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NSG223 Exam 4 Study Guide
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 NSG223.11.01 Glaucoma-characterized by elevated IOP
The optic nerve damage is related to the IOP caused by congestion of aqueous humor in the eye.
RISK FACTORS Glaucoma African American race Cardiovascular disease Diabetes Family history of glaucoma Migraine syndromes Nearsightedness (myopia) Older age Previous eye trauma Prolonged use of topical or systemic corticosteroids Thin cornea
Pathophysiology
The direct mechanical theory suggests that high IOP damages the retinal layer as it passes through the optic nerve head. The indirect ischemic theory suggests that high IOP compresses the microcirculation in the optic nerve head, resulting in cell injury and death.
Assessment & Diagnostic Findings
The types of examinations used in glaucoma:
- Tonometry to measure the IOP
- Ophthalmoscopy to inspect the optic nerve
- Central visual field testing
Changes in the optic nerve related to glaucoma are
Pallor & cupping of the optic nerve disc.
The pallor of the optic nerve is caused by a lack of blood supply. Cupping is characterized by exaggerated bending of the blood vessels as they cross the optic disc, resulting in an enlarged optic
Family members should be encouraged to undergo examinations at least once every two years to detect glaucoma early
Medication Administration NSG223.11.
Cataracts- Nursing Assessment NSG223.11.02 A cataract is a lens opacity or cloudiness. Leading cause of blindness!
Clinical Manifestations
Painless, blurry vision Perceives those surroundings are dimmer, as if their glasses need cleaning Light scattering Person experiences reduced contrast sensitivity, sensitivity to glare, & reduced visual acuity.
Other effects include Myopic shift (return of ability to do close work [e., reading fine print] without eyeglasses)
Astigmatism (refractive error due to an irregularity in the curvature of the cornea) Monocular diplopia (double vision) Color changes as the lens becomes browner in color
Assessment & Diagnostic Findings
Decreased visual acuity is directly proportionate to cataract density.
The Snellen visual acuity test Ophthalmoscopy Slit-lamp biomicroscopic examination
Medical Management
Pts should be educated by primary providers about risk reduction strategies such as: Smoking cessation Weight reduction Optimal blood sugar control for pts w/diabetes Be advised to wear sunglasses outdoors to prevent early cataract formation
Macular Degeneration- Patient Education
NSG223.11.02 MD is characterized by tiny, yellowish spots called drusen beneath the retina
Macular degeneration is a progressive eye disease wherein the central portion of the retina gradually deteriorates.
Most people >60 years have at least a few small drusen, which are clusters of debris or waste material.
There are two types of AMD: the dry type & the wet type
Pathophysiology
2 ways: Via the bloodstream as a consequence of other infections By direct spread, such as might occur after a traumatic injury to the facial bones or secondary to invasive procedures
Complications include visual impairment, deafness, seizures, paralysis, hydrocephalus, & septic shock
Clinical Manifestations
Headache that usually is steady or throbbing & very severe as a result of meningeal irritation Fever that tends to remain high throughout the course of the illness.
Neck immobility: A stiff and painful neck (nuchal rigidity) can be an early sign, & any attempts at flexion of the head are difficult because of spasms in the muscles of the neck. Usually, the neck is supple, & the pt can easily bend the head & neck forward.
Positive Kernig sign: When the pt is lying w/ the thigh flexed on the ABD, the leg cannot be completely extended. When Kernig sign is bilateral, meningeal irritation is suspected.
Positive Brudzinski sign: When the pt's neck is flexed (after ruling out cervical trauma or injury), flexion of the knees & hips is produced; when the lower extremity of one side is passively flexed, a similar movement is seen in the opposite extremity Brudzinski sign is a more sensitive indicator of meningeal irritation than Kernig sign.
Photophobia (extreme sensitivity to light): This finding is common d/t irritation of the meninges, especially around the diaphragm sellae.
Skin lesions develop, ranging from a petechial rash w/ purpuric lesions to large areas of ecchymosis.
Disorientation and memory impairment are common early in the course of the illness.
Seizures may occur!!!
Dx tools!!!
Computed tomography (CT) scan is used to detect a shift in brain contents (which may lead to herniation) prior to a lumbar puncture in the pt w/ altered LOC, papilledema, neurologic deficits, new onset of seizure, immunocompromised state, or Hx of (CNS) disease.
Gram staining allows for rapid identification of the causative bacteria & initiation of appropriate ABX therapy.
Nursing Management
Instituting infection control precautions until 24 hrs after initiation of ABX therapy (oral and nasal discharge is considered infectious) Assisting w/ pn management d/t overall body aches & neck pn Assisting w/ getting rest in a quiet, darkened room Implementing interventions to Tx the elevated temperi, such as antipyretic agents & cooling blankets Encouraging the pt to stay hydrated either orally or peripherally Ensuring close neurologic monitoring
Other important components of nursing care include the following
Confusion or change in mental status Trouble speaking or understanding speech Visual disturbances Difficulty walking, dizziness, or loss of balance or coordination Sudden severe headache
Motor loss: Most common motor dysfunction is hemiplegia (paralysis of one side of the body, or part of it) caused by a lesion of the opposite side of the brain. Hemiparesis, or weakness of one side of the body, or part of it, is another sign.
Communication loss Most common cause of aphasia (inability to express oneself or to understand language)
Other problems 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 pt makes verbal substitutions for desired syllables or words.
Perceptual Disturbances Homonymous hemianopsia (blindness in half of the visual field in one or both eyes) may occur from stroke & may be temporary or permanent.
Sensory Loss
An agnosia is the loss of the ability to recognize objects through a particular sensory system; it may be visual, auditory, or tactile.
Assessment and Diagnostic Findings
Initial assessment focuses on airway patency, which may be compromised by loss of gag or cough reflexes & altered respiratory pattern; cardiovascular status (including blood pressure, cardiac rhythm & rate, carotid bruit); & gross neurologic deficits
Initial Dx test for a stroke is usually a non-contrast computed tomography (CT) scan!
Should be performed within 25 min or less from the time the pt presents to the (ED)
Managing Potential Complications
Adequate oxygenation begins w/ pulmonary care Maintenance of a patent airway, and administration of supplemental oxygen as needed. The importance of adequate gas exchange in these pts cannot be
shoulder while the pt is in bed?
Place a pillow in the armpit area when there is limited external rotation; this keeps the arm away from the chest. A pillow is placed under the arm, & the arm is placed in a neutral (slightly flexed) position, w/ distal joints positioned higher than the more proximal joints (i., the elbow is positioned higher than the shoulder & the wrist higher than the elbow).
This helps to prevent edema & the resultant joint fibrosis that will limit range of motion if the pt regains control of the arm
Positioning the Hand and Fingers. The fingers are positioned so that they are barely flexed. The hand is placed in slight supination (palm faces upward), which is its most functional position.
If the upper extremity is flaccid, a splint can be used to support the wrist & hand in a functional position. If the upper extremity is spastic, a hand roll is not used, because it stimulates the grasp reflex. In this instance, a dorsal wrist splint is useful in allowing the palm to be free of pressure. Every effort is made to prevent hand edema.
(OT) may be helpful in assessing the home environment & recommending modifications to help the pt become more independent.
What is F.A.S???
The American Stroke Association (2015) is promoting the F.A.S. campaign (Face drooping, Arm weakness, Speech difficulty, Time to call 9-1-1) to improve awareness of stroke & to expedite activation of EMS for stroke victims. It is critical to establish the time of onset of symptoms because this determines whether a pt meets the 4-hour eligibility window for thrombolytic Tx!!!
Hemorrhagic Stroke- Nursing Assessment
NSG223.12.
Clinical Manifestations
The conscious pt most commonly reports a severe headache.
Other symptoms that may be observed more frequently in pts w/ acute intracerebral hemorrhage (compared w/ ischemic stroke) are n/v, an early sudden change in LOC, & possibly seizures.
Unique characteristics would be: May be pain & rigidity of the back of the neck (nuchal rigidity) & spine d/t meningeal irritation Visual disturbances (visual loss, diplopia, ptosis) Tinnitus, dizziness, & hemiparesis may also occu
Assessment and Diagnostic Findings
Any Pt w/ suspected stroke should undergo a CT scan or MRI scan to determine the type of stroke, the size and location of the hematoma, & the presence or absence of ventricular blood & hydrocephalus.
A (CT) scan is usually obtained first because it can be done rapidly.
Cerebral angiography using the conventional method or CT (CTA) confirms the Dx of an intracranial aneurysm or AVM.
MONITORING AND MANAGING POTENTIAL COMPLICATIONS
Vasospasm.
Pt is assessed for signs of possible vasospasm: intensified headaches, a decrease in level of responsiveness (confusion, disorientation, lethargy), or evidence of aphasia or partial paralys, must be reported immediately.
Calcium channel blocker nimodipine should be given for prevention of vasospasm
Seizures.
Should a seizure occur, maintaining the airway & preventing injury are the primary goals. Medication therapy is initiated at this time.
Hydrocephalus.
A CT scan that indicates dilated ventricles confirms the Dx.
Acute hydrocephalus is characterized by sudden onset of stupor or coma & is managed w/ a ventriculostomy drain to decrease ICP. Symptoms of subacute & delayed hydrocephalus include gradual onset of drowsiness, behavioral changes, & ataxic gait.
A ventriculoperitoneal shunt is surgically placed to Tx chronic hydrocephalus. Changes in pt responsiveness are reported immediately.
Rebleeding.
HTN is the most serious & modifiable risk factor, which shows the importance of appropriate antihypertensive Tx
Symptoms of rebleeding include sudden severe headache, n/v, decreased LOC, & neurologic deficit. Rebleeding is confirmed by CT scan.
Bp is carefully maintained w/ meds.
Hyponatremia.
Pt's primary provider needs to be notified of a low serum sodium level that has persisted for 24 hrs or longer
Pharmacologic Treatment of Stroke NSG223.12. Pharmacologic Treatment of Stroke NSG223.12.
Cancer- Risk Factors NSG223.13. Risk factors: Hx of Viruses and Bacteria Human papillomavirus (HPV) lead to (cervical & head & neck cancers)
Hepatitis B virus (HBV) lead to (liver cancer)
Epstein-Barr virus (EBV) lead to (Burkitt lymphoma & nasopharyngeal cancer)
Physical Agents Physical factors associated w/ carcinogenesis include: Exposure to sunlight Radiation Chronic irritation or inflammation Tobacco carcinogens Industrial chemicals & asbestos
Genetics & Familial Factors
Lifestyle Factors Lifestyle factors, such as diet, obesity, & insufficient physical activity.
Hormonal Agents
describe many solid tumors
Cancer Surgical Treatment NSG223.13.01 The range of possible Tx goals include: Complete eradication of malignant disease (cure) Prolonged survival & containment of cancer cell growth (control) Relief of symptoms associated w/ the disease & improvement of quality of life (palliation)
Postoperatively, the nurse assesses pt responses to Sx & monitors the pt for possible complications, such as infection, bleeding, thrombophlebitis, wound dehiscence, fluid & electrolyte imbalance, & organ dysfunction. Pharmacologic Management of Cancer
NSG223.13.
Chemotherapy Effects NSG223.13. How it effects the entire body?
Gastrointestinal System
The most common side effects of chemotherapy are N/V, which may persist for 24 to 48 hours; delayed N/V may occur up to one wk after administration.
Hematopoietic System
Many chemotherapy agents cause some degree of myelosuppression (depression of bone marrow function), resulting in decreased WBCs (leukopenia), granulocytes (neutropenia), red blood cells (RBCs) (anemia), and platelets (thrombocytopenia) & increased risk of infection
NSG223 Exam 4 Study Guide
Course: Medical-Surgical Nursing II (NSG 223)
University: Herzing University
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