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NSG223 EXAM 4 Blueprint
Medical-Surgical Nursing II (NSG 223)
Herzing University
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NSG 223 Medical Surgical Nursing II EXAM 4 STUDY GUIDE
Topic Location Student Notes
Glaucoma- Nursing Assessment “Increased Pressure within the eye” [optic nerve issue] front of eye NSG223.11. peripheral vision (tunnel vision)
Open Angle Glaucoma: Mild Pain & Gradual loss of peripheral vision (tunnel vision)
Closed Angle Glaucoma: Sudden/Severe/ Extreme Eye Pain [Medical Emergency]
At risk: African American, Age 60+, Corticosteroids
S&S [Halos around light, Headache, Eye Pain, Blurred Vision]
Glaucoma- Nursing Assessment NSG223.11.01 Dx: Tonometry Test (Normal IOP 10-21 mmHg) >21 HIGH
Glaucoma- Medical Treatment NSG223.11.01 Surgery: Laser Trabeculoplasty-Stabilize the optic nerve Peripheral Iridotomy- Drainage implants/shunts Pt needs to avoid coughing, sneezing, bending, Valsalva maneuvers, lifting, anticholinergics, Benadryl meds, wear sunglasses, during surgery 1 eye is tx at a time. Glaucoma- Pharmacologic Management
NSG223.11.01 Beta Blockers (Timolol)- DO NOT give to a pt with asthma or bradycardia, lowest dose 1st until you reach desired levels. Mannitol (Osmotic Diuretic)-Increase outflow to reduce IOP Pilocarpine: Causes HEADACHE Atropine- Dilates Pupils ½ hrs before eye exam. Causes Constriction Glaucoma- Nursing Management NSG223.11.01 Nasolacrimal Occlusion- Hold pressure over tear duct for 3- mins Teaching: Causes photobia wear sunglasses after, no driving after eye dilation exam, exam q1-2yrs Medication Administration NSG223.11.01 Shake drops 1st, tilt head back, index finger to hold down lower lid conjunctiva, 15 mins before putting in contacts. Wait 5-10 minutes between eyedrops Pilocarpine- Solution and gel Rx, eye drops 1st then after 5- 10mins gel drops. Drops are for daytime, Ointments are for night
Cataracts- Nursing Assessment “Cloud over lens leading to blurry vison r/t aging” [behind iris]
NSG223.11.
Risks- Smoking, Obesity, Diabetes, Not wearing Sunglasses S&S- Blurry vision, Astigmatism, Myopic shift-can’t see close, Sensitivity to light, Poor night vison, Color Changes, Halo, Diplopia
Surgical Nursing Management NSG223.11.02 Phacoemulsification-Most common “IOL Implants”. Small opening in eye to reach clouded lens, laser breaks lens to pieces, suction fragments, inserts new lens replacement Pre Op- CBC, ECG, Urinalysis, Hx **MD needs to know if pt has taken Tamsulosin “Flomax” it can cause intraoperative floppy disk syndrome. Discharge Teaching NSG223.11.02 Post Op- Wear eye shield at bedtime for 1 week, ABT, Tylenol monitor for increase in IOP. Macular Degeneration- Patient Education
“ Central vision changes r/t age, macular damage that effects the retina”
NSG223.11.
Risks: Genetics S&S Dark spots in central visions, Straight lines look curved, color less vivid. Wet- blood vessel leaks into retina causing swelling, bleeding into retina causing sudden or gradual vision loss. Vascular Endothelial Growth Factor [Vegf] binds to receptors signal that causes leaky blood vessels to form underneath the retina causing retina to become swollen and vison declines Abrupt onset- S&S: more damaging vision, words broke, straight lines curved Tx: Injection of medication Ranibizumab into eye (Vasoproliferation Ranibizumab “Lucentis”)
Dry- affects health of retina, metabolic product collects under retina causing gradual loss. Slow break down Tx: None
Teaching: Pt will do Amsler Grid at home they should monitor for a sudden onset or distortion in vision. Look at Grid 1 eye at
Management EMERGECNY: pt has low BP give bolus IV normal saline to raise BP Increase fluids 3,000ml in 24hrs, check sensations in lower extremities, quiet-dark room, antipyretics, protective eyewear, handwashing, avoid long periods of reading/computers. Report redness & irritation.
Meds: Bacterial IV abt broad spectrum, corticosteroids Dexamethasone before ABT Stroke- Clinical Manifestations Ischemic: Clots there are 5 DIFF TYPES (Most common) Hemorrhagic-Bleeds
S&S: Trouble speaking, paralysis or numbness, problems seeing in one or both eyes, sudden severe headache, psychological things like depression, hostility, lack of cooperation etc.. Hemorrhagic Stroke- 1st Sign SUDDEN SEVERE HEADACHES
Thrombotic Stroke: caused by atherosclerosis clot Lacunar strokes: Hypertension Embolic Stroke- A fib- traveling mass/clot lodged in the brain Blocked carotid artery
Stroke- Nursing Assessment NSG223.12.01 Face, speech, motor
Stroke Screening and Risk Factors NSG223.12.01 Dx: FIRST NON-CONTRAST CT SCAN <25 mins from the time pt comes in ED Labs: INR 2- Platelet 150,000-450, Glucose 90- Transient Ischemic Accident Risk Factors
NSG223.12.01 African American, 20-44yrs 35-64yrs dying from stroke Hemorrhagic Stroke- Nursing Assessment
NSG223.12.02 1 st sign SEVERE HEADACHE Change in LOC, N/V, weakness/numbness, seizures, loss of balance, dizzy, problems w/ speech & swallowing Delegation of Tasks to LPN NSG223.12.02 Interventions: Mobility & preventing joint deformities, prevent contractures, good alignments, nutrition, bowel and bladder Stable Pts only!
Hemorrhagic Stroke- Nursing Management
NSG223.12.02 Most common cause is aneurysm from high blood pressure Carotid artery- protein build up in smaller vessels in brain, 75yrs+. Precautions: BEDREST!!!! No straining, bed rest/laydown! Elevate HOB 15-30 degrees
Pharmacologic Treatment of Stroke NSG223.12.02 If bleeding is caused by anticoagulation (warfarin) INR may be corrected w/ fresh-frozen plasma and vitamin k Bed rest, SCD/s, Tylenol, Accucheck, Cooling blankets, Hemodialysis. Pharmacologic Treatment of Stroke NSG223.12.02 Monitor bp NOTIFY MD IF BLOOD PRESSURE IS HIGH, Hob 30 degrees, q2h, check cranial nerves, gag reflex, passive ROM
Ischemic Tx: Warfarin/Coumadin INR 2-3, do not use w/ patients’ w/ creatinine clearance of less than 15 ml/min TIA- aspirin/ clopidogrel Statins reduce cholesterol Antihypertensives “ACE” Lowers BP ONLY FOR ISHEMIC (FOR CLOTS) Thrombolytic Therapy- t-PA to be given within 60 minutes of the pt arriving to the ED, initiation within 3 hours Antidote= aminocaproic acid
Hemorrhagic- Vitamin K-reverse bleeding INR levels greater than 5 (too much warfarin) Cancer- Risk Factors NSG223.13.01 Smoking, Socioeconomic disparities, genetics, radiation, exposure to sunlight, industrial chemicals, asbestos, obesity, diet, hormonal imbalance Cancer Treatment Plans NSG223.13.
Cancer Preventions and Familial History
NSG223.13.
Cancer Prevention NSG223.13.01 Maintain healthy weight, exercise, limit sitting & lying down for long periods, limit processed & red meats, ear veggies & fruits daily, limit alcohol to 1 drink per day, whole grains. Primary-reducing risks [immunizations, Secondary screening & early detection, Tertiary- monitoring and preventing recurrence of the primary cancer
Nursing Care of the Terminally Ill Patient
NSG223.113.
Patient Coping of the Dying Process NSG223.13.
Hospice and Palliative Care NSG223.13.
Hospice and Palliative Care NSG223.13.
Hospice Management for the Terminally Ill Patient
NSG223.13.
Advanced Directives NSG223.13.
Cultural and Spiritual Care of the Terminally Ill Patient
NSG223.13.
Pharmacologic Management of the Terminally Ill Patient
NSG223.13.
Disease Process for the Actively Dying Patient
NSG223.13.
Pharmacologic Management of the Terminally Ill Patient
NSG223.13.
Pharmacologic Management of the Terminally Ill Patient
NSG223.13.
Stages of Grief NSG223.13.
Dysarthria (difficulty in speaking) or dysphasia (impaired speech), caused by paralysis of the muscles responsible for producing speech Aphasia, which can be expressive aphasia (inability to express oneself), receptive aphasia (inability to understand language), or global (mixed) aphasia. Apraxia (inability to perform a previously learned action), as may be seen when a patient makes verbal substitutions for desired syllables or words. hemianopsia (blindness in half of the visual field in one or both eyes) agnosia is the loss of the ability to recognize objects through a particular sensory system; it may be visual, auditory, or tactile.
Functions R Side paralysis= d/t damage or injury from left side of brain CAN’T SPEAK
R side of brain is creative side (emotions, attention, creativity) music, art, memory, jokes, solving everyday problems Right Side- YOU WILL HAVE LEFT SIDED WEAKNESS, LOGICAL ISSUES, confused, can’t see things on left side, poor ability to make decisions, short attention span, denial
L Side paralysis= less likely to have speech disturbances L side is Logical side (speaking, reading, writing, math, planning, analyzing) Left Side- YOU WILL HAVE RIGHT SIDED WEAKNESS, CREATIVE/EMOTIONAL ISSUES- right sided hemiplegia APHASIA, trouble understanding written words, math issues with seeing on the right side.
Whatever side stroke is on it affects the other side, Broca Area- Aphasia can’t express themselves or understand
1 st 15 Sensory
- Timolol can’t be taken with Asthma, Heart Failure or Bradycardia
- A pt with macular degeneration is preparing to eat lunch where should the food tray be? On peripheral side of his visual field
- Which of pt symptoms should the nurse report immediately to the MD? Sudden Onset of Severe Pain
- Closed Angle Glaucoma S&S- Nausea/Vomiting, Sudden Headache [Emergency]
- Open Angle Glaucoma- Gradual peripheral vision loss, often goes unnoticed until it is severe. “Silent thief of sight”
- Pt has a hx of closed angle glaucoma. What med should they avoid [anticholinergics] Ex: Atropine
- Pt reports having difficulty passing stool and reports constipation NOTIFY MD
- Wait 5-10 minutes between eye drops
- The slit lamp is helpful with detecting cataracts because it enlarges the front area of the eye so the Md can observe the cornea, iris & lens.
- Pt going for cataract surgery, notify MD if they report they are taking Tamsulosin” Flomax” medication
- Pt is Post Op for cataract surgery in right eye. Reeducate pt if the pt is laying on their right side. 1 st 14 Neuro
- Client has dysphagia and is at risk for aspiration, nurse should assist client with to a upright position and assist with meals
- Pt had thrombotic stroke, what priority assessment is most important? Neurological assessment [pupil size, pupillary response, verbal response, motor response]
- Pt has expressive aphasia and the intervention [PICTURE BOARD] is client driven for communication between client and staf
- Pt will only receive tPA for ischemic stroke [clot] NOT A HEMMORHAGIC STROKE [BLEED]
- Nurse is about to administer tPA to a pt who experienced an ischemic stroke, she should ask the time of the onset of the stroke.
- Pt has RIGHT sided brain damage from a stroke WHICH WILL AFFECT THE L SIDE Confusion on date and time, place, unilateral neglect, impulsive, short attention span
- LEFT sided brain damage. Aphasia, impaired math skills, issues w/ seeing on r side, depression and anger, agraphia
NSG223 EXAM 4 Blueprint
Course: Medical-Surgical Nursing II (NSG 223)
University: Herzing University
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