NSG 223

Assessment

100

What are the signs and symptoms of an ischemic stroke?

The signs and symptoms of an ischemic stroke can vary depending on the area of the brain affected, but may include:

• Sudden weakness or numbness on one side of the body (face, arm, or leg)
• Sudden confusion or trouble speaking/understanding speech
• Sudden vision problems in one or both eyes
• Sudden difficulty walking, dizziness, or loss of balance/coordination
• Sudden severe headache with no known cause

Additional symptoms may include:

• Transient loss of vision in one eye (amaurosis fugax)
• Temporary inability to speak
• Numbness or loss of sensation
• Tinnitus
• Vertigo
• Darkened or blurred vision
• Diplopia (double vision)
• Ptosis (drooping eyelid)
• Dysarthria (slurred speech)
• Dysphagia (difficulty swallowing)

200

What are the signs and symptoms of hepatitis?

The signs and symptoms of hepatitis include:

• Jaundice (yellowing of skin and eyes)
• Dark urine
• Light-colored stools
• Fatigue
• Nausea and vomiting
• Abdominal pain, especially in the upper right quadrant
• Loss of appetite
• Fever
• Joint pain
• Itching

In acute hepatitis:

• Symptoms may appear suddenly and be more severe
• Anorexia and distaste for food are common
• Rest is critical for recovery

In chronic hepatitis:

• Symptoms may be milder initially but can progress to liver dysfunction
• There is an increased risk of liver failure and associated complications

It's important to note that some people, especially those with chronic hepatitis, may not experience noticeable symptoms in the early stages. Regular screening and monitoring of liver function are crucial for those at risk.

300

What are key assessment differences between diverticulosis and diverticulitis?

The key assessment differences between diverticulosis and diverticulitis are:

Diverticulosis:

• Often asymptomatic
• May have mild abdominal discomfort or bloating
• No fever or significant pain
• Normal white blood cell count
• No signs of inflammation on imaging

Diverticulitis:

• Acute onset of severe abdominal pain, typically in left lower quadrant
• Fever and chills
• Nausea and vomiting
• Changes in bowel habits (constipation or diarrhea)
• Elevated white blood cell count
• Tenderness and guarding on abdominal examination
• Evidence of inflammation on imaging (CT scan)
• Possible complications like abscess, fistula, or perforation

In diverticulitis, nurses should assess for signs of peritonitis or sepsis, which may indicate a more severe condition requiring immediate intervention.

400

How does the nursing management differ between hemorrhagic and ischemic stroke?

The nursing management for hemorrhagic and ischemic strokes differs in several key areas:

1. Blood Pressure Management:

   • Hemorrhagic: Strict BP control (SBP < 185 mm Hg) using IV antihypertensives like labetalol or nicardipine.
   • Ischemic: Less aggressive BP management; treatment only if SBP > 220 mm Hg or DBP > 120 mm Hg.

2. Thrombolytic Therapy:

   • Hemorrhagic: Contraindicated.
   • Ischemic: May receive tPA if within time window and meets criteria.

3. Anticoagulation:

   • Hemorrhagic: Avoid; reverse if patient was on anticoagulants.
   • Ischemic: May be initiated after acute phase to prevent further clots.

4. Neurological Monitoring:

   • Both: Frequent assessments, but hemorrhagic strokes may deteriorate more rapidly.

5. Intracranial Pressure (ICP) Management:

   • Hemorrhagic: More likely to need ICP monitoring and management.
   • Ischemic: Less common, but still possible.

6. Surgical Interventions:

   • Hemorrhagic: May require surgical evacuation of hematoma.
   • Ischemic: May undergo thrombectomy in certain cases.

7. Respiratory Management:

   • Both require close monitoring, but hemorrhagic strokes (especially brainstem) may need more aggressive airway management.

8. Medication Administration:

   • Hemorrhagic: Focus on BP control and reversal of anticoagulation if needed.
   • Ischemic: May include antiplatelet therapy (e.g., aspirin) after acute phase.

In both types, nurses must prioritize maintaining adequate cerebral perfusion, preventing complications, and providing supportive care tailored to the specific stroke type and individual patient needs.

500

What are the signs and symptoms of short bowel syndrome and describe its pathophysiology?

Short bowel syndrome (SBS) is a condition that occurs when a significant portion of the small intestine has been removed or is non-functional. The pathophysiology involves:

1. Reduced absorptive surface area:

   • Limits the absorption of nutrients, fluids, and medications

2. Altered gastrointestinal motility:

   • Rapid transit time through the remaining intestine

3. Malabsorption:

   • Inadequate absorption of macronutrients, micronutrients, and fluids

4. Electrolyte imbalances:

   • Due to impaired absorption and excessive loss

5. Gastric hypersecretion:

   • Increased acid production, potentially leading to further mucosal damage

6. Bacterial overgrowth:

   • Altered gut microbiome due to changes in intestinal anatomy

7. Adaptation of remaining intestine:

   • Hyperplasia of intestinal villi to increase absorptive capacity

8. Altered drug absorption:

   • As noted in the textbook material, medication absorption can be significantly impacted

These pathophysiological changes lead to various clinical manifestations and complications associated with SBS, including malnutrition, dehydration, and electrolyte abnormalities.

Key nursing assessment findings for short bowel syndrome include:

1. Gastrointestinal symptoms:

   • Chronic diarrhea
   • Abdominal pain or cramping
   • Bloating and gas
   • Nausea and vomiting

2. Nutritional status:

   • Unintended weight loss
   • Muscle wasting
   • Signs of malnutrition (e.g., dry skin, brittle nails)

3. Fluid and electrolyte imbalances:

   • Dehydration (dry mucous membranes, poor skin turgor)
   • Electrolyte abnormalities (e.g., hypokalemia, hypomagnesemia)

4. Vitamin and mineral deficiencies:

   • Anemia (fatigue, pallor)
   • Bone disorders (osteoporosis, osteomalacia)
   • Neurological symptoms (numbness, tingling)

5. Skin integrity:

   • Perianal skin breakdown due to frequent diarrhea

6. Medications:

   • Altered effectiveness of oral medications

7. Psychological well-being:

   • Signs of anxiety or depression related to chronic illness

8. Growth and development (in children):

   • Delayed growth or developmental milestones

Nurses should also assess for any history of abdominal surgeries, presence of stomas, and current nutritional support methods (e.g., parenteral nutrition).

Diagnosis

100

What is the highest priority nursing diagnoses for cirrhosis?

The highest priority nursing diagnoses for cirrhosis typically include:

1. Risk for Impaired Liver Function
2. Excess Fluid Volume (related to ascites and edema)
3. Risk for Bleeding (due to impaired clotting factor production)
4. Impaired Gas Exchange (related to ascites and pleural effusion)
5. Risk for Infection (due to compromised immune function)

These diagnoses address the most urgent physiological needs and potential complications associated with cirrhosis. They focus on maintaining vital functions, preventing further liver damage, and managing life-threatening symptoms. Priorities may shift based on the individual patient's condition and stage of disease progression.

200

What are key assessment differences between celiac disease and peritonitis?

The key assessment differences between celiac disease and peritonitis are:

Celiac Disease:

• Chronic condition with gradual onset
• Abdominal pain, bloating, and diarrhea (may be chronic or intermittent)
• Fatigue and anemia
• Weight loss or failure to thrive in children
• No fever typically
• Symptoms worsen after consuming gluten-containing foods
• May have extraintestinal manifestations (e.g., skin rashes, joint pain)
• Blood tests show elevated celiac-specific antibodies

Peritonitis:

• Acute onset with severe, generalized abdominal pain
• Abdominal rigidity and guarding
• Fever and chills
• Nausea and vomiting
• Decreased or absent bowel sounds
• Signs of shock in advanced cases
• Elevated white blood cell count
• Positive rebound tenderness on abdominal examination
• May have a known cause (e.g., perforated appendix, bowel perforation)

Celiac disease is a chronic autoimmune condition triggered by gluten, while peritonitis is an acute, potentially life-threatening inflammation of the peritoneum often requiring immediate medical intervention.

300

What are key laboratory labs for hepatitis and acute pancreatitis?

Key laboratory tests for hepatitis:

1. Liver function tests:

   • Alanine aminotransferase (ALT)
   • Aspartate aminotransferase (AST)
   • Alkaline phosphatase (ALP)
   • Gamma-glutamyl transferase (GGT)
   • Bilirubin (total and direct)

2. Viral hepatitis serology:

   • Hepatitis A antibodies (anti-HAV)
   • Hepatitis B surface antigen (HBsAg)
   • Hepatitis B core antibody (anti-HBc)
   • Hepatitis C antibody (anti-HCV)

3. HCV RNA testing for chronic infection and viral load

4. Prothrombin time (PT) / International Normalized Ratio (INR)

5. Complete blood count (CBC)

6. Serum albumin

Key laboratory tests for acute pancreatitis:

1. Serum lipase (primary test)

2. Serum amylase

3. Urinary amylase (elevated after 48 hours)

4. Urinary trypsinogen-2 (dipstick test)

5. Complete blood count (CBC)

6. Comprehensive metabolic panel (CMP)

7. C-reactive protein (CRP)

8. Triglycerides

9. Calcium levels

500

What diagnostic tests are crucial for differentiating between hemorrhagic and ischemic stroke in the initial assessment?

The crucial diagnostic tests for differentiating between hemorrhagic and ischemic stroke in the initial assessment are:

1. Non-contrast CT scan:

   • Primary and most rapid test
   • Can detect blood in hemorrhagic strokes
   • May show early signs of ischemia

2. MRI with diffusion-weighted imaging (DWI):

   • More sensitive than CT for early ischemic changes
   • Can detect hemorrhage

3. CT angiography (CTA) or MR angiography (MRA):

   • Visualize blood vessels to identify blockages or aneurysms

4. Carotid ultrasound:

   • Assesses blood flow in carotid arteries

5. Laboratory tests:

   • Complete blood count
   • Coagulation profile
   • Blood glucose levels

6. Electrocardiogram (ECG):

   • To rule out cardiac causes of stroke

7. National Institutes of Health Stroke Scale (NIHSS):

   • Standardized assessment of neurological deficits

These tests, combined with a thorough clinical examination and patient history, help determine the stroke type and guide appropriate treatment decisions.

Planning and Implementation

100

What is a highest nursing priority intervention for appendicitis?

The highest priority nursing intervention for appendicitis is pain management. This involves:

1. Assessing the patient's pain level regularly
2. Administering prescribed pain medications as ordered
3. Monitoring the effectiveness of pain relief measures
4. Positioning the patient for comfort, often in a right side-lying or semi-Fowler's position
5. Applying ice packs to the affected area if appropriate

Additionally, it's crucial to:

• Monitor for signs of perforation or peritonitis
• Prepare the patient for potential emergency surgery
• Keep the patient NPO (nothing by mouth) in case surgery is needed
• Administer IV fluids and antibiotics as ordered
• Monitor vital signs and abdominal symptoms closely

Prompt pain management is essential to prevent complications and ensure patient comfort while preparing for definitive treatment.

200

What are 7 highest nursing priority intervention for liver cancer?

1. Pain management: Assess pain regularly and administer prescribed analgesics.

2. Nutritional support: Monitor nutritional status and provide appropriate dietary interventions.

3. Symptom management: Address complications like ascites, edema, and hepatic encephalopathy.

4. Infection prevention: Implement strict infection control measures due to compromised immune function.

5. Emotional support: Provide counseling and resources to help patients cope with their diagnosis and treatment.

6. Patient education: Teach patients and caregivers about the disease process, treatment options, and self-care strategies.

7. Monitoring for complications: Regularly assess for signs of gastrointestinal bleeding, liver failure, and treatment side effects.

These interventions focus on managing symptoms, preventing complications, and supporting the patient's overall well-being during treatment for liver cancer.

300

What is the pharmacological management for hemorrhagic stroke?

The pharmacological management for hemorrhagic stroke focuses primarily on blood pressure control and prevention of complications. Key aspects include:

1. Blood Pressure Management:

   • Target systolic blood pressure (SBP) < 185 mm Hg
   • Intravenous antihypertensives preferred:
     • Labetalol
     • Nicardipine

2. Reversal of Anticoagulation (if applicable):

   • Administer reversal agents for patients on anticoagulants

3. Neuroprotection:

   • Nimodipine (calcium channel blocker) to treat cerebral vasospasms and minimize neurological deficits

4. Seizure Prophylaxis:

   • Antiepileptic medications may be prescribed

5. Cerebral Edema Management:

   • Osmotic diuretics (e.g., mannitol) if significant edema is present

6. Pain Management:

   • Analgesics as needed, avoiding those that may increase bleeding risk

7. Stress Ulcer Prophylaxis:

   • Proton pump inhibitors or H2 receptor antagonists

It's crucial to note that thrombolytic agents (like tPA) are contraindicated in hemorrhagic stroke. The focus is on supportive care and preventing further bleeding while managing intracranial pressure.