HESI Advanced Clinical Concepts 2022

HESI Advanced Clinical Concepts 2022/ HESI ADVANCED CLINICAL CONCEPTS 2022 Maintaining an open airway (the allergic reaction damages the lining of the airways causing edema). Also, keep the client warm without constricting clothing; keep legs elevated (not HESI ADVANCED CLINICAL CONCEPTS ARDS is an unexpected, catastrophic pulmonary complica- Trendelenburg because the weight of the lower organs re-  tion occurring in a person with no previous pulmonary prob- stricts breathing). lems. The mortality rate is high (50%)  Epinephrine: 1:1000, 0.2 to 0.5ml subq for mild  In ARDS, a common laboratory finding is lowered PO2. However, these clients are not very responsive to high con-  Epinephrine: 1:10,000, or 5ml IV for severe centrations of oxygen.  Volume expanding fluids are usually given to clients in shock.  Think about the physiology of the lungs by remembering However, if the shock is cardiogenic, pulmonary edema may PEEP: Positive End Expiratory Pressure is the instillation result. and maintenance of small amounts of air into the alveolar sacs to prevent them from collapsing each time the client ex-  Drugs of choice for shock hales. The amount of pressure can be set with the ventilator - Digitalis preparations: Increase the contractility of the heart and is usually around 5 to 10 cm of water. muscle - Vasoconstrictors (Levophed, Dopamine): Generalized vason-  Suction only when secretions are present. constriction to provide more available blood to the heart to help maintain cardiac output.  Before drawing arterial blood gases from the radial artery, perform the Allen test to assess collateral circulation. Make  A common volume-expanding substance is plasma and possi- the client’s hand blanch by obliterating both the radial and ul- bly whole blood. nar pulses. Then release the pressure over the ulnar artery only. If flow through the ulnar artery is good, flushing will be  You are caring for a woman who was in severe automobile ac- seen immediately. The Allen test is then positive, and the ra- cident several days ago. She has several fractures and inter- dial artery can be used for puncture. If the Allen test is neg- nal injuries. The exploratory laparotomy was successful in ative, repeat on the other arm. If this test is also negative, controlling the bleeding. However, today you find that this seek another site for arterial puncture. The Allen test en- client is bleeding from her incision, short of breath, has a weak sures collateral circulation to the hand if thrombosis of the thready pulse, has cold and clammy skin, and hematuria. radial artery should follow the puncture. - What do you think is wrong with the client, and what would you expect to do about it?  If the client does not have O2 to his/her brain, the rest of the - These are typical signs and symptoms of DIC crisis. Expect injuries do not matter because death will occur. However, to administer IV heparin to block the formation of thrombin they must be removed from any source of imminent danger, (Coumadin does not do this). However, the client described is such as a fire. already past the coagulation phase and into the hemorrhagic phase. Her management would be administration of clotting  PC)2 45 or PO2 60 on 50% O2 signifies respiratory fail- factors along with palliative treatment of the symptoms as they ure. arise. (Her prognosis is poor).  A child in severe distress should be on 100% O2.  NCLEX-RN questions on CPR often deal with prioritization of actions. Question: What actions are required for each of the  Early signs of shock are agitation and restlessness resulting following situations? from cerebral hypoxia. - A 24-year old motorcycle accident vistim with a ruptured artery if the leg is pulseless and apneic.  If cardiogenic shock exists with the presence of pulmonary - A 36-year old first time pregnant woman who arrests during la- edema, i.e., from pump failure, position client to REDUCE bor. venous return (HIGH FOWLER’s with legs down) in order to - A 17-year old with no pulse or respirations who is trapped in decrease venous return further to the left ventricle. an overturned car, which is starting to catch fire. - A 40-year old businessman who arrests two days after a cervi- cal laminectomy.  Severe shock leads to widespread cellular injury and impairs the integrity of the capillary membranes. Fluid and osmotic proteins seep into the extra vascular spaces, further reduc- ing cardiac output. A vicious cycle of decreased perfusion to  WHEN TO SEEK EMERGENCY MEDICAL SERVICE (EMS) ALL cellular level activities ensues. All organs are damaged, - The American Heart Association recommends that those with and if perfusion problems exist, the damage can be perma- known angina pectoris seek emergency medical care if chest nent. pain is NOT relieved by three nitroglycerin tablets 5 minutes apart over a 150minute period.  All vasopressors/vasodilator drugs are potent and danger- - A person with previously unrecognized coronary disease ex- ous and require weaning on and off. Do not change infusion periencing chest pain persisting for 2 minutes or longer should rates simultaneously. seek emergency medical treatment.  A client is brought into the hospital suffering shock symp- toms as a result of a bee sting. What is the first priority? 1 nal function than is the BUN. Creatinine is generally used in conjunction with the BUN test and they normally are in a 1:20  It is important for the nurse to stay current with the American Heart Association’s guidelines for Basic Life Support (BLS) ratio. by being certified every two years as required. - Serum osmolality measures the concentration of particles in a solution. It refers to the fact that the same amount of solute is present, but the amount of solvent (fluid) is decreased. There-  If one rescuer is performing CPR, 1 15:2 ratio of compres- sion to ventilations is performed for 4 cycles, then reassess fore, the blood can be considered “more concentrated.” for breathing and pulse. If two rescuers are performing - Urine osmolality and specific gravity increase. CPR, a 15:2 ratio is now recommended for compressions to ventilations. Perform for 15 cycles with a 100/min compres-  Check the IV tubing container to determine the drip factor be- cause drip factors vary. The most common drip factors are sion rate. When trading off, start with compressions. 10, 12, 15, and 60 drops per milliliter. A microdrip is 60 drops per milliliter.  Initiate CPR with BLS guidelines immediately, then move on to Advanced Cardiac Life Support (ACLS) guidelines.  Flushing a saline lock requires approximately 1 ½ times the amount of fluid that the tubing will hold in order to efficiently  When significant arterial acidosis is noted, try to reduce PCO2 by increasing ventilation, which will correct arterial, flush the tubing. REMEMBER to use sterile technique to pre- venous, and tissue acidosis. Bicarbonate may exacerbate vent complications such as infiltration, emboli and infection. acidosis b producing CO2. Thus, the ACLS guidelines have recommended bicarbonate NOT be used unless hyper-  A pH of less than 6.8 or more than 7.8 is NOT COMPATIBLE WITH LIFE. kalemia and/or preexisting acidosis is documented.   Infants/prematures may have problems with the following that can predispose to arrest: Beware of the “H’s” – hypoxia, The acronym ROME can help you remember: Respiratory, Opposite, Metabolic, Equal. hypoglycemia, hypothermia, increased H+ (metabolic and/or respiratory acidosis), hypercoagulability (if polycythemia ex-  - Review the order of blood flow to the heart: Unoxygenated blood flows from the superior and inferior vena ists). cava into the right atrium, then to the right ventricle. It flows out of the heart through the pulmonary artery, to the lungs for  Changes is osmolarity cause shifts in fluid. The osmolarity of the extracellular fluid (ECF) is almost entriely due to oxygenation. The pulmonary vein delivers oxygenated blood sodium. The osmolarity of intracellular fluid (ICF) is related back to the left atrium, then to the left ventricle (largest, to many particles, with potassium being the primary elec- strongest chamber) and out the aorta. trolyte. The pressures in the ECF and the ICF are almost - Review the three structures that control the one-way flow of identical. If either ECF or ICF change in concentration, fluid blood through the heart: shifts from the area of lesser concentration to the area of 1. Valves Atrioventricular valves Tricuspid (right side) Mi- tral (left side) greater concentration. Semilunar valves Pulmonary (in pulmonary  Dextrose 10% is a hypertonic solution and should be admin- artery) Aortic (in aorta) istered IV. 2. Cordae Tendinae 3. Papillary muscles  Normal saline is an isotonic solution and is used for irriga- tions, such as bladder irrigations or IV flush lines with inter-  Since the T waves represents repolarization of the ventricle, this is a critical time in the heartbeat. This action represents a mittent IV medication. resting and regrouping stage so that the next heartbeat can occur. If defibrillation occurs during this phase, the heart can  Use only isotonic (neutral) solutions in irrigations, infusions, etc., unless the specific aim is to shift fluid into intracellular be thrust into a life-threatening dysrhythmia. or extracellular spaces.  Observe the client for tolerance of the current rhythm. This in - formation is the most important data the nurse can collect on  Potassium imbalances are potentially life-threatening, must be corrected immediately. A low magnesium often accompa- the client with an arrythmia. nies a low K+, especially with the use of diuretics.  REMEMBER to monitor the client as well as the machine! If the EKG monitor shows a severe dysrhythmia, but the client is  - Fluid Volume Deficit: Dehydration Elevated BUN: The BUN measures the amount of urea nitro- sitting up quietly watching a TV without any sign of distress, gen in the blood. Urea is formed in the liver as the end assess to determine if the leads are attached properly. product of protein metabolism. The BUN is directly related to the metabolic function of the liver and the excretory func-  Marking the operative site is required for procedures involving right/left distinctions, multiple structures (fingers, toes), or lev- tion of the kidneys. Creatinine, as with BUN, is excreted entirely by the kidneys - els (spinal procedures). Site marking should be done with the and is therefore directly proportional to renal excretory func- involvement of the client. tion. However, unlike BUN, the creatinine level is affected very little by dehydration, malnutrition, or hepatic function.  Wound dehiscence is separation of the wound edges and is more likely to occur with vertical incisions. It usually occurs The daily production of creatinine depends on muscle mass, which fluctuates very little. Therefore, it is a better test of re- 2 after the early postoperative period, when the client’s own granulation tissue is “taking over” the wound, after absorp-  Narcotic analgesics are prepared for pain relief because they bind to the various opiate receptor sites in the CNS. Morphine tion of the sutures has begun. Evisceration of the wound is is often the preferred narcotic (REMEMBER: it causes respira- protrusion of intestinal contents (in an abdominal wound) tory depression). and is more likely in clients who are older, diabetic, obese, or malnourished and have prolonged paralytic ileus.  Other agonists are meperidine and methadone. Narcotic an- tagonists block the attachment of narcotics to the receptors,  NCLEX-RN items will focus on the nurse’s role in terms of such as Narcan (naloxone). Once Narcan has been given, the entire perioperative process. Sample: A 43-year old additional narcotics cannot be given until the Narcan effects mother of 2 teenage daughters enters the hospital to have have passed. her gallbladder removed in a same-day surgery using a scope instead of an incision. What nursing needs will domi-  Do not take away the coping style used in a crisis state…DE- NIAL. It is a useful and needed tool at the initial stage for nate each phase of her short hospital stay? Preparation phase: Education about postoperative care, - some. Support, do not challenge, unless it hinders/blocks NPO, assist with meeting family needs. treatment – endangering the patient. - Operative phase: Assessment, management of the operative suite. M EDICAL –SURGICAL NURSING - Post-anesthesia phase: Pain management, post-anesthesia precautions. R ESPIRATORY SYSTEM - Post-operative phase: Prevent and assess for complications, pain management, dietary restrictions, activity.  Fever can cause dehydration from excessive fluid loss in di- aphoresis. Increased temperature also increases metabolism  HIV clients with tuberculosis require respiratory isolation. and the demand for oxygen. Tuberculosis is the only real risk to non-pregnant caregivers that is not related to a break in universal precautions (i.e.,  - High risk for pneumonia: Any person, who has altered level of consciousness, has de- needle sticks, etc.). pressed or absent gag reflex and cough reflexes, is suscepti- ble to aspirating oropharyngeal secretions. (Alcoholics, anes-  - STANDARD PRECAUTIONS: Wash hands, even if gloves have been worn to give care thesized individuals, those with brain injury, drug overdose, or - Wear gloves (latex) for touching blood or body fluids, or any stroke victims). non-intact body surface. - When feeding, raise the head of the bed and position the - Wear gowns during any procedure that might generate client on side – not on back. splashes (changing clients with diarrhea). - Use masks and eye protection during activity which might  Bronchial breath sounds are heard over areas of density or consolidation. Sound waves are easily transmitted over con- solidated tissue. - disperse droplets (suctioning). Do not recap needles, dispose of in puncture-resistant con- tainers. Use mouth piece for resuscitation efforts. -  Hydration – enables liquification of mucous trapped in the bronchioles and alveoli, facilitating expectoration. Essential for the client experiencing fever. Important because 300 to - Refrain from giving care if you have open skin lesions.  Caregivers who are pregnant may choose not to care for a 400 ml of fluid are lost daily by the lungs through evaporation. client with Cytomegalovirus (CMV).  Irritability and restlessness are early signs of cerebral hypoxia – the client is not getting enough oxygen to the brain.  Pediatric HIV is often evidenced by lymphoid interstitial pneumonitis.  - Pneumonia preventatives: Elderly: flu shots; pneumonia immunizations; avoiding sources  The focus of NCLEX-RN questions is likely to be assess- ment of early signs of the disease and management of com- of infection and indoor pollutants (dust, smoke, and aerosols); plications associated with HIV. do not smoke. - Immunosuppressed and debilitated persons: infection avoid- ance, sensible nutrition, adequate intake, balance of rest and  For narcotic induced respiratory depression, administer Naloxone 0.1mg to 0.4mg IV every 2-3 minutes as needed, activity. until 1.0mg is achieved. - Comatose and immobile persons: elevate head of bed to feed; turn frequently.  Use non-invasive methods for pain management when pos- sible:  Compensation occurs over time in clients with chronic lung disease, and arterial blood gases (ABGs) are altered. It is im- - - Relaxation techniques Distraction perative that baseline data are obtained on the client. - Imagery - Biofeedback  Productive cough and comfort can be facilitated by Semi- Fowler’s or high Fowler’s positions, which lessen pressure on - - Interpersonal skills Physical care: altering positions, touch, hot and cold applica- the diaphragm from abdominal organs. Gastric distention be- tions. 3  Tracheostomy care involves cleaning the inner cannula, suc- tioning, and applying a clean dressing. comes a priority in these clients because it elevates the di- aphragm and inhibits lung expansion.  Air entering the lungs is humidified along the naso-bronchial tree. This natural humidifying pathway is gone for the client  Pink puffer: Barrel chest is indicative of emphysema and is caused by use of accessory muscles to breathe, which who has had a laryngectomy. If the air is not humidified be- causes the person to work harder to breathe, but the amount fore entering the lungs, secretions tend to thicken and become of O2 taken in in adequate to oxygenate the tissues. crusty.  A laryngectomy tube has a larger lumen and is shorter than the tracheostomy tube. Observe the client for any signs of  Blue bloater: insufficient oxygenation occurs with chronic bronchitis and leads to generalized cyanosis and often right- bleeding or occlusion, which are the greatest immediate post- sided heart failure. operative risks (first 24 hours).  Cells of the body depend on oxygen to carry out their func- tions. Inadequate arterial oxygenation is manifested by  Fear of choking is very real for laryngectomy clients. They cannot cough as before because the glottis is gone. Teach cyanosis and slow capillary refill (3 seconds). A chronic sign is clubbing of the fingernails, and a late sign is clubbing the “glottal stop” technique to remove secretions (take a deep of the fingers. breath, momentarily occlude the tracheostomy tube, cough, and simultaneously remove the finger from the tube).  Caution must be used in administering O2 to COPD client. The stimulus to breathe is hypoxia (hypoxic drive) not the  TB SKIN TEST: a positive TB skin test is exhibited by an in- duration 10mm or greater in diameter 48 hours after skin test. usual hypercapnia, the stimulus to breathe for healthy per- sons. Therefore, if too much oxygen is given, the client may Anyone who has received a BCG vaccine will have a positive stop breathing! skin test and must be evaluated using a chest x-ray.   - Health Promotion: Eating consumes energy needed for breathng. Offer me- Teaching is very important with the TB client. Drug therapy is usually long term (9 months or longer). It is essential that the chanically soft diets, which do not require as much chewing client take the medications as prescribed for the entire time. and digestion. Assist with feeding if needed. Skipping doses or prematurely terminating the drug therapy - Prevent secondary infections – avoid crowds, contact with can result in a public health hazard. persons who have infectious diseases, and respiratory irri- tants (tobacco smoke).  - TEACHING POINTS – Rifampin: Reduces effectiveness of oral contaceptives; should - Teach client to report any change in characteristics of spu- tum. use other birth control methods during treatment; gives body - Encourage client to hydrate well and to obtain immuniza- fluids orange tinge; stains soft contacts. tions needed (flu and pneumonia). - Isoniazid (INH): Increases Dilantin levels. - Ethambutal: Vision check before starting therapy and monthly; may have to take 1 to 2 years longer.  - When asked to prioritize nursing actions, use the ABC rule: Airway first - Teach rationale for combination drug therapy to increase com- - Then breathing pliance. Resistance develops more slowly if several anti-TB - Then circulation drugs given, instead of just one drug at a time.   Look and listen. If breath sounds are clear, but the client is cyanotic and lethargic, adequate oxygenation is not occur- Some tumors are so large that they fill entire lobes of the lung. When removed, large spaces are left. Chest tubes are not ring. usually used with these clients because it is helpful if the me- diastinal cavity, where the lung used to be, fills up with fluid. This fluid helps prevent a shift of the remaining chest organs  The key to respiratory status assessment of breath sounds as well as visualization of the client. Breath sounds are bet- to fill the empty space. ter “described,” not named, e.g., sounds should be de- scribed as “crackles,” “wheeze,” “hihg-pitched whistling  If the chest tube remains disconnected, do not clamp! Imme- diately place the end of the tube in a container of sterile saline sound,” rather than “rales,” “rhonchi,” etc., which may not mean the same thing to each clinical professional. or water until a new drainage system can be connected.   Watch for NCLEX-RN questions that deal with oxygen deliv- ery. In adults, O2 must bubble through some type of water If the chest tube is accidentally removed from the client, the nurse should apply pressure immediately with an occlusive solution so it can be humidified if given at 4 L/min or deliv- dressing and notify the healthcare provider. ered directly to the trachea. If given at 1 to 4 L/min or by mask or nasal prongs, the oropharynx and nasal pharynx  Chest Tube NCLEX-RN content: Fluctuations (tidaling) in the fluid will occur if there is no external suction. These fluctuat- provide adequate humidification. ing movements are a good indicator that the system is intact and should move upward with each inspiration and downward  With cancer of the larynx, the tongue and mouth often ap- pear white, gray, dark brown, or black, and may appear with each expiration. If fluctuations cease, check for kinked patchy. tubing, accumulation of fluid in the tubing, occlusions, or change in the client’s position, since expanding lung tissue 4  Clients with renal failure retain sodium. With water retention, the sodium becomes diluted and serum levels may appear may be occluding the tube opening. Remember, when ex- ternal suction is applied the fluctuations cease. Most hospi- near normal. With excessive water retention, the sodium lev- tals DO NOT MILK chest tubes as a means of clearing or els appear decreased dilution). Limit fluid and sodium intake preventing clots – it is too easy to remove chest tubes. Me- in ARF clients. diastinal tubes may have orders to be stripped because of location, compared to larger thoracic cavity tubes.  During oliguric phase, minimize protein intake. When the BUN and creatinine return to normal, aRF is determined to be  Various pathophysiological conditions can be related to the resolved. nursing diagnosis “Ineffective Breathing Patterns.” 1. Inability of air sacs to fill and empty properly (emphysema,  Accumulation of waste products from protein metabolism is the primary cause of uremia. Protein must be restricted in cystic fibrosis) Obstruction of the air passages (carcinoma, asthma, chronic 2. CRF clients. However, if protein intake is inadequate, a nega- bronchitis) tive nitrogen balance occurs causing muscle wasting. The 3. Accumulation of fluid in the air sacs (pneumonia) glomerular filtration rate (GFR) is most often used as an indi- 4. Respiratory muscle fatigue (COPD, pneumonia) cator of level of protein consumption. RENAL SYSTEM  - DIALYSIS COVERED BY MEDICARE: All persons in the United States are eligible for Medicare as of  Normally, kidney excrete approximately 1ml of urine per kg their first day of dialysis under special End Stage Renal Dis- of body weight per hour, which is about 1 to 2 liters in a 24- ease funding. hour period. - Medicare card will indicate ESRD. - Transplantation is covered by Medicare procedure; coverage terminates six months postoperative if dialysis is no longer re-  Electrolytes are profoundly affected by kidney problems. There must be a balance between extracellular fluid and in- quired. tracellular fluid to maintain homeostasis. A change in the number of ions or in the amount of fluid will cause a shift in  Protein intake is restricted until blood chemistry shows ability to handle protein catabolites: urea, creatinine. Ensure high one direction or the other. Sodium and chloride are the pri- mary extracellular ions. Potassium and phosphate are the calorie intake so protein is spared for its own work: give hard primary intracellular ions. candy, jelly beans, flavored carbohydrate powders.   In some cases, persons in ARF may not experience the olig- uric phase but may progress directly to diuretic phase during As kidneys fail, medications must often be adjusted. Of partic- ular importance is digoxin toxicity since digitalis preparations which the urine output may be as much as 10 liters per day. are excreted by the kidneys. Signs of toxicity in adults include nausea, vomiting, anorexia, visual disturbances, restlessness, headache, cardiac arrythmias, and pulse 60 beats per  Body weight is a good indicator of fluid retention and renal status. Obtain accurate weights on all clients with renal fail- minute (bradycardia). ure – done on the same scale at the same time every day.  The major difference between dailysate for hemodialysis and peritoneal dialysis is the amount of glucose. Peritoneal dialy- sis dialysate is much higher in glucose. For this reason, if the   - Fluid Volume Alterations Fluid Excess symptoms: Dyspnea dialysate is left in the peritoneal cavity too long, hyperglycemia - Tachycardia may occur. - Jugular vein distention - Peripheral edema  The key to resolving UTI with most antibiotics is to keep the blood level of the antibiotic constant. It is important to tell the client to take the antibiotics round-the-clock and not skip -  - Pulmonary edema Fluid deficit symptoms: Decreased urine output doses so that a consistent blood level can be maintained for - Reduction in body weight optimal effectiveness. - Decreased body turgor - Dry mucous membranes  - Location of the pain can help determine location of the stone. Flank pain usually means the stone is in the kidney or upper - - Hypotension Tachycardia ureter. If it radiates in the abdomen or scrotum, the stone is - likely to be in the ureter or bladder. Excruciating, spastic-type pain is called colic.  Watch for signs of hyperkalemia: dizziness, weakness, car- diac irregularities, muscle cramps, diarrhea, and nausea. - During kidney stone attacks, it is preferable to administer pain medications at regularly scheduled intervals rather than PRN to prevent spasm and optimize comfort.  Potassium has a critical safe range (3.5 to 5.0 mEg/L) be- cause it affects the heart, and any imbalance must be cor- rected by medications or dietary modification. Limit high  Percutaneous nephrostomy: A needle/catheter is inserted through the skin into the calyx of the kidney. The stone may potassium foods (bananas, avocados, spinach, fish) and salt substitutes, which are high in potassium. be dissolved by percutaneous irrigation with a liquid which will dissolve the stone, or ultrasonic sound waves (lithotripsy) can 5  Remember the risk factors for hypertension: heredity, race, age, alcohol abuse, increased salt intake, obesity, and use of be directed through the needle/catheter to break up the stone which then can be eliminated through the urinary tract. oral contraceptives.  Bladder spasms frequently occur after TURP. Inform the  The number one cause of CVA with hypertensive clients is client that the presence of the oversized balloon on the non-compliance with medication regime. Hypertension is of- catheter (30 to 45 cc inflate) will cause a continuous feeling ten symptomless, and antihypertensive medications are ex- of needing to void. The client should not try to avoid around pensive and have side effects. Studies have shown that the the catheter since this can precipitate bladder spasms. more clients know about their antihypertensive medications, Medications to reduce or prevent spasms should be given. the more likely they are to take them – teaching is important.  Instillation of hypertonic or hypotonic solution into a body  Decreased blood flow results in diminished sensation in the cavity will cause a shift in cellular fluid. Use only sterile lower extremities. Any heat source can cause severe burns saline for bladder irrigation after TURP since the irrigation before the client actually realizes the damage is being done. must be isotonic to prevent fluid and electrolyte imbalance.  A client is admitted with severe chest pain and states that he  Inform the client prior to discharge that some bleeding is ex- feels a terrible, tearing sensation in his chest. He is diag- pected after TURP. Large amounts of blood or frank bright nosed with a dissecting aortic aneurysm. What assessment bleeding should be reported. However, it is normal for the should the nurse obtain in the first few hours? client to pass small amounts of blood during the healing - Vital signs q1 hour process as well as small clots. He should rest quietly and - Neurological vital signs continue drinking large amounts of fluid. - Respiratory status - Urinary output C ARDIOVASCULAR SYSTEM - Peripheral pulses  What is the relationship of the kidneys to the cardiovascular  During aortic aneurysm repair, the large arteries are clamped system? for a period of time and kidney damage can result. Monitor - The kidneys filter about a liter of blood per minute daily BUN and creatinine levels. Normal BUN is 10 to 20 - If cardiac output is decreased, the amount of blood going mg/dl and normal creatinine is 20:1. When this ratio increases through the kidneys is decreased; urinary output is de- or decreases, suspect renal problems. creased. Therefore, a decreased urinary output may be a sign of cardiac problems.  A positive Homen’s sign is considered an early indication of - When the kidneys produce and excrete 0.5 ml of urine per thrombophlebitis. However, it may also indicate muscle in- kg of body weight or average 30 ml/hr output, the blood sup - flammation. If a deep vein thrombosis has been confirmed, a ply is considered to be minimally adequate to perfuse the vi- Homan’s sign should not be elicited because of the increased tal organs. risk of embolization.  Angina is caused by myocardial ischemia. Which cardiac  Heparin prevents conversion of fibrinogen to fibrin and pro- medications would be appropriate for acute angina? thrombin to thrombin, thereby inhibiting clot formation. Since - Digoxin – Not appropriate – Increases the strength and con- the clotting mechanism is prolonged, do not cause tissue tractility of the heart muscle; the problem in angina is that trauma which may lead to bleeding when giving heparin sub- the muscle is not receiving enough oxygen. Digoxin will not cutaneously. Do not massage area or aspirate; give in the ab - help. domen between the pelvic bones; 2 inches from umbilicus; ro- - Nitroglycerin – Appropriate – Causes dilation of the coronary tate sites. arteries, allowing more oxygen to get to the heart muscle. - Atropine – Not appropriate – Increases heart rate by block-  HEPARIN: ing vagal stimulation, which suppresses the heart rate. - Antagonist: Protamine Sulfate Does not address the lack of O2 to the heart muscle. - LAB: PTT or APTT determines efficacy - Propanolol (Inderal) – Not appropriate – for acute angina at- - Keep 1.5 to 2.5 times normal control tack; however, is appropriate for long-term management of stable angina because it acts as a beta-blocker to control  COUMADIN: vasoconstriction. - Antagonist: Vitamin K - LAB: PT determines efficacy  Blood pressure is created by the difference in the pressure - Keep 1.5 to 2.5 times normal control of the blood as it leaves the heart and the resistance it meets flowing out to the tissues. Therefore, any factor that  INR: Desirable therapeutic level usually 2 to 3 seconds (re- alters cardiac output or peripheral vascular resistance will al- flects how long it takes a blood sample to clot). ter blood pressure. Diet and exercise, smoking cessation, weight control, and stress management can control many  A holter monitor offers continuous observation of the client’s heart rate. To make assessment of the rhythm strips, most factors that influence the resistance blood meets as it flows from the heart. meaningful, teach the client to keep a record of: - Medication times and doses - Chest pain episodes – type and duration 6 - - Valsalva maneuver (straining at stool, sneezing, coughing) Sexual activity  A Fowler’s or semi-Fowler’s position is beneficial in reducing the amount of regurgitation as well as preventing the en- - Exercise croachment of the stomach tissue upward through the open- ing in the diaphragm.  Cardioversion is the delivery of synchornized electrical shock to the myocardium.  Stress can cause or exacerbate ulcers. Teach stress reduc- tion methods and encourage those with a family history of ul-  Differentiate in synchronous and asynchronous pacemakers: cers to obtain medical surveillance for ulcer formation. - Synchronous or demand pacemaker fires only when the client’s heart rate falls below a rate set on the generator.  - CLINICAL MANIFESTATIONS OF GI BLEEDING: Pallor: conjuctival, mucous membranes, nail beds - Asynchronous or fixed pacemaker fires at a constant rate. - - Dark, tarry stools Bright red or coffee-ground emesis  Restricting sodium reduces salt and water retention, thereby reducing vascular volume and preload. - Abdominal mass or bruit - Decreased BP, rapid pulse, cool extremities (shock).  - DIGITALIS: Side effects of digitalis are increased when the client is hy-  The GI tract usually accounts for only 100 to 200 ml fluid loss per day, although it filters up to 8 liters per day. Large fluid pokalemic. Has a negative chronotropic effect, i.e., it shows the heart - losses can occur if vomiting and/or diarrhea exists. rate. Hold the digitalis if the pulse rate is 60, 120, or has markedly changed rhythm.  Opiate drugs tend to depress gastric motility. However, they should be given with care, and those receiving them should be - Bradycardia, tachycardia, or dysrhythmias may be signs of digitalis toxicity: these signs include nausea, vomiting, and closely monitored because a distended intestinal wall accom- headache in adults. panied by decreased muscle tone may lead to intestinal perfo- - If withheld, consult with physician. ration.   Infective endocarditis damage to heart valves occurs with the growth of vegetative lesions on valve leaflets. These le- Diverticulosis is the presence of pouches in the wall of the in- testine. There is usually do discomfort, and the problem goes sions pose a risk of embolization; erosion/perforation of the unnoticed unless seen on radiological examination (usually valve leaflets; or abscesses within adjacent myocardial tis- prompted by some other condition). sue. Valvular stenosis or regurgitation (insufficiency), most commonly of the mitral valve, can occur depending upon the  Diverticulitis is an inflammation of the diverticula (punches), which can lead to perforation of the bowel. type of damage inflicted by the lesions, leading to symptoms of left – or right-sided heart failure.  A client admitted with complaints of severe lower abdominal pain, cramping, and diarrhea is diagnosed with diverticulitis.  Acute and Subacute Infective Endocarditis - There are 2 types of infective endocarditis: What are the nutritional needs of this client throughout recov- - Acute, which often affects individuals with previously normal ery? hearts and healthy valves, and carries a high mortality rate - Acute phase – NPO graduating to liquids. - Subacute, which typically affects individuals with preexisting - Recovery phase – no fiber or foods that irritate the bowel. conditions, such as rheumatic heart disease, mitral valve - Maintenance phase – high-fiber diet, with bulk-forming laxa- prolapse, or immunosuppression. Intravenous drug abusers tives to prevent pooling of foods in the pouches where they are at risk for both acute and subacute bacterial endocardi- can become inflamed. Avoid small, poorly digested foods tis. When this population develops Subacute Infective En- such as popcorn, nuts, seeds, etc. docarditis, the valves on the right side of the heart (tricuspid and pulmonic) are typically affected due to the introduction  - Bowel obstructions: Mechanical: due to disorders outside the bowel (hernia, adhe- of common pathogens which colonize on the skin (S. epider- mis and Candida) into the venous system. sions), due to disorders within the bowel (tumors, diverticuli- tis), or due to blockage of the lumen in the intestine (intussus- ception, gall stone).  Pericarditis – presence of a friction rub is an indication of pericarditis (inflammation of the lining of the heart). ST seg- - Non-mechanical: paralytic ileus, which does not involve any ment elevation and T wave inversion are also signs of peri- actual physical obstruction, but results from inability of the carditis. bowel itself to function.   With mitral valve stenosis, blood is regurgitated back into the left atrium from the left ventricle. In early period, there may Blood gas analysis will show alkalotic state if the bowel ob- struction is high in the small intestine where gastric acid is se- be no symptoms; but, as the disease progresses, the client creted. If the obstruction is in the lower bowel where base so- will exhibit excessive fatigue, dyspnea on exertion, orthop- lutions are secreted, the blood will be acidic. nea, dry cough, hemoptysis, or pulmonary edema. There will be a rumbling apical diastolic murmur, and atrial fibrilla-  A client admitted with complaints of constipation, thready stools and rectal bleeding over the past few months is diag- tion is common. GASTROINTESTINAL SYSTEM 7  Liver tissue is destroyed by hepatitis. Rest and adequate nu- trition are necessary for regeneration of liver tissue being de- nose with a rectal mass. What are the nursing priorities for this client? stroyed by the disease. Since many drugs are metabolized in - NPO the liver, drug therapy must be scrutinized carefully. Caution - NG tube (possibly an intestinal tube such as a Miller-Abbott) the client that recovery takes many months, and previously - IV fluids taken medications should not be resumed without the health- - Surgical preparations of bowel (if obstruction is complete) care provider’s directions. - Teaching (preoperative, nutrition, etc.)  Acute pancreatic pain is located retroperitoneally. Any en- largement of the pancreas causes the peritoneum to stretch  Diet recommended by the American Cancer Society to pre- vent bowel cancer: tightly. Therefore, sitting up or leaning forward will reduce the - Eat more cruciferous vegetables (from the cabbage family pain. such as broccoli, cauliflower, Brussels sprouts, cabbage, and kale).  Following an endoscopic retrogade cholangiopancreatography (ERCP), the client may feel sick. The scope is placed in the - - Increase fiber intake. Maintain average body weight gallbladder and the stones are crushed and left to pass on - Eat less animal fat. their own. These clients may be prone to pancreatitis.   AMERICAN CANCER SOCIETY RECOMMENDATIONS for early detection of Colon Cancer: Non-surgical management of the client with cholecystitis in- cludes: - A digital rectal examination every year after 40. - Low-fat diet - A stool blood test every year after 50. - Medications for pain and clotting if required - A sigmoidoscopy examination every 3 to 5 years after the - Decompression of the stomach via NG tube age of 50, based on the advice of a physician. E NDOCRINE SYSTEM  Cancer of the colon is the most common cancer in the US when considering men and women together. An early sign  Thyroid storm is a life-threatening event that occurs with un- controlled hyperthyroidism due to Grave’s disease. Symp- is the rectal bleeding. Encourage patients 50 years of age or older, or those with increased risk factors, to be screened toms include fever, tachycardia, agitation, anxiety, and hyper- yearly with fecal occult blood testing. Routine colonoscopy tension. at 50 is also recommended. - Primary nursing interventions include maintaining an airway and adequate aeration. Propylthiouracil (PTU) or methimazole (Tapazole) are antithy-  - CLINICAL MANIFESTATIONS OF JAUNDICE Yellow skin, sclera, and/or mucous membranes (bilirubin in - roid drugs used to treat thyroid storm. Propanolol (Inderal) skin) may be given to decrease excessive sympathetic stimulation. - Dark-colored urine (bilirubin in urine) - Chalky or clay-colored stools (absence of bilirubin in stools)  Post-operative thyroidectomy: be prepared for the possibility of laryngeal edema. Put a tracheostomy set at bedside along  Fetor hepaticus is a distinctive breath odor of chronic liver with oxygen and a suction machine; Ca++ gluconate easily disease. It is characterized by a fruity or musty odor which accessible. results from the damaged liver’s inability to metabolize and detoxify mercaptan which is produced by the bacterial  Normal serum calcium is 9.0 to 10.5 mEq/L. The best indica- tor of parathyroid problems is a decrease in the client’s cal- degradation of metionine, a sulfurous amino acid. cium compared to the preoperative value.  For treatment of ascities, paracentesis and peritoneovenous shunts (LaVeen and Denver shunts) may be indicated.  If two or more parathyroid glands have been removed, the chance of tetany increases dramatically:  Esophageal varices may rupture and cause hemorrhage. - Monitor serum calcium levels (9.0 to 10.5 mg/dl is normal Immediate management includes insertion of an esopha- range) gogastric balloon tamponade – a Blakemore-Sengstaken or - Check for tingling of toes, fingers, and around the mouth. Minnesota tube. Other therapies include vasopressors, vita- - Check for Chvostek’s sign (tap over the parotid gland and min K, coagulation factors, and blood transfusions. which for twitching of lip = positive) - Check Trousseau’s sign (carpopedal spasm after inflating BP cuff above systolic pressure = positive).  Ammonia is not broken down as usual in the damaged liver; therefore, the serum ammonia level rises.  Myxedema coma can be precipitated by acute illness, with- drawal of thyroid medication, anesthesia, use of sedatives, or  PROVIDE AN ENVIRONMENT CONDUCIVE TO EATING for clients who are anorexic and/or nauseated: hypoventilation (with the potential for respiratory acidosis and - Remove strong odors immediately; they can be offensive carbondioxide narcosis). The airway must be kept patent, and and increase nausea. ventilator support as indicated. - Encourage client to sit up for meals; this can decrease the propensity to vomit.  Many people take steroids for a variety of conditions. NCLEX- RN questions often focus on the need to teach clients the im- - Serve small, frequent meals. 8  In the joint, the normal cartilage becomes soft, fissures and pitting occur, and the cartilage thins. Spurs form and inflam- portance of precisely following the prescribed regimen. They should be cautioned against suddenly stopping the mation sets in. The result is deformity marked by immobility, medications and be informed that it is necessary to taper off pain, and muscle spasm. The prescribed treatment regimen taking steroids. is corticosteroids for the inflammation; splinting, immobiliza- tion, and rest for joint deformity; and NSAIDS for the pain.  ADDISON”S CRISIS IS A MEDICAL EMERGENCY: Brought on by sudden withdrawal of steroids or a stressful  Synovial tissues line the bone of the joints. Inflammation of this lining causes destruction of tissue and bone. Early detec- event (trauma, severe infection) Vascular Collpase: Hypotension and tachycardia occur; ad- - tion of rheumatoid arthritis can decrease the amount of bone minister IV fluids at rapid rate until stabilized. and joint destruction. Often the disease will go into remission. - Hypoglycemia: Administer IV glucose Decreasing the amount of bone and joint destruction will re- - ADMINISTER PARENTERAL HYDROCORTISONE: Essen- duce the amount of disability. tial for reversing the crisis. - ALDOSTERONE REPLACEMENT: Administer fludrocorti-  What activity recommendations should the nurse provide a client with rheumatoid arthritis? sone acetate(Florinef) PO (only available as oral prepara- tion) with simultaneous administration of salt (sodium chlo- - Do not exercise painful, swollen joints. ride) if client has a sodium deficit. - Do not exercise any joint to the point of pain. - Perform exercises slowly and smoothly; avoid jerky move- ments.  Teach clients to take steroids with meals to prevent gastric irritation. They should never skip doses. If they have nau- sea or vomiting for more than 12 to 24 hours, they should  NCLEX-RN questions often focus on the fact that avoiding sunlight is key in management of lupus erythematosus – this contact the physician. is what differentiates it from other connective tissue diseases.  Why do diabetics have trouble with wound healing? High blood glucose contributes to damage of the smallest ves-  Degenerative joint disease (DJD) and osteoarthritis are often described as the same disease, and indeed they both result in sels, the capillaries. This damage causes permanent capil- lary scarring, which inhibits the normal activity of the capil- hypertrophic changes in the joints. However, they differ in that lary. This phenomenon causes disruption of capillary elas- osteoarthritis is an inflammatory disease and DJD is charac- ticity and promotes problems such as diabetic retinopathy, terized by non-inflammatory degeneration of the joints. poor healing or breaks in the skin, cardiovascular abnormali- ties, etc.  Postmenopausal, thin, Caucasian women are at highest risk for development of osteoporosis. Encourage exercise, a diet  Glycosylated Hgb (Hgb A1C) high in calcium, and supplemental calcium. While TUMS is an - Indicates glucose control over previous 120 days (life of excellent source of calcium, it is also high in sodium and hy - RBC) pertensive or edematous individuals should seek another - Valuable measurement of diabetes control. source for supplemental calcium.  The main cause of fractures in the elderly, especially women, is osteoporosis. The main fracture sites seem to be hip, verte-  The body’s response to illness/stress is to produce glucose. Therefore, any illness results in hyperglycemia. bral bodies, and Colles’ fracture of forearm.   If in doubt whether the client is hyperglycemic or hypo- glycemic, treat for hypoglycemia. NCLEX-RN questions focus on safety precautions. Improper use of assistive devices can be very risky. When using a non- wheeled walker, the client should lift and move the walker for- ward, then take a step into it. The client should avoid scooting  - SELF-MONITORING BLOOD GLUCOSE (SMBG) Provides tight glucose control thereby decreasing the poten- the walker or shuffling forward into it which takes more energy tial for long-term complications and is less stable than a single movement. - Technique is specific to each meter if meter is used. - Monitor before meals, at bedtime, and any time symptoms  What type of fracture is more difficult to heal, an extra capsu- lar fracture (below the neck of the femur) or an intracapsular occur. Record results and report to healthcare provider at time of - fracture (in the neck of the femur)? visit. - The blood supply enters the femur below the neck of the fe- mur. Therefore, an intra-capsular fracture is much more M USCULOSKELETAL SYSTEM harder to heal and has a greater likelihood of necrosis since it is cut off from the blood supply.  A client comes to the clinic complaining of morning stiffness, weight loss, and swelling of both hands and wrists.  The risk of a fat embolism, a syndrome in which fat globules migrate into the bloodstream and combine with platelets to Rheumatoid arthritis is suspected. Which methods of as- sessment might the nurse use and which methods would the form emboli, is greatest in the first 36 hours after a fracture. It nurse not use? is more common in clients with multiple fractures, fractures of - Use inspection, palpation, and strength testing. long bones, and fractures of the pelvis. The initial symptom of - Do not use range of motion (this activity promotes pain be- a fat embolism is confusion due to hypoxemia (check blood cause ROM is limited). gases for PO2). Assess for respiratory distress, restlessness, 9 Without the lens, which becomes opaque with cataracts, light cannot be filtered and vision is blurred. irritability, fever, and petechiae. If an embolus is suspected, notify physician STAT, draw blood gases, administer oxygen, and assist with endotracheal intubation. When the cataract is removed, the lens is gone, making pre-  vention of falls important. If the lens is replaced with an im- plant, vision is better than if a contact lens is used (some vis-  In clients with hip fractures, thromboembolism is the most common complication. Prevention includes passive range of ual distortion) or if glasses are used (greater visual distortion – motion exercises, elastic stocking use, elevation of the foot everything has a curved shape). of the bed 25 degrees to increase venous return, and low- dose hepatin therapy.  The ear consists of three parts: the external ear, middle ear, and the inner ear. Inner ear disorders, or disorders of the sen-  Clients with fractures, casts, or edema to the extremities sory fibers going to the CNS., often are neurogenic in nature need frequent neurovascular assessment distal to the injury. and may not be helped with a hearing aid. External and mid- Skin color, temperature, sensation, capillary refill, mobility, dle ear problems (conductive) may result from infection, pain and pulses should be assessed. trauma or wax buildup. These types of disorders are treated more successfully with hearing aids.  Assess the “5 Ps” of neurovascular functioning: pain, pares- thesia, pulse, pallor and paralysis.  NCLEX-RN questions often focus on communicating with older adults who are hearing impaired.  Orthopedic wounds have a tendency to ooze more than other wounds. A suction drainage device usually accompa- - Speak in a low-pitched voice, slowly, and distinctly. nies the client to the postoperative floor. Check drainage of- - Stand in front of the person with the light source behind the ten. client. - Use visual aids if available.  A big problem after joint replacement is infection. N EUROLOGICAL SYSTEM  Fractures of bone predispose the client to anemia, espe- cially if long bones are involved. Check hemtocrit every 3 to 4 days to monitor erythropoiesis.  Use of the Glasgow Coma Scale eliminates ambiguous terms to describe neurologic status such as lethargic, stuporous, or obtunded. Instruct the client not to lift the leg upward from a lying posi- tion or to elevate the knee when sitting. This upward motion   Almost every diagnosis in the NANDA format is applicable, as severely neurologically impaired persons require total care.   can pop the prosthesis out of the socket. Immobile clients are prone to complications: skin integrity problems, formation of urinary calculi (may limit milk intake), and venous thrombosis (may be on prophylactic anticoagu- lants). Clients with an altered state of consciousness are fed by en- teral routes since the likelihood of aspiration with oral feedings is great. Residual feeding is the amount of previous feeding still in the stomach. The presence of 100 ml residual in adults usually indicates poor gastric emptying and the feeding should  The residual limb should be elevated on one pillow. If the residual limb (stump) is elevated too high, the elevation can be held. cause contracture. Paralytic ileus is common in comatose clients. Gastric tube aids in gastric decompression. NEUROSENSORY SYSTEM   Glaucoma is often painless and symptom-free. It is usually picked up as part of a regular eye exam. Any client on bedrest/immobilized must have range of motion exercises often and very frequent position changes. Do not leave the client in any one position for longer than 2 hours. Any position that decreases venous return is dangerous, i.e.,  Eye drops are used to cause pupil constriction since move- ment of the muscles to constrict the pupil also allows aque- sitting with dependent extremities for long periods. ous humor to flow out, thereby decreasing the pressure in the eye. Pilocarpine is often used. Caution client that vision  If temperature elevates, take quick measures to decrease it since fever increases cerebral metabolism and can increase may be blurred 1 to 2 hours after administration of pilo- carpine and adaptation to dark environments is difficult be- cerebral edema. cause of pupillary constriction (desired effect of the drug).  - Safety measures for immobilized clients: Prevent skin breakdown with frequent turning.  There is an increased incidence of glaucoma in the elderly population. Older clients are prone to problems associated - Maintain adequate nutrition. with constipation. Therefore, the nurse should assess these - Prevent aspiration with slow, small feedings or NG feedings. clients for constipation and postoperative complications as- - Monitor neurological signs to detect the first signs that in- sociated with constipation, and implement a plan of care di- tracranial pressure may be increasing. rected at prevention, and, if necessary, treatment for consti- - Provide range of motion exercises to prevent deformities. pation. - Prevent respiratory complications – frequent turning and posi- tioning for optimal drainage.  The lens of the eye is responsible for projecting light, which enters onto the retina so that images can be discerned. 10  Bedrest often relieves symptoms. Bladder and respiratory in- fections are often a recurring problem. Need for health pro-  Restlessness may indicate a return to consciousness but can also indicate anoxia, distended bladder, covert bleeding, motion teaching. or increasing cerebral anoxia. Do not over-sedate, and re- port any symptoms of restlessness.  Myasthenic crisis is associated with a positive edrophonium (Tensilon) test, while a cholinergic crisis is associated with a  The forces of impact influence the type of head injury. They negative test. include acceleration injury, which is caused by the head in motion, and deceleration injury, which occurs when the head  NCLEX-RN questions often focus on the features of Parkin- son’s disease – tremors (a coarse tremor of fingers and thumb stops suddenly. Helmets are a GREAT preventive measure for motorcyclists and bicyclists. on one hand which disappears during sleep and purposeful activity – also called “pill rolling”), rigidity, hypertonicity, and stooped posture. Focus: SAFETY!  Even subtle behavior changes, such as restlessness, irri- tability, or confusion, may indicate increased ICP.   CSF leakage carries the risk of meningitis and indicates a deteriorating condition. Because of CSF leakage, the usual An important aspect of Parkinson’s treatment is drug therapy. Since the pathophysiology involves an imbalance between signs of increased ICP may not occur. acetylcholines and dopamine, symptoms can be controlled by administering dopamine precursor (Levodopa).  Try not to use restraints; they only increase restlessness. AVOID narcotics since they mask level of responsiveness.  - CNS involvement related to cause of CVA: Hemorrhagic: caused by a slow or fast hemorrhage into the  Physical assessment should concentrate on respiratory sta- brain tissue – often related to hypertension. tus, especially in clients with injury at C-3 to C-5, as cervical - Embolytic: caused by a clot, which has broken away from plexus innervates diaphragm. some vessel and has lodged in one of the arteries of the brain, blocking the blood supply. It is often related to atherosclerosis (may happen again).  It is imperative to reverse spinal shock as quickly as possi- ble. Permanent paralysis can occur if a spinal cord is com- pressed for 12 to 24 hours.  Atrial flutter/fibrillation has a high incidence of thrombus for- mation following arrythmias due to turbulence of blood flow  A common cause of death after spinal cord injury is urinary through all valves/heart chambers. tract infection. Bacteria grow best in alkaline media, so keeping urine diluted ad acidic is prophylactic against infec-  A woman who had a stroke two days ago has left-sided paral- ysis. She has begun to regain some movement in her left tion. Also, keeping the bladder emptied assists in avoiding bacterial growth in urine, which is stagnated in the bladder. side. What can the nurse tell the family about the client’s re- covery period? The quicker movement is recovered, the better the prognosis  Benign tumors continue to grow and take up space in the confined area of the cranium causing neural and vascular - is for more or full recovery. She will need patience and under- compromise for the brain, increased intracranial pressure, standing from her family as she tries to cope with the stroke. and necrosis of brain tissue – even benign tumors must be Mood swings can be expected during the recovery period, and treated as they may have malignant effects. bouts of depression and tearfulness are likely.  Words that describe losses from CVA:  - Craniotomy post-operative medications: Corticosteroids to reduce swelling - Apraxia: inability to perform purposeful movements in the ab- - Agents and osmotic diuretics to reduce secretions (atropine, sence of motor problems. robinul) - Dysarthria: difficulty articulating - Agents to reduce seizures (phenytoin) - Dysphasia: impairment of speech and verbal comprehension - Prophylactic antibiotics - Aphasia: loss of the ability to speak - - Agraphia: loss of the ability to write Alexia: loss of the ability to read  Symptoms involving motor function usually begin in the up- per extremities with weakness progressing to spastic paraly- - Dysphagia: dysfunctional swallowing sis. Bowel and bladder dysfunction occurs in 90% of the cases. MS is more common in women. Progression is not  Steroids are administered after a stroke to decrease cerebral edema and retard permanent disability. H2 inhibitors are ad- “orderly.” ministered to prevent peptic ulcers.  Drug therapy for MS clients: ACTH, cortisone, Cytoxan, and other immunosuppressive drugs. Nursing implications for HEMATOLOGY/ONCOLOGY Physical symptoms occur as a compensatory mechanism when the body is trying to make up for a deficit somewhere in the system. For instance, cardiac output increases when he- moglobin levels drop below 7g/dl. ONLY use normal saline to flush IV tubing or to run with blood. NEVER add medications to blood products. TWO registered administration of these drugs should focus on prevention of infection. In clients with Myasthenia Gravis, be alert for changes in respiratory status – the most severe involvement may result in respiratory failure. 11  The major emphasis in nursing management of cancers of the reproductive tract is early detection. nurses should simultaneously check the physician’s pre- scription, client’s identity, and blood bag label.  The importance of teaching female clients how to do self- breast examination cannot be overemphasized. Early detec-  A 24-year old is admitted with large areas of ecchymosis on both upper and lower extremities. She is diagnosed with tion is related to positive outcomes. acute