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SE5l, Medical-Surgical Review curse PowerPoint.

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Medical-Surgical Nursing
Certification Review

SE5l, Medical-Surgical Review curse PowerPoint.pdf

CMSRN Exam

Given four times a year


Spring (usually May)
Fall (usually October)
AMSN Annual Convention
(usually September)
Nursing 200x Symposium in the
Spring

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AMSN Nursing Practice Roles

Helping Role 17% (32-36)


Teaching/coaching role 17% (32-36)
Diagnostic and Patient Monitoring Role
25% (38-42)
Administering and Monitoring
Therapeutic Intervention 25% (58-62)

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AMSN Nursing Practice Roles

Effective Management of Rapidly


Changing Situations 10% (18-22)
Monitoring/Ensuring Quality Health
Care Practice 3% (4-7)
Organizational and Work-Role
Competencies 3% (4-7)

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Distribution Patient Problem

GI 19% (36-40)
Pulmonary 19% (36-40)
Cardiovascular 15% (28-32)
Diabetes/Other endocrine 15% (28-32)

SE5l, Medical-Surgical Review curse PowerPoint.pdf

Distribution Patient Problem

Renal/GU-12%(22-29)
Musculoskeletal/Neuro 11%
(20-24)
Hematological / Immune /
Integumentary 9% (16-20)

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Preparing for the Test


Medsurg Nursing Certification
Board Requirements CMSRN
credential
Minimum of 3,000 hours in Medsurg
nursing as a staff nurse, clinical nurse
specialist, clinical educator, faculty,
manager, or supervisor.

SE5l, Medical-Surgical Review curse PowerPoint.pdf

Practice in medical-surgical nursing


for at least two full years of the past
five years
Registered Nurse

SE5l, Medical-Surgical Review curse PowerPoint.pdf

Preparing for the Test


Contacting Medical- Surgical
Nursing Certification Board
MSNCB Home Office
East Holly Avenue, Box 56, Pitman, NJ
08071-0056
Phone: 856-256-2323 or Toll free 866877-2676
Fax: 856-589-7463 (fax)
E-mail: msncb@ajj.com
http://www.medsurgnurse.org
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Publications to review

Scope and Standards for MedicalSurgical Nursing Practice


ANA Code for Nurses
Human Rights Guidelines for Nurses in
Clinical and other Research

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Preparing for the Test

AMSN Core Curriculum for MedicalSurgical Nursing


Medical Surgical Nursing Review
Questions
Review Course
Examination Prep Guide
Your nursing experience

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Test Taking Tips

Read questions all the way through


Eliminate obvious wrong answers
Take moment to relax occasionally
Have good reason to change answers

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Stress Reduction

Review prior to exam, but dont cram


especially the night before (raises
stress levels making it more difficult)
Take time during the exam to take deep
breaths and relax.
You will have 4 hours to take the exam
which has 200 questions plenty of
time!

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A patient begins to experience a severe GI


bleed. The plan of care to meet the
patients fluid needs should include, as a
priority, planning for which of the following?

A. Provision for skin care


B. Monitoring vital signs frequently
C. Decreasing PH of gastric fluids
D. Rapid infusion of IV blood and fluids

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To prevent complications on the third day


after an uncomplicated acute MI, the nurse
would implement which action?
A. Monitor the patients ability to perform
activities of daily living without shortness
of breath
B. Accompany the patient ambulating for a
short distance at least each shift
C. Apply anti-embolic hose to the legs
D. Give the patient a nitroglycerin sublingual
to prevent chest pain before all out of bed
activities
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A patient is having a seizure activity. What


should the nurse do during this activity?
A. Insert an oropharyngeal airway
B. Promote safety of body systems
C. Protect the patients head on a pillow
D. Observe the length and after effects of the
seizure

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A patient in acute renal failure developed


acute pulmonary edema. Which of the
following interventions would be
inappropriate to include in the patients
care?
A. Administration of oxygen at 3 L/min per
nasal cannula
B. Administration of morphine and
Furosemide (Lasix)
C. Place the patient in high Fowlers position
D. Replace fluids with normal saline

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Fluids and Electrolytes

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Fluid
Intracellular
Body water
Extracellular
Body water

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Electrolytes
Same electrolytes in
intracellular space as
in extracellular space
Always measure
extracellular space

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Sodium

Necessary for protein synthesis


Fluid volume in extracellular spaces

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Hyponatremia

Dilutional most common

Excessive fluid intake


Edema, confusion
Treatment decrease fluid intake

True

Fluid and sodium loss


Dry tissue
Treatment replace both sodium and
water
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Hypernatremia

Most common, fluid loss without loss


of sodium

Dry tissue
Treatment replace fluids

Increased sodium with diet rare could


occur with full strength high protein
tube feeding

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Potassium

Irritant at neuromuscular junction


Increased muscular irritability

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Hyperkalemia

Causes cell wall destruction,


increased intake, renal failure

Symptoms irritable muscles

Treatment Kayexalate, calcium


gluconate, insulin

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Hypokalemia

Increased loss of potassium


or increased fluid
Muscle

flaccidity
Treatment potassium supplements

IV
Oral

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Calcium

Sedative at the neuro level


Necessary for coagulation

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Hypercalcemia

Increased intake, hyperparathyroidism


Symptoms

Sedation

Treatment

Decrease calcium intake

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Hypocalcemia

Decreased calcium intake, increased


phosphate levels, renal disease
Hyperactive deep tendon reflexes
Chvosteks
Trousseaus
Laryngospasm

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Phosphate

Informal inverse relationship with


calcium
Symptoms may be opposite of
calcium (hypophosphatemia looks like
hypercalcemia, etc)

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Magnesium

Hypermagnesemia
Usually poor renal excretion
Muscular depression

Hypomagnesemia
Hyperactive

deep tendon reflexes

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Serum Osmolality

2(Na) + BUN/5 + glucose/20 = 275-295


mOsm/l
Quick and dirty 2(Na)
Higher the number, dryer the patient

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IV Fluids

Hypertonic = above 295 mOsm/L

Isotonic = 275 295 mOsm/L

D5LR, D5NS
NS, LR

Hypotonic = below 275 mOsm/L


NS

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A patient experiencing a sodium imbalance


must be assessed for which of the following
symptoms?

A. Changes in level of consciousness


B. Irritability of skeletal muscles
C. Depression of deep tendon reflexes
D. Evidence of acid-base imbalances

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A patient who is severely dehydrated would


most likely be treated initially with which of the
following IV solutions?

A. Hypertonic
B. Isotonic
C. Hypotonic
D. Colloidal

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Which of the following assessment data are


consistent with hypovolemia?

A. Increased pulse and a swollen tongue


B. Neck vein distention and dry skin
C. Weight loss and thirst
D. Increased blood pressure and a fever

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Which of the following sets of signs and


symptoms would be exhibited by a patient with
a serum potassium of 6.8 mEq/L?

A. Bradycardia and constipation


B. Confusion and muscle cramps
C. Paralytic ileus and paresthesias
D. Diarrhea and spastic paralysis

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Immune System
Leukocytes
A. Granulocytes
1. Neutrophils first line of
defense against bacteria
2. Eosinophils phagocytize
antigen-antibody complexes
3. Basophils- contain
histamine and heparin
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Immune System
B. Nongranulocytes
1) Monocytes phagocytize
bacteria
2) Lymphocytes provide
immunity against foreign
invaders including transplants
C. Immune Response
1) Humoral B lymphocytes,
memory
2) Cellular T lymphocytes,
foreign invaders

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Compromised
Immune System

Steroids
suppression of system
Chemotherapy

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Acquired Immune
Deficiency Syndrome

In 2009
33.3 million people worldwide living
with AIDS
2.6 million new infections this year
Women and those 15-24 accounted for
50% of infections
Project that by 2012 100 million people
will be infected
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Transmission of AIDS

Blood
Semen
Vaginal fluids
Breast milk
Transplacental ?
Transmitted even when asymptomatic

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Pathophysiology

Retrovirus, part of the Lentivirius family


Infects CD4 lymphocytes
Carries genetic information on RNA into
the cells DNA
CD4 cells, necessary to immune function,
decrease in numbers in acute phase

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CD 4 Classification of AIDS

> 500 CD4 cells /micro L

Category I:

Category II: 200-400 CD4 cells/ micro L

Category III:

< 200 CD4 cells/ micro L

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Clinical Classification of AIDS

Clinical Category A= asymptomatic or


have persistent generalized
lymphadenopathy or symptoms of primary
HIV infection
Clinical category B= symptoms of immune
deficiency not serious enough to be AIDS
defining
Clinical Category C= AIDS-defining illness

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Treatment of AIDS

Prevention
Optimal treatment includes combination of
at least 3 drugs, often referred to as
HAART
Reverse transcriptase inhibitors
Protease inhibitors
Fusion inhibitors

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Hematologic System

Erythrocytes: 120 day life span


Requires erythropoietin from kidneys
(80%) and liver (20%)
Thrombocytes: 7.5 day life span, 1/3
sequestered in spleen. Increased blood
platelet level following splenectomy
a. Clotting cascade
Extrinsic
Intrinsic
Enzymes
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White blood cells


Neutrophils- first line of defense against
bacteria
Immature

cells are Bands

Eosinophils- break down antigen/antibody


complex

Basophils- work to keep blood flowing


through micro-vascular system
Monocytes-effective bacterial macrophage

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Lymphocytes:
T-lymphocytes-react against foreign or
abnormal cells
B-lymphocytes- becomes antibodies when
exposed to something seen as a long term
threat

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Assessment

History
Objective information
Physical

assessment
Diagnostic studies

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Hematologic concerns

Anemia
Blood loss, Hemolytic
Sickle cell
Iron deficiency
Pernicious
Disseminated Intravascular coagulation
Hodgkins

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Sam Andrew had just been diagnosed with


pernicious anemia following his gastric
resection. He asked how long he will need to
take the vitaminnB12. You tell him hell need to
continue:
A. Until his anemia is corrected
B. For the rest of his life
C. It depends on his physicians assessment of
him
D. Its different in everyone

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A.
B.
C.
D.

Which of the following laboratory results


would be considered the most indicative of
DIC?
High platelet count
Elevated blood glucose
Increased bleeding times
Presence of fibrin degradation products
(FDP)

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Cardiovascular system

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Anatomy and Physiology


A. Heart: atria, ventricles, valves,
coronary circulation, cardiac,
conduction system
B. Cardiac Cycle: Systole, diastole
C. Peripheral vascular system:
Veins, arteries, arterioles, venioles,
capillaries

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CO=HR

SV

Stroke

volume
Preload
Afterload
Contractility
Heart Rate
Impact of the ANS

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Assessment:
Nursing History

Past medical
Diet
Medication
Pain
Edema
Other
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Chest Pain

Description?
Location?
Does it radiate?
What causes it?
What causes it worse?
What makes it better?

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Physical Assessment

Inspection
Edema, skin assessment, hair
growth
Palpation
Peripheral pulses, PMI

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Heart sounds

Normal
S1
S2
Abnormal
S3 lub DUB dub
S4 lub dub DUB
Murmurs
Friction rub
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Diagnostic studies

Cardiac enzymes & proteins


Troponins
CPK-MB, myoglobin, troponins
LDH
Doppler ultrasound
ECHO:TEE
Thallium imaging
Pericardial fluid analysis
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Diagnostic procedures

Electrocardiogram
Electrophysiology
Echocardiography
Stress test
Doppler Ultrasound
Cardiac Catheterization

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Acute Coronary Syndromes (ACS)


Sudden Death
Stable Angina

Coronary
Arterial
Thrombosis
Non-ST-Elevation
MI

STElevation MI

Sudden Death
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ECG Changes Consistent with


ACS

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Anti- ischemic Options


Nitrates

Dilate blood vessels; relaxes and expands


artery, increasing blood flow

Morphine

Pain relief, Dilate blood vessels; relaxes and


expands artery, including blood flow

Beta blockers

ACE inhibitors

Calcium blockers

Slows pumping action of the heart, reduce


oxygen requirements
Dilate blood vessels, prevent fluid retention, and
ease the workload of the heart
Dilate blood vessels and reduce vascular
smooth-muscle contraction

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Antiplatelets and Antithrombin Agents

Salicylates: Aspirin
ADP-receptor inhibitors: Clopidogrel
Glycoprotein(GP) Iib-IIIa receptor antagonists
Heparin-unfractionated heparin (UFH)
Low- Molecular weight heparins (LMWH) with
UA/NSTEMI indications
Enoxaparin
Dalteparin
Direct- acting Antithrombins
Bivalirudin
Argatrobran
Lepirudin
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CV Conditions

CHF
Diuretics,

ACE Inhibitors, Digitalis, Beta

Blockers
BNP- Brain Naturetic Peptide
Hypertension
Highest Risk: African American males in
southeast United States
Weight loss- diet management; exercise,
Diuretics, Ace inhibitors, Beta blockers,
Angiotensin 2 receptor blockers
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CV conditions
Chronic Peripheral Circulatory Disease
Arterial(

PAD-peripheral arterial disease):


Thrombolytics, antiplatelet aggregates,
revascularization-stents, arterioplasty,
bypass grafting
Venous )PVD-peripheral venous disease):
elevation, wound prevention- assessmentmanagement, antiplatelet aggregates
DVT: Heparin, LMWH, warfarin, labs:
PT/PTT/INR, D-dimer: SVC filter
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Which of the following complications would


likely to happen in a client receiving both a
calcium channel blocker and Lanoxin?
A.
B.
C.
D.

A change in the blood pressure


A decrease in the pulse rate
An increase in respiratory rate
Presence of a systolic murmur

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You are caring for a patient post MI, who


suddenly develops bradycardia and
hypotension. What is the likely cause?
A.
B.
C.
D.

Anxiety reaction
Cardiogenic shock
Medication overdose
Pulmonary edema

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Mr. Jones, just returning from a coronary


angiogram, develops bradycardia and a
narrowing pulse pressure. What is the
most likely cause?
A. Cardiac tamponade
B. Positional hypotension
C. Myocardial infarction
D. Anaphylactic shock

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Which of the following antihypertensive


should be avoided in a person with
diabetes?
A.
B.
C.
D.

Calcium channel blockers


Beta Blockers
ACE inhibitors
Nitrates

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Cancer

Uncontrolled growth of cells Due

to alteration in cells genes


Immune system fails to destroy

Etiologic factors
Chemicals
Radiation
Viruses
Host-related

factors (tobacco use etc)

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Cancer Prevention

Age
Sex
Geographical
location
Racial or ethnic
origin
Familial tendency
Environmental

Lifestyle

Tobacco use
Diet
Alcohol

Occupational risks
Biological risks
Iatrogenic risks
Psychosocial

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Cancer screening and early


Detection

Early detection-attempt to diagnose at


a curable stage
Secondary prevention- to identify and treat
before disease is symptomatic thus halting
the disease
Health promotion requires consumer
involvement

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Therapeutic modalities

Surgery- for staging and treatment


Radiation-Side effects at site of radiation
Biologic therapy-alter host responses to
malignant cells
Chemotherapy- use of chemical agents

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Sue Lynn, a 50 year old diagnosed with an


autoimmune disorder, asks what that
means. You tell her:
1.

2.

3.

4.

The bodys ability to fight off infections has been


lost
She is experiencing an increase in one white
cell line
Her immune system is attacking her own body
cells
It is a short lived event which will make her
susceptible to bruising
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Which of the following sets of signs and


symptoms would be exhibited by a patient
with a serum potassium of 6.8 MEq/l?

A.
B.
C.
D.

Bradycardia and constipation


Confusion and muscle cramps
Paralytic ileus and paresthesia
Diarrhea and GI spasms

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A patient on your unit has been diagnosed


with AIDS. He expresses concerns for
your safety during his am care. You would
state:
1. lets talk about what we can call body
substance isolation
2. Youre not bleeding so theres no risk
3. Its just part of my job, so I dont think
about it.
4. It is scary, but you deserve my care

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Gastrointestinal system

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History and subjective assessment

Past history of GI disorders, Surgery, allergy,


lactose intolerance
Pain: location and r/t eating (full or empty
stomach)
Condition of teeth, tongue, oral mucosa
Dysphagia, belching, indigestion/heart burn,
nausea, vomiting
Weight loss, anorexia
Bowel movement frequency: Diarrhea,
constipation, laxative or enema use, presence of
dark stools or frank blood
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Objective Assessment

Inspection: Weight, spider angioma


on trunk, visible peristalsis, distention,
jaundice, icterus, ecchymosis or
petechiae
2. Auscultation: Bowel sounds
3. Palpation: Distention, as, cites,
hepatomegaly (firm ridge below the rib
cage.
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Diagnostic Studies

Lab tests: Electrolytes, LFTs, fecal


studies, analysis of gastric secretions
2. Radiography: Barium swallow,
barium enema, ultrasound, ERCP,
endoscopy, arteriography,
colonoscopy, nuclear medicine
imaging, CT scan

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Liver Disease

Cirrhosis- Hardening of the liver


Medical

treatment-paracentesis, Transjugular
intra-hepatic Porto-systemic shunting (TIPS),
organ transplant
Nursing interventions: Monitor for bleeding,
albumin, B vitamin levels, serum ammonia;
treat alcoholism (refer to rehab); teach
avoidance of hepatotoxic substances and use
of OTC meds; control ammonia related
encephalopathy-neomycin, lactulose, reduced
protein intake

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Esophageal varices

Medical treatment- Banding, sclerosing,


esophageal balloon tamponade,
transfusion of RBCs and clotting factors
(FFP)
Nursing interventions: monitor VS, S&S of
bleeding, PT, PTT, platelets, refer to
treatment for alcoholism

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Viral Hepatitis

Transmission
A-

Fecal-oral, contaminated food


B and C-Blood and body fluid

Medical treatment
Hepatitis

A- supportive treatment, antdiarrhea and anti ememitics


Hepatitis B gamma globulin, prevention with
hepatitis vaccine

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Hepatitis C initial infection is rarely treated


due to flu-like symptoms. Chronic state is
treated with antiviral therapy(ribavirin,
interferon injections) treatment similar to
cirrhosis when fibrosis develops
Nursing interventions
Teach hand washing and safe food handling,
safe sex, and recommend hepatitis A and
B vaccines
Monitor LFTs
Provide symptom management

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Bowel disease

Inflammatory bowel disease


Medical

treatment- corticosteroids, azulvidine,


surgery( Colectomy/Colostomy or ileostomy)
Nursing Interventions: monitor for S&S of
bleeding, test stools for occult blood, ostomy
care including diet teaching and address body
image

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Irritable bowel syndrome

Conventional medical treatment-imodium for


diarrhea; tegaserod maleate (Zelnorm) for
constipation; Alosetron hydrochloride ( Lotronex)
for diarrhea if conventional therapy is not
effective
Nursing intervention: Teach avoidance of the
individuals triggers- large meals, wheat, rye,
barley, chocolate, milk products, alcohol, drinks
with caffeine; stress or emotional upsets. Teach
avoidance of overusing saline enemas and OTC
laxatives

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Bowel Disease
Obstruction

Medical treatment- NG tube, NPO, surgery


Nursing interventions: Monitor bowel
sounds, IV fluids, TPN, prepare for
diagnostic studies and surgery, treat N&V

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Colon Cancer

Medical Treatment- polypectomy, tumor


resection, colectomy/ostomy, chemo and
or radiation
Nursing Interventions: Bowel prep, ostomy
care, diet teaching, teach effects of chemo
and radiation

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Pancreatitis

Acute: NPO, fluids, possibly TPN.


Monitor glucose, acid balance, K, Ca,
Serum Co2, and amylase, lipase. Pain
management, I7O monitoring; be alert for
signs of hemorrhage, renal and respiratory
failure
Chronic: Pancreatic enzymes, teach low
fat diet, pain management

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Peptic Ulcer disease

Causes: Helicobter pylori has been found


to be the cause in most ulcers, 50% of the
population is colonized
NASAIDS are another significant factor for
gastric and duodenal ulcers in individuals
over 60
Corticosteroids cause erosion of gastric
mucosa

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Peptic Ulcer disease

Interventions:
Assess

VS for signs of blood loss, assess


emesis for coffee ground appearance, and
test stools for occult blood
During acute bleeding-NG tube, NPO, IV
fluids, Monitor Hgb & Hct, RBC transfusions
may be necessary
Teach patient bland diet and medication
regimen

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Peptic Ulcer disease

Antibiotics
Histamine 2 blockers
proton pump inhibitors
Barrier medications

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Peritonitis

Nursing assessment
Monitor VS, WBCs, assess pain level,
assess firmness of the abdomen(rebound
tenderness)
Treatment:
Antibiotics(

intraperitoneal in peritoneal
dialysis patient)
Pain management
Antiemetics PRN
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Mrs. Stone, 68, is on your unit with


ascites, as a complication of her liver
cancer. Her potassium level is elevated
and would most likely be related to:

A. Hypomagnesemia
B. Increased ammonia levels
C. Decreased albumin levels
D. Poor lymphatic system

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A client with advanced cirrhosis is


admitted to your unit from the E.D.
Which of the following orders should
you question?
A. Phenobarbital 100 mg HS
B. Neomycin sulfate 300 mg
Q6 x 4 doses
C. Low protein diet
D. Serum ammonia levels daily

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Jerry Thomas, 22, is being treated with


dexamethasone (Decadron) for an
acute head injury caused by a skiing
accident. He is also receiving ranitidine
(Zantac) because of dexamethasones
propensity to:
A. Increase peristalsis
B. Erode gastric mucosa
C. Decrease secretions
D. Irritate mucous membranes

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Nutrition
Essential for adequate functioning of all
body systems

Calculating nutrition intake is based on kcalKilocalories


Carbohydrates 4 Kcal/gram
Protein
4 Kcal/gram
Fat
9 Kcal/gram
Enteral feeding is preferred over parenteral
feeding because it is important to maintaining a
functioning GI tract

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