Nursing Review 2

8/4/2019 Nursing Review 2

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Nursing Review 2Medical Surgical Nursing - A

Ana H. Corona, MSN, FNP-C

Nursing Clinical InstructorJune 2008

Nursing Review 2

Medical Surgical Nursing


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Abdominal Assessment

Abdominal assessment is performed in thefollowing order: inspection, auscultation,palpation, and percussion.

Abdominal assessment is performed in the following order: inspection, auscultation, palpation, andpercussion.


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Abdominal Distention The causes of abdominal distention are

represented by the six Fs:

Flatus Feces

Fetus Fluid Fat and Fatal malignant neoplasm

A patient who has abdominal distention as aresult of flatus can be treated with a carminativeenema (Harris flush).

The causes of abdominal distention are represented by the six Fs:

Flatus

Feces

Fetus

Fluid

Fat and

Fatal malignant neoplasm

A patient who has abdominal distention as a result of flatus can be treated with a carminative enema (Harrisflush).


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Abdominal Pain

The nurse should use Fowlers position for

a patient who has abdominal pain causedby appendicitis.

A patient who has abdominal painshouldnt receive an analgesic until the

cause of the pain is determined.

The nurse should use Fowlers position for a patient who has abdominal pain caused by appendicitis.

A patient who has abdominal pain shouldnt receive an analgesic until the cause of the pain is determined.


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Ace Inhibitors

Angiotensin-converting enzyme inhibitors inhibitthe enzyme that converts angiotensin I intoangiotensin II, which is a potent vasoconstrictor.

Through this action, they reduce peripheralarterial resistance and blood pressure.

Angiotensin-converting enzyme inhibitorsinclude captopril and enalapril maleate

(Vasotec).

Ace Inhibitors

Angiotensin-converting enzyme inhibitors inhibit the enzyme that converts angiotensin I into angiotensin II,which is a potent vasoconstrictor.

Through this action, they reduce peripheral arterial resistance and blood pressure.

Angiotensin-converting enzyme inhibitors include captopril and enalapril maleate (Vasotec).


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Acetaminophen

Acetaminophen - Tylenol overdose canseverely damage the liver.

The antidote for acetaminophen ismucomyst.

Acetaminophen

Acetaminophen - Tylenol overdose can severely damage the liver.

The antidote for acetaminophen is mucomyst.


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Acid Base Balance

Acid-base balanceis the bodys hydrogenion concentration, a measure of the ratio ofcarbonic acid to bicarbonate ions 1 part

carbonic acid to 20 parts bicarbonate isnormal.

Acidosis may cause insulin resistance.

In determining acidbase problems, thenurse should first note the pH.

Acid-base balance is the bodys hydrogen ion concentration, a measure of the ratio of carbonic acid to

bicarbonate ions 1 part carbonic acid to 20 parts bicarbonate is normal.Acidosis may cause insulin resistance.In determining acidbase problems, the nurse should first note the pH.


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Acid Base Balance

If its above 7.45, its a problem of alkalosis

If the pH is below 7.35, its a problem of

acidosis.

The nurse should next look at the partialpressure of arterial carbon dioxide PaCO2.

This is the respiratory indicator.

If the pH indicates acidosis and the PaCO2indicates acidosis as well greater than 45 mmHg, the source of the problem is respiration.

Its called respiratory acidosis.If its above 7.45, its a problem of alkalosisIf the pH is below 7.35, its a problem of acidosis.The nurse should next look at the partial pressure of arterial carbon dioxide PaCO2.This is the respiratory indicator.If the pH indicates acidosis and the PaCO2 indicates acidosis as well greater than 45 mm Hg, the source ofthe problem is respiration.Its called respiratory acidosis.


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Acid Base Balance

If the pH indicates alkalosis and thePaCO2 also indicates alkalosis (less than35 mm Hg), then theres a match, and the

source of the problem is respiration. This is called respiratory alkalosis.

If the PaCO2 is normal, then the nurse

should look at the bicarbonate (HCO3),which is the metabolic indicator, and notewhether its acidic (less than 22 mEq/L) oralkaline (greater than 26 mEq/L).

If the pH indicates alkalosis and the PaCO2 also indicates alkalosis (less than 35 mm Hg), then theres a

match, and the source of the problem is respiration.This is called respiratory alkalosis.If the PaCO2 is normal, then the nurse should look at the bicarbonate (HCO3), which is the metabolicindicator, and note whether its acidic (less than 22 mEq/L) or alkaline (greater than 26 mEq/L).


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Acid Base Balance

Determine which value the pH matches; itwill determine whether the problem ismetabolic acidosis or metabolic alkalosis.

If both the PaCO2 and HCO3 areabnormal, then the body is compensating.If the pH has returned to normal, the body

is in full compensation.

Determine which value the pH matches; it will determine whether the problem is metabolic acidosis ormetabolic alkalosis.If both the PaCO2 and HCO3 are abnormal, then the body is compensating. If the pH has returned tonormal, the body is in full compensation.


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AIDS

In a patient who has acquired immunodeficiencysyndrome, the primary purpose of drugs is toprevent secondary infections.

The antiviral agent zidovudine (Retrovir)

successfully slows replication of the humanimmunodeficiency virus, thereby slowing thedevelopment of acquired immunodeficiencysyndrome.

Early signs of acquired immunodeficiencysyndrome include fatigue, night sweats,enlarged lymph nodes, anorexia, weight loss,pallor, and fever.

In a patient who has acquired immunodeficiency syndrome, the primary purpose of drugs is to preventsecondary infections.The antiviral agent zidovudine (Retrovir) successfully slows replication of the human immunodeficiencyvirus, thereby slowing the development of acquired immunodeficiency syndrome.Early signs of acquired immunodeficiency syndrome include fatigue, night sweats, enlarged lymph nodes,anorexia, weight loss, pallor, and fever.AIDS


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AIDS

Interventions for the patient with acquiredimmunodeficiency syndrome include treatingexisting infections and cancers, reducing the riskof opportunistic infections, maintaining adequatenutrition and hydration, and providing emotionalsupport to the patient and family.

A patient who has acquired immunodeficiencysyndrome shouldnt share razors ortoothbrushes with others, but there are nospecial precautions for dinnerware or laundryservices.

Interventions for the patient with acquired immunodeficiency syndrome include treating existing infectionsand cancers, reducing the risk of opportunistic infections, maintaining adequate nutrition and hydration, andproviding emotional support to the patient and family.

A patient who has acquired immunodeficiency syndrome shouldnt share razors or toothbrushes with others,

but there are no special precautions for dinnerware or laundry services.


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Acute Alcohol Withdrawal

Acute alcohol withdrawal causes anorexia,insomnia, headache, and restlessness andescalates to a syndrome thats

characterized by agitation, disorientation,vivid hallucinations, and tremors of thehands, feet, legs, and tongue.

Acute alcohol withdrawal causes anorexia, insomnia, headache, and restlessness and escalates to asyndrome thats characterized by agitation, disorientation, vivid hallucinations, and tremors of the hands,

feet, legs, and tongue.


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Addisons Disease

Addisons disease is caused by

hypofunction of the adrenal gland and ischaracterized by fatigue, anemia, weight

loss, and bronze skin pigmentation.

Without cortisol replacement therapy, its

usually fatal.

Addisons disease is caused by hypofunction of the adrenal gland and is characterized by fatigue, anemia,

weight loss, and bronze skin pigmentation.Without cortisol replacement therapy, its usually fatal.


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Adrenalectomy

An adrenalectomy can decrease steroidproduction, which can cause extensiveloss of sodium and water.

A patient who has bilateral adrenalectomymust take cortisone for the rest of his life.

An adrenalectomy can decrease steroid production, which can cause extensive loss of sodium and water.A patient who has bilateral adrenalectomy must take cortisone for the rest of his life.


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Adult Respiratory DistressSyndrome

Patients with adult RDS can have highpeak inspiratory pressures.

The nurse should monitor these patients

closely for signs of spontaneouspneumothorax, such as acute deteriorationin oxygenation, absence of breath soundson the affected side, and crepitusbeginning on the affected side.

Adult Respiratory Distress SyndromePatients with adult RDS can have high peak inspiratory pressures.The nurse should monitor these patients closely for signs of spontaneous pneumothorax, such as acutedeterioration in oxygenation, absence of breath sounds on the affected side, and crepitus beginning on theaffected side.


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Afterload

Afterload is the force that the ventricle

must exert during systole to eject the

stroke volume.

It isventricular wall tension during systolicejection.

Its increased in patients who have septal

hypertrophy, increased blood viscosity,and conditions that cause blockage ofaortic or pulmonary outflow.

Afterload is the force that the ventricle must exert during systole to eject the stroke volume.It is ventricular wall tension during systolic ejection.Its increased in patients who have septal hypertrophy, increased blood viscosity, and conditions that cause

blockage of aortic or pulmonary outflow.


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Airway

If gagging, nausea, or vomiting occurswhen an airway is removed, the nurseshould place the patient in a lateral

position with the upper arm supported on apillow.

AirwayIf gagging, nausea, or vomiting occurs when an airway is removed, the nurse should place the patient in alateral position with the upper arm supported on a pillow.


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Airway Obstruction

The tongue is the most common airwayobstruction in an unconscious patient.

The primary postoperative concern ismaintenance of a patent airway.

The tongue is the most common airway obstruction in an unconscious patient.The primary postoperative concern is maintenance of a patent airway.


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Albumin

Albumin is a colloid that aids inmaintaining fluid within the vascularsystem.

If albumin were filtered out through thekidneys and into the urine, edema wouldoccur.

Albumin is a colloid that aids in maintaining fluid within the vascular system.If albumin were filtered out through the kidneys and into the urine, edema would occur.


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Alcohol Metabolism

Alcohol is metabolized primarily in theliver.

Smaller amounts are metabolized by the

kidneys and lungs. The body metabolizes alcohol at a fixedrate, regardless of serum concentration.

In an alcoholic beverage, proof reflects thepercentage of alcohol multiplied by 2.

For example, a 100-proof beveragecontains 50% alcohol.

Alcohol is metabolized primarily in the liver.Smaller amounts are metabolized by the kidneys and lungs.The body metabolizes alcohol at a f ixed rate, regardless of serum concentration.In an alcoholic beverage, proof reflects the percentage of alcohol multiplied by 2.For example, a 100-proof beverage contains 50% alcohol.


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Alcoholic

An alcoholic uses alcohol to cope with thestresses of life.

An alcoholic who achieves sobriety is calleda recovering alcoholicbecause no cure for

alcoholism exists. Chlordiazepoxide (Librium) is the drug of

choice for treating alcohol withdrawal

symptoms. The alcoholic patient receives thiamine to

help prevent peripheral neuropathy andKorsakoffs syndrome.

An alcoholic uses alcohol to cope with the stresses of life.An alcoholic who achieves sobriety is called a recovering alcoholic because no cure for alcoholism exists.Chlordiazepoxide (Librium) is the drug of choice for treating alcohol withdrawal symptoms.The alcoholic patient receives thiamine to help prevent peripheral neuropathy and Korsakoffs syndrome.


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Alcohol Withdrawal

Early signs and symptoms of alcoholwithdrawal include anxiety, anorexia,tremors, and insomnia.

They may begin up to 8 hours after thelast alcohol intake.

Treatment for alcohol withdrawal mayinclude administration of I.V. glucose for

hypoglycemia, I.V. fluid containingthiamine and other B vitamins, andantianxiety, antidiarrheal, anticonvulsant,and antiemetic drugs.

Early signs and symptoms of alcohol withdrawal include anxiety, anorexia, tremors, and insomnia.They may begin up to 8 hours after the last alcohol intake.Treatment for alcohol withdrawal may include administration of I.V. glucose for hypoglycemia, I.V. fluidcontaining thiamine and other B vitamins, and antianxiety, antidiarrheal, anticonvulsant, and antiemeticdrugs.


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Aldosterone

The primary function of aldosterone issodium reabsorption.

The primary function of aldosterone is sodium reabsorption.


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Aluminum Hydroxide

Constipation is a common adverse reactionto aluminum hydroxide.

The nurse should administer an aluminumhydroxide antacid at least 1 hour after anenteric-coated drug because it can causepremature release of the enteric-coateddrug in the stomach.

Aluminum hydroxide (Amphojel) neutralizesgastric acid.

Constipation is a common adverse reaction to aluminum hydroxide.The nurse should administer an aluminum hydroxide antacid at least 1 hour after an enteric-coated drugbecause it can cause premature release of the enteric-coated drug in the stomach.Aluminum hydroxide (Amphojel) neutralizes gastric acid.


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Alzheimers Disease

The diagnosis of Alzheimers disease is basedon clinical findings of two or more cognitivedeficits, progressive worsening of memory, andthe results of a neuropsychological test.

For a patient with Alzheimers disease, the

nursing care plan should focus on safetymeasures.

Factors that contribute to the death of patientswith Alzheimers disease include infection,

malnutrition, and dehydration.

The diagnosis of Alzheimers disease is based on clinical findings of two or more cognitive deficits,

progressive worsening of memory, and the results of a neuropsychological test.For a patient with Alzheimers disease, the nursing care plan should focus on safety measures. Factors that contribute to the death of patients with Alzheimers disease include infection, malnutrition, and

dehydration.


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Alzheimers Disease

The early stage of Alzheimers diseaselasts 2 to 4 years.

Patients have inappropriate affect,

transient paranoia, disorientation to time,memory loss, careless dressing, andimpaired judgment.

The symptoms of Alzheimers diseasehave an insidious onset.

The early stage of Alzheimers disease lasts 2 to 4 years.Patients have inappropriate affect, transient paranoia, disorientation to time, memory loss, carelessdressing, and impaired judgment.The symptoms of Alzheimers disease have an insidious onset.


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Ambulation

Before ambulating, a postoperative patientshould dangle his legs over the side of thebed and perform deep-breathing

exercises. Ambulation is the best method to prevent

postoperative atelectasis.

Other measures include incentivespirometry and turning, coughing, andbreathing deeply.

Before ambulating, a postoperative patient should dangle his legs over the side of the bed and performdeep-breathing exercises.Ambulation is the best method to prevent postoperative atelectasis.Other measures include incentive spirometry and turning, coughing, and breathing deeply.


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Aminoglycosides

Aminoglycosidesare natural antibioticsthat are effective against gram-negativebacteria.

They must be used with caution becausethey can cause nephrotoxicity andototoxicity.

Aminoglycosides are natural antibiotics that are effective against gram-negative bacteria.They must be used with caution because they can cause nephrotoxicity and ototoxicity.


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Amitriptyline

Tricyclic antidepressants such asamitriptyline (Elavil) shouldnt be

administered to patients with narrow-angle

glaucoma, benign prostatic hypertrophy, orcoronary artery disease.

Tricyclic antidepressants such as amitriptyline (Elavil) shouldnt be administered to patients with narrow -angle glaucoma, benign prostatic hypertrophy, or coronary artery disease.


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Amputation

For the first 24 hours after amputation, the nurse

should elevate the stump to prevent edema.

After an amputation, moist skin may indicatevenous stasis; dry skin may indicate arterial

obstruction. To promote venous return after an amputation, the

nurse should wrap an elastic bandage around thedistal end of the stump.

At discharge, an amputee should be able todemonstrate proper stump care and performstump-toughening exercises.

For the first 24 hours after amputation, the nurse should elevate the stump to prevent edema.After an amputation, moist skin may indicate venous stasis; dry skin may indicate arterial obstruction.To promote venous return after an amputation, the nurse should wrap an elastic bandage around the distalend of the stump.At discharge, an amputee should be able to demonstrate proper stump care and perform stump-tougheningexercises.


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Amputation After an amputation, the stump may shrink

because of muscle atrophy and decreasedsubcutaneous fat.

Immediately after amputation, patient careincludes monitoring drainage from thestump, positioning the affected limb,assisting with exercises prescribed by aphysical therapist, and wrapping and

conditioning the stump. The patient who has a lower limb

amputation should be instructed to assumea prone position at least twice a day.

After an amputation, the stump may shrink because of muscle atrophy and decreased subcutaneous fat.Immediately after amputation, patient care includes monitoring drainage from the stump, positioning theaffected limb, assisting with exercises prescribed by a physical therapist, and wrapping and conditioning thestump.

The patient who has a lower limb amputation should be instructed to assume a prone position at least twicea day.


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Analgesics

Full agonist analgesics include morphine,codeine, meperidine (Demerol),propoxyphene (Darvon), and

hydromorphone (Dilaudid).

Full agonist analgesics include morphine, codeine, meperidine (Demerol), propoxyphene (Darvon), andhydromorphone (Dilaudid).


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Anaphylaxis

The signs and symptoms of anaphylaxisare commonly caused by histaminerelease.

The signs and symptoms of anaphylaxis are commonly caused by histamine release.


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Anemia

Anemia can be divided into four groupsaccording to its cause: blood loss,impaired production of red blood cells

(RBCs), increased destruction of RBCs,and nutritional deficiencies.

Anemia can be divided into four groups according to its cause: blood loss, impaired production of red bloodcells (RBCs), increased destruction of RBCs, and nutritional deficiencies.


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Anesthetics

Mild reactions to local anesthetics mayinclude palpitations, tinnitus, vertigo,apprehension, confusion, and a metallic

taste in the mouth. Ultra-short-acting barbiturates, such as

thiopental (Pentothal), are used asinjection anesthetics when a short durationof anesthesia is needed such as outpatientsurgery.

Mild reactions to local anesthetics may include palpitations, tinnitus, vertigo, apprehension, confusion, and ametallic taste in the mouth.Ultra-short-acting barbiturates, such as thiopental (Pentothal), are used as injection anesthetics when ashort duration of anesthesia is needed such as outpatient surgery.


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Angina

Angina pectoris is characterized by substernalpain that lasts for 2 to 3 minutes.

The pain, which is caused by myocardialischemia, may radiate to the neck, shoulders, or

jaw; is described as viselike, or constricting; andmay be accompanied by severe apprehensionor a feeling of impending doom.

The nurse should instruct a patient with anginato take a nitroglycerin tablet before anticipatedstress or exercise or, if the angina is nocturnal,at bedtime.

Angina pectoris is characterized by substernal pain that lasts for 2 to 3 minutes.The pain, which is caused by myocardial ischemia, may radiate to the neck, shoulders, or jaw; is describedas viselike, or constricting; and may be accompanied by severe apprehension or a feeling of impendingdoom.

The nurse should instruct a patient with angina to take a nitroglycerin tablet before anticipated stress orexercise or, if the angina is nocturnal, at bedtime.


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Angina The primary difference between the pain of

angina and that of a myocardial infarction is itsduration. During an anginal attack, the cells of the heart

convert to anaerobic metabolism, whichproduces lactic acid as a waste product.

As the level of lactic acid increases, paindevelops.

A patient who has anginal pain that radiates orworsens and doesnt subside should be

evaluated at an emergency medical facility. A 12-lead electrocardiogram reading should be

obtained during a myocardial infarction or ananginal attack.

The primary difference between the pain of angina and that of a myocardial infarction is its duration.During an anginal attack, the cells of the heart convert to anaerobic metabolism, which produces lactic acidas a waste product.As the level of lactic acid increases, pain develops.A patient who has anginal pain that radiates or worsens and doesnt subside should be evaluated at anemergency medical facility.A 12-lead electrocardiogram reading should be obtained during a myocardial infarction or an anginal attack.


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ACE Inhibitors

Angiotensin-converting enzyme inhibitors, suchas captopril (Capoten) and enalapril (Vasotec),decrease blood pressure by interfering with the

renin-angiotensin-aldosterone system. Angiotensin-converting enzyme inhibitors

include captopril and enalapril maleate(Vasotec).

Angiotensin-converting enzyme inhibitors, such as captopril (Capoten) and enalapril (Vasotec), decreaseblood pressure by interfering with the renin-angiotensin-aldosterone system.Angiotensin-converting enzyme inhibitors include captopril and enalapril maleate (Vasotec).ACE Inhibitors


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Anorexia Nervosa

In a patient who has anorexia nervosa, thehighest treatment priority is correction ofnutritional and electrolyte imbalances.

Signs and symptoms of anorexia nervosa

include amenorrhea, excessive weight loss,lanugo, abdominal distention, and electrolytedisturbances.

Patients with anorexia nervosa or bulimia mustbe observed during meals and for some timeafterward to ensure that they dont purge whatthey have eaten.

In a patient who has anorexia nervosa, the highest treatment priority is correction of nutritional andelectrolyte imbalances.Signs and symptoms of anorexia nervosa include amenorrhea, excessive weight loss, lanugo, abdominaldistention, and electrolyte disturbances.Patients with anorexia nervosa or bulimia must be observed during meals and for some time afterward toensure that they dont purge what they have eaten.


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Antacids

Patients shouldnt take bisacodyl,

antacids, and dairy products all at thesame time.

Patients shouldnt take bisacodyl, antacids, and dairy products all at the same time.


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Antiarrhythmic Agents

Antiarrhythmic agents include quinidinegluconate (Quinaglute), lidocainehydrochloride, and procainamide

hydrochloride (Pronestyl).

Antiarrhythmic agents include quinidine gluconate (Quinaglute), lidocaine hydrochloride, and procainamidehydrochloride (Pronestyl).


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Antibiotics

Antibiotics arent effective against viruses,protozoa, or parasites.

Antibiotics that are given four times a day

should be given at 6 a.m., 12 p.m., 6 p.m.,and 12 a.m. to minimize disruption ofsleep.

I.V. antibiotic therapy is used to treat achild who has bacterial meningitis so thatthe drug will penetrate the blood-brainbarrier.

Antibiotics arent effective against viruses, protozoa, or parasites.Antibiotics that are given four times a day should be given at 6 a.m., 12 p.m., 6 p.m., and 12 a.m. tominimize disruption of sleep.I.V. antibiotic therapy is used to treat a child who has bacterial meningitis so that the drug will penetrate theblood-brain barrier.


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Anticholinergic Agents

Anticholinergic medication is administeredbefore surgery to diminish secretion ofsaliva and gastric juices.

Anticholinergic medication is administered before surgery to diminish secretion of saliva and gastric juices.


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Anticoagulants

Drugs that potentiate the effects of anticoagulantsinclude aspirin, chloral hydrate, glucagon,anabolic steroids, and chloramphenicol.

Excessive intake of vitamin K may significantlyantagonize the anticoagulant effects of warfarin(Coumadin). The patient should be cautioned toavoid eating an excessive amount of leafy greenvegetables.

Anticoagulants cant dissolve a formed thrombus.

A patient who is receiving anticoagulant therapyshould take acetaminophen instead of aspirin forpain relief.

AnticoagulantsDrugs that potentiate the effects of anticoagulants include aspirin, chloral hydrate, glucagon, anabolicsteroids, and chloramphenicol.Excessive intake of vitamin K may significantly antagonize the anticoagulant effects of warfarin (Coumadin).The patient should be cautioned to avoid eating an excessive amount of leafy green vegetables.Anticoagulants cant dissolve a formed thrombus.A patient who is receiving anticoagulant therapy should take acetaminophen instead of aspirin for painrelief.


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Antidiabetic Agents

Oral antidiabetic agents, such aschlorpropamide (Diabinese) and tolbutamide(Orinase), stimulate insulin release from beta

cells in the islets of Langerhans of thepancreas.

Oral hypoglycemic agents stimulate the

islets of Langerhans to produce insulin.

Antidiabetic AgentsOral antidiabetic agents, such as chlorpropamide (Diabinese) and tolbutamide (Orinase), stimulate insulinrelease from beta cells in the islets of Langerhans of the pancreas.Oral hypoglycemic agents stimulate the islets of Langerhans to produce insulin.


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Antiembolism Stockings

Antiembolism stockings decompress thesuperficial blood vessels, reducing the riskof thrombus formation.

Antiembolism stockings should be wornaround the clock, but should be removedtwice a day for 30 minutes so that skincare can be performed.

Antiembolism StockingsAntiembolism stockings decompress the superficial blood vessels, reducing the risk of thrombus formation.Antiembolism stockings should be worn around the clock, but should be removed twice a day for 30 minutesso that skin care can be performed.


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Antihistamines

The classic adverse reactions toantihistamines are dry mouth, drowsiness,and blurred vision.

AntihistaminesThe classic adverse reactions to antihistamines are dry mouth, drowsiness, and blurred vision.


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Antihypertensive Drugs

Antihypertensive drugs includehydralazine hydrochloride (Apresoline)and methyldopa (Aldomet).

Antihypertensive DrugsAntihypertensive drugs include hydralazine hydrochloride (Apresoline) and methyldopa (Aldomet).


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Antisocial Personality Disorder

A patient with antisocial personalitydisorder often engages in confrontationswith authority figures, such as police,

parents, and school officials.

Antisocial Personality DisorderA patient with antisocial personality disorder often engages in confrontations with authority figures, such aspolice, parents, and school officials.


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Anuria

Anuriais daily urine output of less than100 ml.

Anuria is daily urine output of less than 100 ml.


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Anxiety

Moderate anxiety decreases a persons ability toperceive and concentrate.

The person is selectively inattentive (focuses onimmediate concerns), and the perceptual fieldnarrows.

Anxiety is nonspecific; fear is specific.

Anxiety is the most common cause of chest

pain.

AnxietyModerate anxiety decreases a persons ability to perceive and concentrate. The person is selectively inattentive (focuses on immediate concerns), and the perceptual field narrows.Anxiety is nonspecific; fear is specific.Anxiety is the most common cause of chest pain.


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Aortic Stenosis

Signs and symptoms of aortic stenosisinclude a loud, rough systolic murmur overthe aortic area; exertional dyspnea;

fatigue; angina pectoris; arrhythmias; lowblood pressure; and emboli.

Aortic StenosisSigns and symptoms of aortic stenosis include a loud, rough systolic murmur over the aortic area; exertionaldyspnea; fatigue; angina pectoris; arrhythmias; low blood pressure; and emboli.


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Appendicitis

A sign of acute appendicitis, McBurneys sign is

tenderness at McBurneys point (about 2 inches

[5 cm] from the right anterior superior iliac spine

on a line between the spine and the umbilicus). The nurse should use Fowlers position for a

patient who has abdominal pain caused byappendicitis.

Signs of appendicitis include right abdominalpain, abdominal rigidity and reboundtenderness, nausea, and anorexia.

AppendicitisA sign of acute appendicitis, McBurneys sign is tenderness at McBurneys point (about 2 inches [5 cm] fromthe right anterior superior iliac spine on a line between the spine and the umbilicus).The nurse should use Fowlers position for a patient who has abdominal pain caused by appendicitis. Signs of appendicitis include right abdominal pain, abdominal rigidity and rebound tenderness, nausea, andanorexia.

A h th i


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Arrhythmias

Are the predominant problem during the first 48

hours after a myocardial infarction. For a patient with heart failure, one of the most

important nursing diagnoses is decreasedcardiac output related to altered myocardial

contractility, increased preload and afterload,and altered rate, rhythm, or electrical conduction.

A decrease in the potassium level decreases theeffectiveness of cardiac glycosides, increases

the possibility of digoxin toxicity, and can causefatal cardiac arrhythmias.

ArrhythmiasAre the predominant problem during the first 48 hours after a myocardial infarction.For a patient with heart failure, one of the most important nursing diagnoses is decreased cardiac outputrelated to altered myocardial contractility, increased preload and afterload, and altered rate, rhythm, orelectrical conduction.

A decrease in the potassium level decreases the effectiveness of cardiac glycosides, increases thepossibility of digoxin toxicity, and can cause fatal cardiac arrhythmias.


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Arterial Blood

Arterial blood is bright red, flows rapidly,and (because its pumped directly from theheart) spurts with each heartbeat.

Arterial blood gas analysis evaluates gasexchange in the lungs (alveolar ventilation)by measuring the partial pressures ofoxygen and carbon dioxide and the pH of

an arterial sample.

Arterial BloodArterial blood is bright red, f lows rapidly, and (because its pumped directly from the heart) spurts with eachheartbeat.Arterial blood gas analysis evaluates gas exchange in the lungs (alveolar ventilation) by measuring thepartial pressures of oxygen and carbon dioxide and the pH of an arterial sample.


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Arterial Disease

The difference between acute and chronicarterial disease is that the acute diseaseprocess is life-threatening.

Arterial Embolism An arterial embolism may cause pain, loss

of sensory nerves, pallor, coolness,paralysis, pulselessness, or paresthesia inthe affected arm or leg.

Arterial DiseaseThe difference between acute and chronic arterial disease is that the acute disease process is life-threatening.Arterial EmbolismAn arterial embolism may cause pain, loss of sensory nerves, pallor, coolness, paralysis, pulselessness, orparesthesia in the affected arm or leg.


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Arthritis

In a patient with arthritis, physical therapyis indicated to promote optimal functioning.

Arthrography Arthrography requires injection of a

contrast medium and can identify jointabnormalities.

ArthritisIn a patient with arthritis, physical therapy is indicated to promote optimal functioning.ArthrographyArthrography requires injection of a contrast medium and can identify joint abnormalities.

A it


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Ascites

Is the accumulation of fluid, containing largeamounts of protein and electrolytes, in theabdominal cavity. Its commonly caused bycirrhosis.

Ascites can be detected when more than500 ml of fluid has collected in theintraperitoneal space.

The nurse should place the patient withascites in the semi-Fowler position becauseit permits maximum lung expansion.

AscitesIs the accumulation of fluid, containing large amounts of protein and electrolytes, in the abdominal cavity. Itscommonly caused by cirrhosis.Ascites can be detected when more than 500 ml of fluid has collected in the intraperitoneal space.The nurse should place the patient with ascites in the semi-Fowler position because it permits maximumlung expansion.

A it


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Ascites

In a patient who has edema or ascites, theserum electrolyte level should be monitored.

The patient also should be weighed daily; havehis abdominal girth measured with a centimeter

tape at the same location, using the umbilicus as a checkpoint; have his

intake and output measured; and have his bloodpressure taken at least every 4 hours.

A patient who has cirrhosis of the liver andascites should follow a low-sodium diet.

In a patient who has edema or ascites, the serum electrolyte level should be monitored.The patient also should be weighed daily; have his abdominal girth measured with a centimeter tape at thesame location,using the umbilicus as a checkpoint; have his intake and output measured; and have his blood pressuretaken at least every 4 hours.A patient who has cirrhosis of the liver and ascites should follow a low-sodium diet.


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Aspirin

A patient should be advised to take aspirin on anempty stomach, with a full glass of water, andshould avoid acidic foods such as coffee, citrus

fruits, and cola. When using rotating tourniquets, the nurse

shouldnt restrict the blood supply to an arm or

leg for more than 45 minutes at a time.

A common symptom of salicylate (aspirin)toxicity is tinnitus (ringing in the ears).

AspirinA patient should be advised to take aspirin on an empty stomach, with a full glass of water, and shouldavoid acidic foods such as coffee, citrus fruits, and cola.When using rotating tourniquets, the nurse shouldnt restrict the blood supply to an arm or leg for more than45 minutes at a time.A common symptom of salicylate (aspirin) toxicity is tinnitus (ringing in the ears).


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Assault

Threatening a patient with an injection forfailing to take an oral drug is an exampleof assault.

AssaultThreatening a patient with an injection for failing to take an oral drug is an example of assault.


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Assessment Data Collection

Assessmentbegins with the nurses firstencounter with the patient and continuesthroughout the patients stay.

The nurse obtains assessment data through thehealth history, physical examination, and reviewof diagnostic studies.

A good way to begin a patient interview is to ask,What made you seek medical help?

Asking a patient an open-ended question is oneof the best ways to elicit or clarify information.

Assessment Data CollectionAssessment begins with the nurses first encounter with the patient and continues throughout the patientsstay.The nurse obtains assessment data through the health history, physical examination, and review ofdiagnostic studies.A good way to begin a patient interview is to ask, What made you seek medical help?Asking a patient an open-ended question is one of the best ways to elicit or clarify information.

Asthma


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Asthma

An asthma attack typically begins with wheezing,coughing, and increasing respiratory distress.

When caring for a patient who has had anasthma attack, the nurse should place the

patient in Fowlers or semi-Fowlers position. In a patient who is having an asthma attack,nursing interventions include administeringoxygen and bronchodilators as prescribed,

placing the patient in the semi-Fowler position,encouraging diaphragmatic breathing, andhelping the patient to relax.

URIs can trigger asthma attacks.

An asthma attack typically begins with wheezing, coughing, and increasing respiratory distress.When caring for a patient who has had an asthma attack, the nurse should place the patient in Fowlers orsemi-Fowlers position.

In a patient who is having an asthma attack, nursing interventions include administering oxygen andbronchodilators as prescribed, placing the patient in the semi-Fowler position, encouraging diaphragmaticbreathing, and helping the patient to relax.

URIs can trigger asthma attacks.

Asthm


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Asthma

Asthmais bronchoconstriction in responseto allergens, such as food, pollen, anddrugs; irritants, such as smoke and paintfumes; infections; weather changes;

exercise; or gastroesophageal reflux. The clinical manifestations of asthma are

wheezing, dyspnea, hypoxemia,

diaphoresis, and increased heart andrespiratory rate.

Asthma is bronchoconstriction in response to allergens, such as food, pollen, and drugs; irritants, such assmoke and paint fumes; infections; weather changes; exercise; or gastroesophageal reflux.The clinical manifestations of asthma are wheezing, dyspnea, hypoxemia, diaphoresis, and increased heartand respiratory rate.


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Ataxia

Ataxiais impaired ability to coordinatemovements. Its caused by a cerebellar or spinalcord lesion.

In ataxia caused by loss of position sense, vision

compensates for the sensory loss. The patient stands well with the eyes open, but

loses balance when theyre closed (positiveRomberg test result).

A patient with a disease of the cerebellum orposterior column has an ataxic gait thatscharacterized by staggering and inability toremain steady when standing with the feettogether.

Ataxia is impaired ability to coordinate movements. Its caused by a cerebellar or spinal cord lesion.In ataxia caused by loss of position sense, vision compensates for the sensory loss.The patient stands well with the eyes open, but loses balance when theyre closed (positive Romberg testresult).A patient with a disease of the cerebellum or posterior column has an ataxic gait thats characterized bystaggering and inability to remain steady when standing with the feet together.


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Atelectasis

Atelectasisis incomplete expansion of lungsegments or lobules.

It may cause the lung or lobe to collapse.

The best method to reduce the risk foratelectasis is to encourage the patient to walk.

Ambulation is the best method to preventpostoperative atelectasis.

Other measures include incentive spirometryand turning, coughing, and breathing deeply.

Atelectasis is incomplete expansion of lung segments or lobules.It may cause the lung or lobe to collapse.The best method to reduce the risk for atelectasis is to encourage the patient to walk.Ambulation is the best method to prevent postoperative atelectasis.Other measures include incentive spirometry and turning, coughing, and breathing deeply.


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Atherosclerosis

Atherosclerosis is the most commoncause of coronary artery disease.

It usually involves the aorta and the

femoral, coronary, and cerebral arteries.

The most common vascular complicationof diabetes mellitus is atherosclerosis.

Atherosclerosis is the most common cause of coronary artery disease.It usually involves the aorta and the femoral, coronary, and cerebral arteries.The most common vascular complication of diabetes mellitus is atherosclerosis.


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Autonomic Nervous System

The autonomic nervous system regulatesthe cardiovascular and respiratorysystems.

And controls the smooth muscles.

Nursing Review 2

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Transcript of Nursing Review 2