Signs & Syndromes
A tear at the gastroesophageal junction from severe vomiting, coughing or sometimes trauma
Mallory Weiss (abdominal trauma, GI bleed, severe vomiting)
The student nurse is shadowing in the emergency department. The trauma page states there is a mva with upper airway trauma. The student nurse is ready to assess what priorities?
Airway, breathing, circulation
3 priority interventions for patient in triage with severe stomatitis
-Frequently assess oral mucosa, airway, & swallowing.
-Implement aspiration precautions,
-administer prescribed medications (pain, antivirals, antimicrobials, antifungals, lubricants),
-teach patient about gentle mouth care and avoiding irritants (alcohol, mouthwash, lemon, spicy foods)
3 nursing diagnoses appropriate for a patient with GERD
-Acute pain (r/t physical injury),
-chronic pain (r/t esophageal irritation),
-Risk for aspiration (r/t physiologic dysfunction-sphincters),
-Impaired swallowing (r/t stricture or inflammation),
-imbalanced nutrition (r/t decreased intake, secondary to dysphagia/pain)
This specific drug is given to clients with cirrhosis. It causes them to have frequent bowel movements in an effort to decrease ______.
Lactulose, protein absorption / ammonia
Pain in the right lower quadrant is elicited by palpating the left lower quadrant of the abdomen
Rovsing’s sign (appendicitis)
The student nurse notes jaundice sclera and extensive bruising to the lower extremities. Which lab values are of interest, and what is the anticipated result?
(increased)ALT (increased)AST (increased)Bilirubin, (increased)PTT, (increased) INR, (decreased) albumin, (decreased) platelets
3 priority interventions for patient with hiatal hernia
-Assess for dysphagia,
-Administer prescribed medications (nausea meds, antacids, h2 agonists, ppis, prokinetic medications),
-Position patient supine on right side,
-HOB elevated after meals.
-Educate patient: stay upright for 2 hours after eating,
-Educate patient to avoid spicy foods, caffeine, carbonation, acidic foods, alcohol,
3 nursing diagnoses appropriate for a patient with hepatitis
-Activity intolerance (r/t fatigue, fever, flu like symptoms),
-Altered nutrition (r/t metabolic dysfunction),
-Altered mental status,
-Altered thought process (related to elevated serum ammonia levels)
-Knowledge deficit (risk behaviors, vaccine availability, methods of transmission)
-Fluid imbalance (r/t altered nutrition, nausea, or vomiting),
-acute pain (r/t liver edema)
This proton pump inhibitor & h2 antagonist can be administered PO or IV as ulcer prophylaxis while hospitalized or as treatment for patient with peptic ulcers.
Pantoprazole (Protonix) and Famotidine (Pepcid)
Bruising around the umbilicus
Cullen’s sign (abdominal trauma, or less frequently with pancreatitis, indicates hemorrhage)
A patient is admitted with acute pancreatitis, the nurse is concerned with which reported social habit
Frequent and heavy alcohol use
3 priority interventions for a patient admitted to the floor after oral trauma
-Assess airway and breathing frequently-
-Monitor pulse oximetry.
-Daily weights- assess for fluid or nutritional deficits using weight.
-Provide frequent mouth care- maintain clean area, free from debris or infection.
-Educate patient about texture modified diet.
3 Nursing diagnoses appropriate for a patient with cirrhosis
-Fluid volume excess (r/t water and sodium retention related to decreased plasma protein)
-fluid volume deficit (r/t 3rdspacing of peritoneal fluid, coagulation abnormalities, variceal bleeds )
-Altered nutrition less than body requires (r/t altered liver metabolism, impaired absorption, insufficient intake)
-Impaired skin integrity (r/t compromised nutrition, edema, decreased immune status),
-Risk for injury;
-Risk for bleeding (r/t coagulopathy)
-Chronic pain (r/t liver enlargement),
-Chronic low self esteem (r/t chronic illness)
This class of medications is first priority for nurse administration in a patient admitted with perforated appendicitis.
Antibiotics
Ecchymosis to flank areas
Turner’s sign (abdominal trauma, or less frequently with pancreatitis, indicates hemorrhage)
The student nurse assesses a cirrhosis patient who endorses difficulty breathing; vital signs are significant for tachypnea, low blood pressure, and tachycardia. The student nurse notes a positive turner’s sign. Which lab values is the SNUA most concerned about?
elevated PT/ INR, assessment indicates posible bleeding, this lab value is critical to assess risk for bleeding.
3 priority interventions for a patient with newly diagnosed diverticulitis
-Administer prescribed antibiotics,
-Insert/maintain NG tube,
-Monitor lab values (decreased electrolytes due to NG or n/v/d),
-Administer pain medication,
-Administer IV fluids,
-Educate patient about NPO status, or diet alterations prior to discharge.
3 nursing diagnoses appropriate for a patient admitted with cholecystitis
-Acute pain (r/t obstruction, edema, related to stones)
-Fluid volume deficit (r/t nausea, vomiting, increased insensible fluid loss)
-Imbalanced nutrition less than body requirements (r/t nausea and vomiting)
-Knowledge deficit (learning need; condition, prognosis, treatment regimen, self-care, and discharge needs)
The nurse is caring for an immigrant patient with no known vaccine history. The patient recently acquired a food handling job in a cafeteria. The nurse recommends vaccination of what type.
Hep a vaccine (recommended for food handlers, health care workers, childcare workers, and people who travel to hep a endemic areas.) and hep B vaccine (recommended for all patients).
Pain on palpation of the RUQ with deep inspiration
Murphy’s sign (cholecystitis)
The student nurse is preparing to admit a patient from the ER with abdominal pain and fever. What test(s) does the student nurse anticipate will be ordered?
CT scan, CBC, CMP, UA
3 priority interventions for a patient in triage with a strangulated hernia
-Preoperative care- medical emergency;
-Collaboration with provider;
-NPO,
-Administer - MIVF, Pain medication,
-Educate family about pre and postoperative procedures.
3 nursing diagnoses appropriate for patient admitted with chronic pancreatitis
-Acute pain (r/t inflammation and obstruction of pancreas)
-Imbalanced nutrition, less than body requirements (due to malabsorption and altered secretion of pancreatic enzymes),
-Hopelessness (related to chronic, progressive, irreversible nature of chronic pancreatitis)
-Ineffective breathing pattern (r/t acute pain from inflammation and disease process),
-Ineffective health maintenance (r/t deficient knowledge),
-Readiness for enhanced knowledge (r/t social habits, alcohol, diet, medications)
The nurse knows to administer this medication prior to each meal or snack for their chronic pancreatitis patient.