HESI MED SURG STUDY GUIDE - HEMATEMESIS INFORMATION NURSING PROCESSES

• Colon Cancer 10 o Greatest risk factors ▪ Ppl >50 y/o ▪ Fam hx (1st degree relative) ▪ Obesity ▪ Polyps ▪ Chronic IBD ▪ Dietslow in fiber, high in fat • Angina o Def: chest discomfort or pain that occurs when myocardial O2 demands exceed supply o When to call 911? ▪ After 3 pills/doses of nitroglycerin call 911 (doses = 5m apart) • Patient Education: o Teaching – show demonstration – gold standard ▪ Seizures: • Ease wife’s concerns – teach pt and fam what to expect when occurring, how long they should last, how to help dec anxiety • Def: uncontrolled electrical dischargesin brain • During: maintain airway, turn pt on side, nothing in mouth, support head • Urination o Signs of UTI ▪ Signs of infection, including fever and chills ▪ Urinary frequency, urgency, or dysuria ▪ Hematuria ▪ Pain at the costovertebral angle ▪ Elevated serum WBCs (>10,000) o Signs of STI/STD (p. 163) ▪ Overlap • Itching, weird discharge,sores • Blood Transfusion o Incapability signs (p. 29) ▪ What you’ll see if pt is rejecting transfusion 11 ▪ Chills, fever, low back pain, flushing, tachycardia, hypotension progressing to acute renal failure, shock, and cardiac arrest ▪ STOP transfusion, keep IV in (for admin of NS) • Abscess- On the face – check ABC o Have fever o Infection • TB Exposure - PPD o 5mm = normal (for general public) o 10mm = HC workers o 15mm = for ppl who’ve come from areas known to have active TB or live in close quarters of person c active TB (ex. nursing home, prison…) • External fixation o Foot pain d/o o Check pedal pulses (ensure circulation present) • Arterial leg ulcer o Cool extremity, dec/absent pulses,sharp pain that inc c walking and elevation, intermittent claudication (cramping pain) o Pt teaching: ▪ Look for wounds ▪ Proper foot care – call podiatrist for nail cutting • Know who’s more acute (prioritize) o Ex. pt that’s actively dying vs pt c sign laceration ▪ Going to go to laceration pt 1 st • Lightening strike o Priority nursing action = put pt on heart monitor • Signs of MI o Sweating Epigastric pain (3 days) o What EKG shows: ST segment elevation