaffected side

Cerebrovascular Accident (CVA)

Sudden loss of brain function resulting from a disruption of blood supply to a part of the brain causing temporary or permanent dysfunction.(TIA warning sign of CVA no neurovascular deficits / complete resolution of manifestation within 24 hours)

Initial Manifestation : depends on the site of brain involvement

Middle cerebral artery : hemiparesis

Internal Carotid artery : hemiplegia

Right hemispheric lesion : spatial disorientation

Left Hemispheric lesion : language disturbances

Common manifestations:

Hemiplegia and homonymous hemianopsia

Emotional and personality disturbances

Aphasia

Dysphagia

Laboratory : Elevated Cholesterol Levels

Nursing Diagnosis : Ineffective Breathing Pattern

Unilateral Neglect

Interventions : Maintain adequate airway

Institute regular bowel and bladder training

Establish means of communication

Chest injury (Flail Chest )

Main Problem : Loss of stability of chest wall with subsequent respiratory impairment

Initial manifestation : Dyspnea , Paradoxical Chest Movement may occur ( detached part of the chest will be pulled in on inspiration and blown out on expiration )

Laboratory data : X ray reveals rib fractures

Nursing Diagnosis : Ineffective breathing pattern

Interventions : Stabilize the flail portion of the chest with hands or cover with impermeable dressing with three sides taped

Turn patient on affected side to provide space for the unaffected lung to reexpand

Place 10 pound sandbag at the site of flail

Cholecystitis / Cholelithiasis

Infection of the biliary tract associated with the presence of gallstones (Cholelithiasis) . Predisposing factors includes Fat, Female, Age Forty and above, and Fair skinned.

Intolerance to fatty foods and severe pain located on the RUQ of abdomen radiating to R scapula with nausea and vomiting. Indigestion, flatulence, belching, jaundice and clay colored stools

Hepatobiliary tract UTZ

Altered nutrition ; less than body requirements

Position in semi-fowlers,provide rest and limit activity

Small frequent meals low fat, low calorie, high carbohydrate and fiber , no gas forming foods.

NPO on acute phase. Administer IV fluids / TPN as ordered

Prepare client for Extracorporeal Shock Wave Lithotripsy or cholecystectomy- T tube for biliary drainage placed

Teach post-op procedures and care(incentive spirometry and deep breathing)

Give medications as ordered:

Analgesics-Demerol ( morphine contraindicated)

Antibiotics-Ceftazidine, Clindamycin , Gentamycin

Anticholinergics- Probanthine

Anti-emetic- Compazine

Anti-pruritic- Benadryl

NGT to low suction to decompress stomach

1) Management for patient post cholecystectomy includes:

a) Adequate fat diet

b) Maintain NPO for 3 days

c) Place patient in supine position

d) Instruct and encourage use of incentive spirometry

Answer : d management for clients post cholocystectomy includes maintaining high fowlers position, deep breathing and coughing, pain management, NPO until peristalsis returns, administer IVF and T tube monitoring and care.

Cardiac Tamponade

Main Problem : Fluid Accumulation in the pericardial sac

Initial Manifestation : hypotension muffled heart sounds is a common sign

Laboratory data : ECG reveals ST and T wave abnormalities

Nursing Diagnosis : Altered cardiac Output

Interventions : prepare the patient for pericardiocentesis. Tjis involves aspirating the fluid or air from the pericardial sac. Assess for complications

Cor pulmonale

A chronic heart condition, is the hypertrophy of the heart, right ventricle and associated structure that results from diseases affecting the function and the structure of the lungs

Chronic productive cough , dyspnea on exertion, edema and fatigue

ABG- decreased Pa O2 < 70 mmHg

CXR and UTZ suggests R ventricular hypertrophy

ECG- shows arrhythmia during severe hypoxia

Altered Tissue perfusion related to cardiopulmonary changes

Measure ABG levels and administer O2 by mask or cannula as ordered. Monitor serum K if on diuretics

Low salt , fluid restricted , small frequent feedings

Monitor digoxin level and check radial pulse prior to cardiac glycoside administration to avoid complications

Reposition and provide meticulous respiratory care

1) Then following are diagnostic tests done to assess the presence of cor pulmonale except:

a. CXR

b. ECG

c. UTZ

d. Venogram

Answer : d insertion of a dye into a vein for the purpose of outlining an obstruction or lesion.

Chronic Bronchitis ( Blue Bloater )

Main problem : excessive mucus secretion with the airways and recurrent cough usually related to smoking , pollution and infection.

Initial Manifestation : Cough with copious sputum

Laboratory data : ABG reveals respiratory acidosis

Nursing Diagnosis : Impaired breathing pattern

Interventions : Increase Humidity

Provide postural drainage before meals

Relieve bronchospasm

Teach the patient about breathing techniques like : blowing bubbles , blowing a trumpet , blowing a feather in the air

Complete Heart Block

Main Problem : altered transmission of wave impulses from the SA node to the AV node

Initial Manifestation : Bradycardia

Laboratory data : ECG reveals prolonged PR interval

Nursing Diagnosis : Altered tissue perfusion

Interventions : Monitor patients ECG

Prepare patient for pacemaker insertion

A common sign of pacemaker failure is hiccups

Atropine Sulfate is given as a vagolytic

Congestive Heart failure

Main Problem : failure of the heart to pump blood to meet oxygen requirements.

Initial manifestations : Right sided edema , hepatomegaly

Left sided : dyspnea , rales

Laboratory data : Elevated CVP above 12 mmHG for right sided failure. Elevated PAP and PCWP for left sided failure

Nursing diagnosis : altered cardiac output related to impaired contractility

Interventions : Maintain patient in semi fowlers position

Administer digitalis and diuretics as ordered

Maintain low sodium and low cholesterol diet

Monitor potassium levels

Crohns Disease ( Regional Enteritis)

Main Problem : Chronic Inflammatory Disease of the small intestines

Initial manifestation : Crampy abdominal pain in the right lower quadrant of the abdomen

Laboratory data : Barium Swallow reveals string sign

Nursing Diagnosis : Pain and alteration in bowel elimination ;diarrhea

Interventions : Maintain high protein , high carbohydrate , low fat diet

Administer steroids as ordered

Provide small frequent feeding

Monitor input and output

Cushing s Syndrome

Main Problem : Hypersecretrion of the glucocorticoids by the adrenal glands

Initial Manifestation : Central type or truncal obesity with thin extremities, moon face , buffalo hump and hirsutism

Laboratory data : Elevated serum cortisol levels, hypernatremia , hypokalemia , hypertension , hyperglycemia

Nursing Diagnosis : Altered skin integrity related to impaired healing

Interventions : Maintain patient on high potassium and low sodium diet

Instruct patient that treatment will involve lifelong administration of glucocorticoid synthesis inhibitors ( Mitotane )

Inform patient about slow wound healing

Cystitis

Main problem : inflammation of the urinary bladder

Initial Manifestation : Frequency and Urgency

Laboratory data : Culture and sensitivity tests reveal the presence of bacteria usually E coli

Nursing diagnosis ; Altered Urinary Elimination

Interventions : Increase Oral Fluid Intake Instruct the patient to avoid bubble baths , silk underwear. Cotton underwear is preferred. Maintain acid ash diet ; (cheese , cranberry , prunes , plums , poultry , eggs)

Diabetes Mellitus

Main Problem : Chronic disorder of cardohydrate , protein and fat metabolism characterized by an imbalance between insulin supply and demand. Type 1 IDDM ( no insulin ) ; Type 2 NIDDM ( little insulin or insensitivity of cells to insulin)

Initial manifestation : Polyuria , Polyphagia , Polydipsia and weight loss

Laboratory data ; elevated FBS level above 120 mg / dl

Nursing Diagnosis : Alteration in nutrition

Interventions :

D-IET : 50-60%cho , 20-30% FATS , 10-20% CHON

I NSULIN TYPE 1

A NTIDIABETIC AGENTS TYPE 2

B LOOD SUGAR MONITORING

E - XERCISE

T RANSPLANT OF PANCREAS

E NSURE ADEQUATE FOOD INTAKE

S CRUPULOUS FOOT CARE

STRICT MONITORING FOR COMPLICATIONS( DKA for IDDM and HHNKS for NIDDM)

Diabetes Insipidus

Main Problem : Hyposecretion of antidiuretic hormone

Initial manifestation : Polyuria , polydipsia

Laboratory data : fluid deprivation test confirms the disorder

Nursing Diagnosis : Fluid Volume Deficit

Interventions : Maintain Adequate fluid intake

Monitor urine specific gravity

Administer Desmopressin acetate or Vasopressin intranasally as ordered

Dementia , Alzheimers

Irreversible progressive impairment in the patients cognitive functioning, memory and personality

Confusion, easy forgetfulness and memory loss( cannot retain or recall recent information)( confabulates to cover up memory loss)

Cognitive assessment- deterioration of cognitive ability

Mental status exam reveals disorientation and recall difficulty. Functional Dementia Scale shows some degree of dementia

Cortical atrophy seen on MRI / CT scan

Altered thought processes

Group therapy and increase social interaction - reminiscence therapy to increase self esteem )

Provide for a safe , highly structured environment. Maintain consistency and provide constant orientation

When agitated redirect focus

Simplify communications , tasks and routines

Diet adequate in folic acid and provide adequate fluids and nutrition

Palliative medical management with:

Anticholinesterase Tacrine(Cognex), Donepezil (Aricept)

Antipsychotics, Benzodiazepines,Antidepressants and Vitamin E supplements

1. Clinical manifestations more typical of dementia include all of the following except:

a. wandering:becoming lost

b. impairment of cognitive functioning

c. memory impairment

d. no personality changes

answer : d - in dementia there is personality changes that interfere with ADL.

Delirium

Acute reversible disturbance of consciousness accompanied by a change in cognition not attributed to pre-existing dementia lasting several hours or days

Altered psychomotor activity such as apathy, withdrawal and agitation with disorientation

Result of a physiologic condition, metabolic imbalance, intoxication, substance withdrawal, toxic exposure, prescribed medicines or combination . No specific laboratory test. Multiple tests to rule out or confirm underlying factors

Altered cerebral perfusion and high risk for injury

Assess and correct underlying physiologic problem

Create a structured safe environment

Decresase sensory stimulation and administer medications as ordered:

Tranquilizer

Benzodiazepines

Cholinesterase inhibitors

Antipsychotics

Risperidone(risperdal)

1) Clinical manifestations not typical of delirium :

a) Slowed thought processes , confusion and disorientation

b) Misperception of stimuli and incoherent speech

c) sundowners syndrome and dream like state

d) memory impairment , aphasia and apraxia

answer : d - memory impairment , aphasia and apraxia more associated with dementia

Compartment Syndrome

Pressure within a muscle and its surrounding structures increases causing circulation impairment or interruption caused by application of dressing, tight casting, burns, closed fractures and crushing injuries

Pain increased with stretching and unrelieved by narcotic analgesics

Paresthesias, pallor, pulseless and paralysis

No specific diagnostic test

Risk for peripheral neurovascular dysfunction

Position the affected extremity lower than the heart to increase circulation to the area

Bivalving or removal of dressings and constrictive coverings from area

Monitor affected extremity and perform neurovascular checks.

1) In patient with complaining of intense pain on the casted extremity unrelieved by analgesics the nurse would :

a) Ask the patient to wiggle the fingers or toes of the extremity

b) The nurse would refer to patient to the AP for increase in narcotics

c) check for distal pulses and elevate the extremity

d) prepare the client for possible bivalving

answer d : in compartment syndrome emergency bivalving is the most appropriate intervention done

Disseminated Intravascular Coagulation ( DIC )

Main Problem : Wide spread coagulation all over the body resulting to subsequent depletion of clotting factors

Initial Manifestation : petechiae and ecchymosis on the skin , mucous membrane , heart lungs and other organs

Laboratory Data : Prolonged PT and PTT

Nursing Diagnosis : Risk for Injury

Interventions : Monitor for signs of bleeding ( tarry stool , hemoptysis , nosebleeding )

Administer heparin as ordered.heparin inhibits thrombin thus preventing further clot formation and allowing coagulation factors to accumulate.

Administer Blood transfusion as ordered

Instruct patient to avoid aspirin and aspirin containing compounds

Diverticulitis

Main Problem _ Inflammation of a pouch or saccular dilation in the colon ( diverticula)

Initial Manifestation : Left lower Quadrant Pain

Laboratory data : Sigmoidoscopy confirms the diagnosis

Nursing Diagnosis : Pain

Interventions : Provide Low Fiber Diet ( avoid vegetables) in diverticulitis, high fiber in Diverticulosis

Administer Metamucil as ordered

Administer meperidine for relief of pain

Dumping Syndrome

Main Problem : Rapid emptying of the stomach contents into the small intestine usually a complication of gastric surgery

Initial manifestations : 3 Ds ( Diarrhea , Diaphoresis , Drowsiness)

Laboratory data : non specific

Nursing Diagnosis : Altered Elimination

Interventions : Maintain patient on supine position after

Meals and withold fluids during meals

Maintain high fat , high protein , dry diet, low in simple sugars ( fat delays emptying of the stomach

Emphysema (Pink Puffer)

Main problem : destruction of the alveoli , narrowing of small airways and trapping of air resulting in loss of lung elasticity

Initial manifestation : shortness of breath ; barrel chest ( increase in anteroposterior diameter of the chest ) is a late sign

Laboratory data : ABG reveals Respiratory Acidosis

Nursing Diagnosis : Ineffective breathing Pattern

Interventions : Keep the patient in orthopneic position / sitting

Administer low flow oxygen

Encourage patient to do pursed lip breathing

Instruct patient to avoid powerful odors , extremes of temperature, pets , fireplace and feather pillows

Endocarditis

Main Problem : Infection of the inner lining of the heart caused by direct invasion of bacteria leading to deformity of the valve leaflets

Initial Manifestation : Fever

Laboratory data : elevated ESR

Nursing Diagnosis : Altered Cardiac Output

Interventions : Record daily weight

Evaluate jugular vein distention, as this signifies the development of CHF

Instruct the patient to take antibiotics before dental procedures that can cause bleeding

Avoid sharing of needles

Teach the women in child bearing years the risks of using IUDs or other birth control ( source of infection )

Epileptic Seizure

Main Problem : Abnormal sudden excessive discharge of electrical activity within the brain

Initial Manifestation : Impaired Consciousness

Laboratory Data : EEG ( abnormal brain waves ) , CT scan reveals brain lesions

Nurisng Diagnosis : Altered tissue Perfusion

Interventions: (On seizure precautions)

Maintain Patent Airway

Protect from injury

Do not restrain

Administer valium,drug of choice as prescribed ; & other anticonvulsants

Oxygen equipment and suction at bedside

Fractures

Break in the continuity of the bone due to trauma, bone tumors and osteoporosis

Acute pain, cyanosis, loss of function, swelling , deformity and crepitus

Antero posterior lateral X-ray of the area

Acute pain and impaired physical activity

Rest

Immobilize

Cold compress and control bleeding

Elevate

Alleviate pain by giving adequate analgesics/narcotics except in presence of head injury

Prepare patient for reduction and alignment ( Splinting , casting, application of traction and surgical fixation (CRIF/ORIF)

Provide adequate care for clients with traction

T-rapeze bar overhead

R equires free hanging weights

A nalgesics is given to relieve pain

C heck circulation (pulse)

T emperature monitoring

I nfection prevention

O utput and intake monitoring

N utrition( appropriate diet)

S kin must be checked frequently

1) In management for fractures by closed reduction the bones are:

a) Realigned through surgical means

b) May involve removal of damaged bone

c) Bone replacement with prosthesis

d) Bones realigned without surgery and cast applied to hold bones in alignment

Answer : d closed reduction bone realignment without surgery

Glaucoma

Main problem: increased intraocular pressure due to accumulation of aqueous humor

Initial manifestation : Tunnel Vision , Gun Barrel Vision

Closed angle with pain

Laboratory Data : Tonometer reading of 25 mm Hg and above

Nursing Diagnosis : Potential for Injury related to visual impairment

Interventions : Explain to the patient that glaucoma cannot be cured but it can be controlled

Administer Miotics ( pilocarpine )

Mydriatics contraindicated(ATSO4)

Instruct patient to avoid activities that can contribute to increased IOP

Teach patient about trabeculoplasty creation of an opening in the trabecular meshwork to increase the outflow of aqueous humor.

Gastritis

Acute and chronic inflammation of gastric mucosa causing edema, hemorrhage and erosion

Abdominal cramping, epigastric discomfort, hematemesis and indigestion

Occult blood in stool and vomitus, decreased Hgb and Hct

Upper GI endoscopy confirms diagnosis when performed within 24 hours of bleeding

Acute and chronic pain

Risk for fluid volume defict

Altered nutrition less than body requirements

Give IVF and antiemetics. Monitor MIO

Provide bland diet in smaller frequent meals

Administer antacids(between meals) and H2 blockers to promote healing, anticholinergics and Vit B12

Angiography with vasopressin infused in NSS during bleeding

Teach importance of smoking cessation , avoid spicy foods and caffeine, taking steroids with milk, foods or antacids and to avoid aspirin containing compounds

1) Complications of gastritis include

a) gastric carcinoma and pernicious anemia

b) bleeding and dehydration

c) a and b

d) b only

answer : b - gastric carcinoma , pernicious anemia,

bleeding and dehydration are complications of gastritis

Guillain Barre Syndrome

Main Problem : acquired acute inflammatory disease of the peripheral nerves

Initial Manifestation : ascending paralysis , weakness at first

Laboratory Data :CSF exam reveals elevated total protein

Nursing Diagnosis: Ineffective Breathing Pattern

Interventions : Maintain a patent airway

Monitor for respiratory involvement

Instruct patient to avoid crowded areas

Keep tracheostomy and suction equipment at bedside

Hemophilia

Main Problem : Deficiency of clotting factors. Sex linked recessive trait ( type A and B ) more common in males. Von Willebrands disease is transmitted to both male and female offsprings of a carrier

Initial Manifestation: Hemarthrosis ( bleeding joints)

Laboratory Data : prolonged Bleeding Time

Nursing Diagnosis: Altered tissue perfusion

Interventions : Avoid Aspirin

Control by :Rest

Immoblize

Cold Compress

Elevate

Hepatic encephalopathy / coma

Main Problem : Decreasing level of consciousness related to accumulation of ammonia

Initial manifestation : personality changes ; flapping tremors (asterexis) common sign

Laboratory Data : Elevated serum ammonia

Nursing Diagnosis : Altered Thought Process

Interventions : Monitor LOC

Maintain low CHON diet

Hiatal Hernia

Main Problem :A portion of the stomach is herniated through the esophageal hiatus of the diaphragm

Initial Manifestation: initially asymptomatic , heartburn is a common complaint

Laboratory Data: Endoscopy reveals herniation of a part of the stomach

Nursing Diagnosis : Altered Nutrition

Interventions : Maintain the patient in an upright position after meals

Instruct patient to avoid bending

Provide small frequent meals

Avoid anticholinergic drugs and coughing

Hip Fracture

Main Problem : Break in the continuity of the hip bone

Initial manifestation: Shortening and external rotation of the affected leg

Laboratory : Hip X ray

Nursing Diagnosis : Impaired Physical Mobility

Interventions : Prepare the patient for surgery

Postoperatively maintain the legs in abduction by placing a wedge pillow between legs

Monitor for signs and symptoms of complications ( petechiae over chest indicates fat embolism)

Hyperparathyroidism

Main Problem : hypersecretion of the parathyroid hormone

Initial manifestation : bone pain

Laboratory Data : elevated serum calcium levels

Nursing Diagnosis : Risk for Injury

Interventions : Prepare the patient for Surgery

Increase oral fluid intake

Provide low calcium diet

Strain all urine

Complication : renal calculi

Hypertension

Main Problem : Persistent BP above 140 / systolic and 90 / diastolic

Initial manifestation : Asymptomatic , occipital headache is a common complaint

Laboratory data : elevated BP

Nursing Diagnosis : Altered Tissue Perfusion

Interventions: Avoid Stimulants

Low salt , low fat diet

Stress reduction techniques

Lifestyle , dietary and behavioral modification

Compliance to HPN pharmacotherapy

Specially maintenance meds

Hyperthyroidism

Main Problem : Hypersecretion of thyroid hormones

Initial manifestation : Fine hand tremors , intolerance to heat is a common symptom

Laboratory Data : Elevated T3 and T4

Nursing Diagnosis : Risk for Injury

Interventions : Maintain a high calorie , High CHON Diet

Provide adequate rest

Provide acool environment

Elevate head of bed

Propylthiouracil medication is lifetime

Prepare patient for thyroidectomy

Post thyroidectomy assess for hemorrhage by slipping the hand behind the neck

Hyperlipidemia

Increased serum levels of two plasma lipids; cholesterol and triglycerides above 200 mg/ dl. Factor causation of atherosclerosis and conductive to arteriosclerosis

Initially asymptomatic

Lipid Profile Test elevated

Non compliance to therapeutic regimen

Instruct patient to eat salmon and tuna at least several times a week and increase intake of high fiber foods

Administer antilipidemic drugs with meals

Clofibrate ( Atromid-S)

and Cholestyramine ( Cuemid)

1) Management for patients with hyperlipidemia:

a) Diet low in cholesterol and saturated fats

b) Carbohydrate restricted diet

c) A and b

d) A only

Answer : c low saturated fat and low cholesterol diet can maintain serum cholesterol below 140 mg/dl. Carbohydrate restriction can lower serum triglyceride levels by reducing lipoprotein derived from carbohydrate

Hypoparathyroidism

Main Problem : Hyposecretion of parathyroid hormone

Initial manifestations : Tingling sensation around the lips and upper extremities

Laboratory Data : Decreased serum calcium levels

Nursing Diagnosis : Potential ; altered cardiac output

Interventions : Assess for increased signs of neuromuscular irritability ( Chvosteks and Trousseaus Sign)

Provide a quiet room , no stimulus

Provide high calcium , low phosphorus diet

Hypothyroidism

Main Problem : Hyposecretion of thyroid hormone

Initial Manifestation : Fatigue , facial edema is a common sign

Laboratory Data : Decreased T3 and T4 levels

Nursing Diagnosis : Activity Intolerance

Interventions : Maintain low calorie , low cholesterol and low saturated fat diet

Provide warm environment and avoid sedatives

Provide frequent rest periods

Instruct patient that administration of synthroid is lifelong

Hypovolemic shock

Main Problem : Loss of effective circulating blood volume leading to circulatory collapse resulting to inadequate tissue perfusion

Initial manifestation : narrowing pulse pressure

Diagnostic data ; Decreased BP and Decreased CVP

Nursing Diagnosis : altered Tissue Perfusion

Interventions : Maintain patent airway

Keep patient in modified trendelenburg position

Start fluid replacement immediately

Administer vasopressors as ordered

Hemorrhoids

Varicosities or outpouching of the veins of the hemorrhoids plexus

Internal- painless bleeding in defecation

External intense rectal itching with bleeding and pain upon defecation

Rectal examination

Pain related to irritation, pressure, sensitivity in recto-anal area

Conservative treatment:

Application of hot and cold compress

Analgesic ointment(nupercaine)

Hot sitz bath

Prepare patient for treatment by ligation, injection of sclerosing agent or preop and post op care for hemorroidectomy

Position prone post hemorroidectomy,

Watch out for hemorrhage 24 hours to 10 days post-op when sutures are sloughing off.

Administer laxative, full diet until few hours before anesthetic is given. Stool softeners and bulk formers(Metamucil)

Increase bulk and fluids

1) Post hemorrhoidectomy nursing care monitoring for potential complication includes observation for:

a) Bleeding and urinary retention

b) Bleeding and atelectasis

c) Respiratory complications and urinary retention

d) None of the above

Answer : a bleeding and urinary retention are possible complications of hemorrhoidectomy

Increased intracranial pressure

Main problem : increase in amount of CNS tissue or CSF fluid leading to an ICP greater than 15 mmHg

Initial Manifestation : Widening pulse pressure , decreasing LOC

Laboratory Data : elevated Blood pressure ( systolic)

Nursing diagnosis : Potential for ineffective breathing pattern

Interventions : Keep the patient in high fowlers position

Administer dexamethasone and mannitol as ordered to decrease cerebral edema

Monitor level of consciousness

Liver Cirrhosis

Main Problem : Normal liver tissues are replaced with scar tissues

Initial manifestation : edema

Laboratory data : elevated SGOT / SGPT ; AST / ALT

Nursing Diagnosis: Altered Fluid Volume

Interventions : Maintain A low protein diet

Assess the patient for bleeding

Prepare the patient for paracentesis

Weigh the patient daily

Asterixis indicates hepatic encephalopathy

Menieres Disease

Main Problem: Dilation of the endolymphatic system causing degeneration of the vestibular and cochlear hair cells in the inner ear . It affects cranial nerve VIII

Initial Manifestations : Vertigo usually described by patients as I feel like Im spinning , I feel as if the room is revolving

Laboratory Data : Caloric Stimulation test reveals moderate nystagmus

Nursing Diagnosis : Risk for Injury

Interventions : Priority Safety Keep the patient in supine position during the attack

Maintain low sodium diet

Encourage the patient ot stop smoking

Keep the room dark when photophobia is present

Multiple Sclerosis

Main Problem : Chronic Progressive disease of the CNS characterized by small patches of demyelination in the brain and spinal cord

Initial Manifestations : Intentional Tremors and Diplopia

Laboratory Data : MRI reveals small plaques scattered throughout the CNS

Nursing Diagnosis : Impaired Physical Mobility related to nuscle weakness ; Risk for injury

Interventions : Promote safety of the client

Teach the patient certain stress management techniques

Encourage daily exercise

Myasthenia Gravis

Main Problem ; Faulty Neuromuscular transmission of the voluntary muscles of the body due to a deficiency in acetylcholine receptor sites in the myoneural junction

Initial Manifestation : Descending muscle weakness initially manifested by ptosis

Laboratory Data : CT scan reveals hyperplasia of the thymus gland. Tensilon test ; increased muscle strength 30 seconds after administration of Endrophonium

Nursing Diagnosis : Ineffective Breathing Pattern

Interventions : Maintain Patent Airway

Instruct the patient to avoid quinidine , morphine and antibiotics since these may trigger muscle weakness.

Instruct the patient to avoid prolonged talking over the phone especially before meals since this will weaken the facial muscles which are also used for eating.

Intestinal obstruction

Blockage of intestinal lumen causing gas, fluid and digested material substance to accumulate near the obstruction and increase peristalsis.H2O and electrolytes are then secreted into the blocked bowel causing inflammation and inhibiting absorption

Abdominal distention, cramping pain, decreased or absent bowel sounds

Abdominal X-ray increased amount of gas in the bowel

Acute pain related to abdominal distention

Constipation related to inability of stool to pass through obstructed area

Place patient on NPO and fluid and electrolyte replacement through IVF infusion

Assess bowel sounds,mio,vs and labs- stoll exams and measure abdominal girth to assess for distention

Semi-fowlers for comfort , bedrest and quiet envt.

Administer analgesics( Demerol)and antibiotics(Gentamycin)

Teach and monitor pre-op and post op care for bowel resection with or without anastomosis

Avoid constipating food

GI decompression using NGT, Miller abbott or cantor tubes maintained position and low intermittent suction

1) The priority nursing diagnosis for patients with bowel obstruction are Constipation related to inability of stool to pass through obstructed area and:

a) Fluid volume deficit, potential for

b) Pain

c) High risk for infection

d) Potential for non compliance

Answer : b : pain is an immediate problem the other choices are potential problems.

Myocardial Infarction

Main Problem : Destruction of the cardiac tissue due to reduced coronary blood flow

Initial Manifestation : lower sternal pain not relieved by rest and nitroglycerine , characterized as crushing or excruciating

Laboratory Data : Elevated CPK and Troponin , ECG reveals ST segment elevation or depression and T wave inversion

Nursing Diagnosis : Pain related to decreased tissue oxygenation

Interventions: Morphine / Demerol to relieve pain

Oxygen Administration

Nitroglycerine

Aspirin

Position in semi-fowlers

Maintain low fat , low cholesterol and low sodium diet

Osteoporosis

Main Problem : Loss of bone matrix leading to bone weakness predisposing it to fractures. Usually associated with smoking , menopause , immobility and hyperparathyroidism

Initial manifestation : asymptomatic

Laboratory Data : X- ray reveals decrease in bone density

Nursing Diagnosis : Potential for Injury

Interventions ; Increase Vit D and Calcium in the diet

Estrogen replacement therapy for post menopausal women

Encourage patient to perform active weight bearing exercises like brisk walking , jumping rope , hiking , tennis and bal;lroom dancing.

Swimming does not meet criteria for resistance needed for prevention of osteoporosis

Metabolic acidosis

state of excess acid accumulation and deficient base bicarbonate

drowsiness and Kussmauls respiration, CNS depression, lethargy and stupor

ABG reveals pH < 7.35 and HCO3 level < 24 mEq / L

Impaired gas exchange

Assess and correct underlying cause

Watch out for increased serum potassium,frequent monitoring of vital signs , labs and level of consciousness

Keep sodium bicarbonate ready and institute seizure precautions.

Teach urine and blood tests for sugar or acetone.

Encourage strict adherence to OHA or insulin therapy

1) Hyperglycemia in patients with IDDM can cause what metabolic imbalance:

a) Metabolic acidosis

b) Metabolic alkalosis

c) All of the above

d) None of the above

Answer : a excess production of metabolic acids such as hyrglycemia in patients with IDDM warrants use of fats which liberates ketone bodies which is a metabolic acid precipitates metabolic acidosis.

Metabolic Alkalosis

Clinical state marked by decreased amounts of acid and increased amounts of base bicarbonate

Confusion, hypoventilation, irritability, picking at bedlinens and twitching

ABG pH . 7.45 and Bicarbonate level > 28 mEq / L

High risk for injury related to metabolic alkalosis

Alteration in tissue perfusion and Impaired gas exchange

Assess and Treat underlying cause

Measure I and O and watch out for tachycardia and hypotension indicating hypokalemia

Avoid the use of alkaline agents such as antacids, bicarbonate of soda and no administration of IVF with increased concentration of bicarbonate or lactate

Acidifying agent- ammonium Chloride IV and potassium Chloride supplements IV ( not given to clients with hepatic and renal diseases and given on slow infusions to prevent hemolysis)

1) Most appropriate nursing intervention to correct metabolic alkalosis is to:

a) infuse Potassium chloride

b) Use of antacids and bicarbonate of soda

c) IVF with bicarbonates and lactate

d) All of the above

Answer : a - Infusion of acidifying agents are beneficial to counteract metabolic alkalosis

Respiratory alkalosis

Deficiency of CO2 in the blood as indicated by decreased PaCO2 caused by alveolar hyperventilation which elevates blood Ph.

Deep rapid breathing > 40 bpm( cardinal)

Circumoral or peripheral paresthesias

Carpopedal spasms and lightheadedness

ABG Pa CO2 < 35 mHg

Impaired gas exchange

Ineffective breathing pattern

Eradicate underlying condition by treatment of CNS disease, fever, sepsis or removal of ingested toxins

Teach effective deep breathing into a paper bag

Watch out for twitching and cardiac arrythmias

Monitor ABGS and serum electrolyte levels

1) Common management for respiratory alkalosis includes:

a) Oxygenation by nasal cannula

b) Oxygen delivery by face mask at 10 LPM

c) Teach deep breathing in a paper bag

d) Encourage patient to breathe deeply in a pursed lip manner

Respiratory Acidosis

Acid base disturbance characterized by excess CO2 in the blood( hypercapnia) >45 mmHg resulting from reduced alveolar ventilation

Restlessness and confusion

ABG Ph below normal < 7.35 ; pCO2 > 45

Impaired gas exchange

Ineffective breathing pattern

Monitor pulmonary function tests

Prepare patient for intubation and /or mechanical ventilation if with hypoxemia, decreased level of consciousness and respiratory distress.

Administer antibiotics, sodium bicarbonate and bronchodilators as needed

Chest physiotherapy, suctioning and O2 with humidification

Eradicate underlyingt cause by intubation and Mech. Ventilation, removal of foreign body and dialysis to remove toxic drugs.

1) Respiratory acid base imbalance caused by retention of CO2 which combines with H2O to form carbonic acid H2CO3 includes the following disorders except:

a) COPD and Asthma

b) hyperventilation

c) CNS depression

d) Pulmonary edema and respiratory paralysis

Answer : b hyperventilation causes alkalosis

Pancreatitis

Main Problem : Autodigestion of the pancreas

Initial Manifestation : Periumbilical Pain

Laboratory Data : Elevated Serum Amylase

Nursing Diagnosis : Pain

Interventions : Administer Demerol to relieve pain. Morphine contraindicated as it causes spasm of the spincter of oddi

Maintain low fat diet , patient on NPO during acute phase

Instruct patient to avoid coffee and alcohol

Parkinson s Disease

Main Problem : Progressive Neurologic Disorder affecting the brain centers responsible for control and regulation of movement due to depletion of dopamine

Initial manifestation : Bradykinesia

Laboratory data : No Specific

Nursing Diagnosis : Risk for Injury

Interventions ; Maintain Exercise program

Maintain a low protein diet at daytime and high protein at night because absorption of levodopa which is usually taken at daytime is slowed down by intake of high protein foods and vitamin B6

Institute safety measures ( rubber soled shoes , low heels and grab bars )

Prepare patient for stereotaxic thalamotomy , surgery done to decrease tremors

Peptic Ulcer Disease , Duodenal

Main Problem : Increased in HCL acid levels in the stomach

Initial manifestation : Right Epigastric Pain which occurs 2-3 hours after meals usually at night and is relieved by eating

Laboratory Data : Gastric Analysis reveals elevated HCL

Nursing diagnosis : Potential for fluid volume deficit

Interventions : Maintain high fat , high carbohydrate and low protein diet. Instruct patient to avoid spicy and caffeine containing foods , alcohol and smoking

Peptic Ulcer Disease , Gastric

Main Problem : Weak Gastric Mucosa

Initial Manifestation : Left epigastric pain which occurs 30 minutes 1 hour after meals usually at day time and is relieved by vomiting

Laboratory Data : Endoscopy reveals ulcer usually in the lesser curvature of the stomach

Nursing Diagnosis : Potential for fluid volume deficit

Interventions ; Maintain High fat , high carbohydrate and low protein diet

Instruct the patient to avoid spicy , caffeine containing foods , alcohol and smoking

Administer antacids separately from other drugs that the patient is taking , as ordered.

Prepare patient for surgery ( Billroth 1 , 2 or gastrectomy or vagotomy)

Raynauds disease

Main Problem : VAsospastic condition of arteries of the hands tha occurs with exposure to cold or stress

Initial Manifestation : Intermittent arteriolar vasoconstriction

Laboratory Data : Allens test reveals circulatory problems

Nursing Diagnosis : Altered Tissue Perfusion

Interventions : Avoid cold weather

Wear leather gloves when getting anything from the refrigerator

Stop smoking

Administer vasodilators as ordered

Renal Colic ( Urolithiasis)

Main Problem : Presence of renal stone in the urinary system

Initial manifestation : Sudden severe pain that leads to shock, unrelieved by analgesics

Laboratory Data : IVP reveals the presence of stone

Nursing diagnosis : Pain

Interventions : Strain all patients urine , to assess if the patient is passing out stones

Increase Oral Fluid Intake

Prepare Patient for Extracorporeal Shock Wave Lithotripsy- area submerged in water and electrically generated shock wave directed to the location of the stone. Pain medications given to minimize pain

Maintain patient on low sodium , low protein diet

Renal Failure , Acute

Main Problem : Abrupt reversible cessation of renal function as a result of trauma , allergy and kidney stones

Initial Manifestation : Oliguria ( U.O. , 400 ml / 24 hours )

Laboratory data : elevated BUN and creatinine

Nursing Diagnosis : Alteration in Urinary Elimination

Fluid and electrolyte imbalance

Interventions : Monitor Intake and output

Maintain a low protein , high carbohydrate , low sodium diet and fluid restricted during the oliguric phase and high protein , high calorie and fluid replacement during diuretic phase

Renal Failure , Chronic

Main Problem : Irreversible slow or progressive failure of the kidneys to function that results in death unless treatment is instituted

Initial manifestation : GI manifestations like anorexia , nausea and vomiting

Laboratory Data : Elevated serum creatinine level and low urine creatinine clearance

Nursing Diagnosis : Alteration in urinary elimination

Fluid Volume Excess

Interventions : Maintain low protein , low sodium , low potassium diet

Prepare patient for hemodialysis / peritoneal dialysis and monitor for complications

Monitor for signs and symptoms of anemia

Administer Epogen , diuretics and antihypertensives as ordered

Pulmonary Embolism

Obstruction of blood flow to pulmonary vessels by an undissolved substance( air, fat, emboli,thrombus) resulting in pulmonary hypertension and possible iinfarction

Sudden onset of dyspnea, tachypnea, crackles and chest pain

ABG hypoxemia; pulmonary angiography shows location of embolism and filing defect

CXR shows pneumoconstriction pulmonary arterial dilation

Lung scan shows VQ mismatch

Impaired gas exchange

Ineffective tissue perfusion; cardiopulmonary

Monitor ABG and watch out for respiratory distress and assess cardiovascular status and CVP

Irregular pulse arrhythmia caused by hypoxemia

Hyperthermia pulmonary embolism caused by thrombophlebitis

Monitor lab studies maintain PTT at 1 to 2 times control in patient with heparin PT at 1 to 2 times control or INR at 2 -3 in patient receiving coumadin

Place patient in fowlers position, suction and administer IVF, analgesics, anticoagulants, diuretics and fibrinolytics as ordered

1) The nursing diagnosis with least significance for patients with pulmonary embolism is:

a) Altered pattern of breathing related to dyspnea

b) Impaired gas exchange related to decreased diffusion

c) Pain related to pleural irritation

d) Anxiety related to hypoxia

Answer : d physiological needs first

Pulmonary Edema

A condition characterized by excessive amount of fluid in the alveoli and pulmonary interstitial tissues which tends to interfere with effective diffusion of gases

Dyspnea, orthopnea, crackles paroxysmal nocturnal dyspnea and pink frothy sputum

Pulmonary function tests decreased VQ ratios, ABGs indicate hypoxemia

Impaired gas exchange related to right to left shunting and decreased V/Q ratios

Fluid volume excess related to left ventricular failure in cardiogenic pulmonary edema

Decreased cardiac output related to left ventricular failure in cardiogenic pulmonary edema

Monitor blood gases

If on ventilator , suction frequently. Maintain oxygenation with ventilator( on PEEP) or nasal cannula

Restrict fluids and sodium for edema

Administer inotropic drugs(Dopamine and dobutamine) and diuretics in cardiogenic pulmonary edema

Prevent pulmonary infection with strict asepsis

Maintain nutrition with parenteral or enteral feedings

1) An example of a drug used in pulmonary edema to decrease circulating fluid volume

a) Dopamine ( Intropin)

b) Dobutamine ( Dobutrex)

c) Lasix( Furosemide)

d) Digoxin ( Digitoxin)

Answer : c furosemide is a diuretic which decreases fluid volume by increasing renal water excretion

Pneumothorax

A restrictive respiratory disease occurs when air enters the pleural space as a result of pulmonary lesion, neoplasms, accidental or surgical opening through the chest wall. Collapse of the lung due to air in the pleural space.

Hemothorax blood

Hydrothorax water

Pyothorax pus and exudates

Acute symptoms of dyspnea and paradoxical chest movement( absent or restricted movement on the affected side with decreased or absent breath sounds , may lead to mediastinal shift)

Lung scan shows VQ ratio mismatches

CXR showing decreased perfusion

ABG showing hypoxemia

Impaired gas exchange

Monitor PFTs and prepare patient for thoracentesis and observe for complications of chest tube placements ( constant bubbling in the water seal chamber indicates leak; 3 days post insertion can indicate lung re-expansion)

Place patient in high fowlers position and place on O2 therapy as indicated.

Instruct patient to do valsalva maneuver during chest tube removal.

1) The following are measures to promote adequate respirations and maintain proper function of the drainage bottle system:

a) Prevent movement to prevent displacement of the tube

b) Keep drainage bottles below chest level and position patient flat on bed

c) Constant clamping of the tubes

d) Milking not routinely done

Answer : d patient is positioned in semi- fowlers,drainage bottles below chest level, milking not routinely done as it increases negative pressure, clamping of the tube done only when bottles are broken or must be raised above the chest.

Systemic Lupus Erythematosus

Chronic autoimmune multi-system disorder with periods of exacerbation and remission and increased production of antibodies to cellular DNA results in inflammatory process involving veins and arteries causing pain swelling and tissue damage.

Pancytopenia and butterfly rash on the face, palmar erythema, psychosis and impaired cognitive function migratory pain and swelling, hypertension & carditis

Positive rheumatoid factor and ANA test positive

ESR elevated and serum globulins elevated

Urine chemistry proteinuria and hematuria

High risk for injury

Diet high in iron , CHON, vita.C

Hemodialysis and kidney transplant if renal failure occurs

Increase rest and sleep

Monitor musculo skeletal, renal and cardiopulmonary status

Administer antiemetics , and antidiarrheals

Encourage expression of body image change

Avoid infections, injury, sunlight exposure, OTC meds, oral contraceptives, hair spray and color

Give medications as ordered analgesics , anti-emetics, anti-rheumatics, cytotoxic drugs, steroids and NSAIDS.

1) Complications of SLE includes peripheral vascular disease which can be a cause of

a. Loss of limbs

b. COPD

c. Congestive heart failure

d. Stroke

Answer : a PVD as a complication of SLE can lead to peripjeral tisuue necrosis which warrants amputation

Urinary Tract Infection

Infection of the urinary tract as a result of urethral ascend of bacteria usually caused by E. Coli.

Cystitis inflammation of the urinary bladder

Pyelonephritis

inflammation of the kidney and its pelvis

Flank pain, with frequency,burning and urgency

Chills , muscle spasm, dysuria

Urinalysis and urine C/ S confirms causative agent

Pain alteration in comfort

Stress the importance of medication compliance and bedrest during acute phase

Relieve flank pain with analgesics , rest massage and external heat application

Sulfonamides and broad spectrum antibiotics, urinary antiseptics ( Bactrim , Septra) and

urinary analgesics ( Pyridium)

Increase oral fluid intake up to 4 liters per day and follow up urinalysis every two weeks for a month then monthly until urine is sterile.

1.)the following statement is true about pyelonephritis except

a. may follow cystitis

b. clinical manifestation includes costovertebral angle tenderness

c. most commonly caused by E coli

d. all of the above

answer : d all statements are descriptive of pyelonephritis

Retinal Detachment

Main Problem : Separation of the sensory retina from the pigment epithelium of the retine

Initial manifestation : Visual floaters described by patients as cobwebs or curtain in eyes

Nursing Diagnosis : Potential for Injury

Interventions : Immediate Bedrest

Position patient with the affected side towards the bed , so gravity may help put the detached retina back into place .

Avoid coughing ,sneezing and straining prepare the patient for eye surgery.

Spinal Cord Injury

Main Problem : Partial or complete disruption of nerve tracts and neurons resulting in paralysis and sensory loss

Initial manifestation : Depends on the level of injury

Cervical : Quadriplegia

Thoracic : Paraplegia

Lumbar : Paraplegia

Laboratory Data : X Ray reveals the location and extent of injury

Nursing Diagnosis : Ineffective Breathing Pattern , Impaired Physical Mobility

Interventions : Avoid hyperflexion and hyperextension of the spine . log roll the patient

Keep a catheter at the bedside to prevent bladder distention which may stimulate autonomic dysreflexia

Syndrome of Inappropriate antidiuretic Hormone (SIADH)

Main Problem : Inappropriate continued release of antidiuretic hormone resulting in water intoxication

Initial Manifestation : Mental Confusion

Laboratory Data : Hyponatremia Na , 120 mEq / L

Nursing Diagnosis : Fluid Volume Excess

Fluid and electrolyte imbalance

Interventions : Fluid Restriction

Assess for signs and symptoms of hyponatremia

Ulcerative Colitis

Main Problem : Ulceration of the mucosa of the lower colon and rectum

Initial manifestation : Bloody Mucoid Diarrhea

Laboratory data : Barium enema reveals lesions

Nursing Diagnosis : Pain

Altered Bowel Elimination ; diarrhea

Interventions : Avoid dairy products

Maintain Low Residue and High protein Diet , avoid cold fluids

Teach patients about familial predisposition

NURSING BULLETS

MEDICAL SURGICAL NURSING

In a patient with hypokalemia (serum potassium level below 3.5 mEq/L), presenting signs and symptoms include muscle weakness and cardiac arrhythmias. During cardiac arrest, if an I.V. route is unavailable, epinephrine can be administered endotracheally. Pernicious anemia results from the failure to absorb vitamin B12 in the GI tract and causes primarily GI and neurologic signs and symptoms. A patient who has a pressure ulcer should consume a high-protein, high-calorie diet, unless contraindicated. The CK-MB isoenzyme level is used to assess tissue damage in myocardial infarction. After a 12-hour fast, the normal fasting blood glucose level is 80 to 120 mg/dl. A patient who is experiencing digoxin toxicity may report nausea, vomiting, diplopia, blurred vision, light flashes, and yellow-green halos around images. Anuria is daily urine output of less than 100 ml. In remittent fever, the body temperature varies over a 24-hour period, but remains elevated. Risk of a fat embolism is greatest in the first 48 hours after the fracture of a long bone. Its manifested by respiratory distress. To help venous blood return in a patient who is in shock, the nurse should elevate the patients legs no more than 45 degrees. This procedure is contraindicated in a patient with a head injury. The pulse deficit is the difference between the apical and radial pulse rates, when taken simultaneously by two nurses. To reduce the patients risk of vomiting and aspiration, the nurse should schedule postural drainage before meals or 2 to 4 hours after meals. Blood pressure can be measured directly by intra-arterial insertion of a catheter connected to a pressure-monitoring device. A positive Kernigs sign, seen in meningitis, occurs when an attempt to flex the hip of a recumbent patient causes painful spasms of the hamstring muscle and resistance to further extension of the leg at the knee. In a patient with a fractured, dislocated femur, treatment begins with reduction and immobilization of the affected leg. Herniated nucleus pulposus (intervertebral disk) most commonly occurs in the lumbar and lumbosacral regions. Laminectomy is surgical removal of the herniated portion of an intervertebral disk. Surgical treatment of a gastric ulcer includes severing the vagus nerve (vagotomy) to reduce the amount of gastric acid secreted by the gastric cells. Valsalvas maneuver is forced exhalation against a closed glottis, as when taking a deep breath, blowing air out, or bearing down. When mean arterial pressure falls below 60 mm Hg and systolic blood pressure falls below 80 mm Hg, vital organ perfusion is seriously compromised. Lidocaine (Xylocaine) is the drug of choice for reducing premature ventricular contractions. A patient is at greatest risk of dying during the first 24 to 48 hours after a myocardial infarction. During a myocardial infarction, the left ventricle usually sustains the greatest damage. The pain of a myocardial infarction results from myocardial ischemia caused by anoxia. For a patient in cardiac arrest, the first priority is to establish an airway. The universal sign for choking is clutching the hand to the throat. For a patient who has heart failure or cardiogenic pulmonary edema, nursing interventions focus on decreasing venous return to the heart and increasing left ventricular output. These interventions include placing the patient in high Fowlers position and administering oxygen, diuretics, and positive inotropic drugs as prescribed. A positive tuberculin skin test is an induration of 10 mm or greater at the injection site. The signs and symptoms of histoplasmosis, a chronic systemic fungal infection, resemble those of tuberculosis. In burn victims, the leading cause of death is respiratory compromise. The second leading cause is infection. The exocrine function of the pancreas is the secretion of enzymes used to digest carbohydrates, fats, and proteins. A patient who has hepatitis A (infectious hepatitis) should consume a diet thats moderately high in fat and high in carbohydrate and protein, and should eat the largest meal in the morning. Esophageal balloon tamponade shouldnt be inflated greater than 20 mm Hg. Overproduction of prolactin by the pituitary gland can cause galactorrhea (excessive or abnormal lactation) and amenorrhea (absence of menstruation). Intermittent claudication (pain during ambulation or other movement thats relieved with rest) is a classic symptom of arterial insufficiency in the leg. In bladder carcinoma, the most common finding is gross, painless hematuria. Parenteral administration of heparin sodium is contraindicated in patients with renal or liver disease, GI bleeding, or recent surgery or trauma; in pregnant patients; and in women older than age 60. Drugs that potentiate the effects of anticoagulants include aspirin, chloral hydrate, glucagon, anabolic steroids, and chloramphenicol. For a burn patient, care priorities include maintaining a patent airway, preventing or correcting fluid and electrolyte imbalances, controlling pain, and preventing infection. Elastic stockings should be worn on both legs. Active immunization is the formation of antibodies within the body in response to vaccination or exposure to disease. Passive immunization is administration of antibodies that were preformed outside the body. A patient who is receiving digoxin (Lanoxin) shouldnt receive a calcium preparation because of the increased risk of digoxin toxicity. Concomitant use may affect cardiac contractility and lead to arrhythmias. Intermittent positive-pressure breathing is inflation of the lung during inspiration with compressed air or oxygen. The goal of this inflation is to keep the lung open. Wristdrop is caused by paralysis of the extensor muscles in the forearm and hand. Footdrop results from excessive plantar flexion and is usually a complication of prolonged bed rest. A patient who has gonorrhea may be treated with penicillin and probenecid (Benemid). Probenecid delays the excretion of penicillin and keeps this antibiotic in the body longer. In patients who have glucose-6-phosphate dehydrogenase (G6PD) deficiency, the red blood cells cant metabolize adequate amounts of gl