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HESI MILESTONE 2 VERSION A BLUEPRINT 202 5
Schizophrenia care- Establish trust and rapport, encourage the client to talk with you, be consistent in setting expectations, explain the procedures and be certain the client understands, give positive feedback for the client successes, show empathy, do not be judgemental, never convey to the client that you accept their delusions as reality. Grief therapeutic response- Allow the 5 steps of grieving: Denial, Anger, Bargaining, Depression, and Acceptance (DABDA), active listening, and offering a supportive presence. Nursing Plans and Interventions: A. If needed, refer to grief counseling or a support group. B. Encourage activities that allow the individual to use past coping strategies to promote a feeling of self-worth and increased self-esteem. C. Encourage the individual to share his or her feelings. D. Encourage socialization with family peers and reminisce about significant life experiences. Delirium care- Know usual mental status and if changes noted are long-term, it probably represents dementia; if they are sudden/acute in onset, it is more likely to be delirium. Recognize and report symptoms immediately. Treatment of underlying causes is important - if untreated, it can lead to permanent, irreversible brain damage and death. The primary goals of nursing care for clients with delirium are: PROTECTION FROM INJURY, MANAGEMENT OF CONFUSION, AND MEETING PHYSIOLOGICAL AND PSYCHOLOGICAL NEEDS.
Ensure patient safety (fall risk) and manage behavioral problems. Alert the prescriber of nonessential medications. Nutritional and fluid intake must be monitored. A quiet and calm environment. Encourage visitors to touch and talk to patients. Assess/manage pain. Alzheimer's hallucination- Occurs in the late-middle to later stages of the disease process and is treated with antipsychotics such as Haldol Alcohol withdrawal- Symptoms of withdrawal usually begin 4 to 12 hours after cessation or marked reduction of alcohol intake. Symptoms include coarse hand tremors, sweating, elevated pulse, and blood pressure, insomnia, anxiety, and nausea or vomiting. Severe or untreated withdrawal may progress to transient hallucinations, seizures, or delirium, called delirium tremors. Alcohol withdrawal usually peaks on the second day and is over in about 5 days. This can vary, however, and withdrawal may take 1 to 2 weeks. Safe withdrawal is usually accomplished with the administration of benzodiazepines, such as lorazepam (Ativan), chlordiazepoxide (Librium), or diazepam (Valium), to suppress the withdrawal symptoms. Nursing Plans and Interventions A. Maintain safety, nutrition, hygiene, and rest. B. Obtain a BAL on admission or when a client appears intoxicated after admission. C. Implement suicide precautions if assessment indicates risk. D. In general
- Monitor vital signs, input and output (I&O), and electrolytes.
- Observe for impending DTs.
The nurse must protect others from these clients' manipulative or aggressive behaviors. At the beginning of treatment, he or she must set limits on unacceptable behavior. The limit setting involves the following three steps: Inform clients of the rule or limits. Explain the consequences if clients exceed the limit. State expected behavior. Nursing Plans and Interventions: Conduct and Defiant Disorders A. Assess verbal and nonverbal cues for escalating behavior so as to decrease outbursts. B. Use a nonauthoritarian approach. C. Avoid asking "why" questions. D. Initiate a "show of force" with a child who is out of control. E. Use a "quiet room" when external control is needed. F. Clarify expressions or jargon if meanings are unclear. G. Teach to redirect angry feelings to safe alternative, such as a pillow or punching bag. H. Implement behavior modification therapy if indicated. I. Role-play new coping strategies with client. Duty to warn- The obligation of a healthcare provider to warn third parties of potential threats or harm aimed at them by another individual. Schizophrenia- treatment evaluation- 1.) Clients should have decreased agitation, combativeness, and psychomotor activity. 2.) Decreased psychotic behaviors such as decreased hallucinations and delusions. Anxiety drugs risk-
Most of these drugs are benzodiazepines, which are commonly prescribed for anxiety. Benzodiazepines have a high potential for abuse and dependence, so their use should be short-term, ideally no longer than 4 to 6 weeks. One chief problem encountered with benzodiazepines is their tendency to cause physical dependence. Significant discontinuation symptoms occur when the drug is stopped; these symptoms often resemble the original symptoms for which the client sought treatment. This is especially a problem for clients with long-term benzodiazepine use, such as those with panic or generalized anxiety disorder. I am 100% convinced that this is the fact that three weeks after starting an anxiolytic, a patient is at a significantly higher risk of suicide due to increased energy and not wanting to go back to feeling anxious or depressed. It's mentioned both in Realize It and in the HESI prep ADHD exam-
- Failure to listen/follow direction
- Difficulty playing quietly/sitting still
- Disruptive, impulsive behavior
- Distractibility to external stimuli
- Excessive talking
- Shifting from one unfinished task to another.
- Underachievement in school performance Obsessive compulsive disorder-Nursing Diagnosis Nursing Diagnosis Ineffective Coping Inability to form a valid appraisal of the stressor Inadequate choices of practiced responses and/or Inability to use available resources. Nursing Assessment
Therapeutic communication abuse victim-
- Listen.
- Believe what the person says.
- Empathize: validate the person's feelings.
- Make it clear that the abuse was wrong and not the victim's fault. Suicide Precautions A. Obtain history.
- A previous suicide attempt is the most significant risk factor. Other risk groups include those with biologic and organic causes of depression, such as substance abuse, organic brain disorders, or other medical problems.
- Clients with a history of a family member's suicide are at heightened risk for suicide. B. Be aware of the major warning signs of an impending suicide attempt.
- A client begins giving away the client's possessions.
- When a previously depressed client becomes happy, he or she may have decided to commit suicide and is no longer debating the possibility. The client may have regained the energy to act on suicidal feelings and has figured out how to accomplish the suicide. Evaluation of Intent A. Directly ask the client about intent to harm self. Example: "Have you thought about harming yourself?" B. Offer the client hope. Example: "We have medication and treatments that can help you through the bad times." C. Identify the method chosen; the more lethal the method, the higher the probability that an attempt is imminent. "What is your plan for harming yourself?" Example: A client mentions a shotgun and plans to use the weapon to injure self.
D. Determine the availability of the method chosen. If the method is readily available, the attempt is more likely. Example: The client has a loaded shotgun in the bedroom, so it is readily available. Appendicitis pre op prep- The nurse prepares the patient for surgery, which includes
- An IV infusion to replace fluid loss and promote adequate renal function.
- Antibiotic therapy to prevent infection.
- Administration of analgesic agents for pain.
- An enema is not given because it can lead to perforation. Anorexia Report Findings- A. Weight loss of at least 15% of ideal or original body weight B. Excessive exercise C. Apathy about physical condition and inordinate pleasure in weight loss D. Skeletal appearance (usually hidden by baggy clothes) E. Distorted body image (usually sees self as fat) F. Low self-esteem G. Hair loss and dry skin H. Irregular heartbeat, decreased pulse, and BP resulting from decreased fluid volume I. Delayed psychosexual development (adolescents) or disinterest in sex (adults) J. Dehydration and electrolyte imbalance (decreased potassium, sodium, and chloride) resulting from
- Diet pill abuse
- Enema and laxative abuse
- Diuretic abuse
- Self-induced vomiting Complication HTN high risk-
F. Assess for headache, edema, nocturia, nosebleeds, and vision changes (may be asymptomatic). G. Assess stress level and source (related to job, economics, family). H. Assess personality type (i.e., determine whether client exhibits perfectionist behavior). HESI Hint Remember the risk factors for HTN: heredity, race, age, alcohol abuse, increased salt intake, obesity, and use of oral contraceptives. Hypothyroidism-
- Action is to increase metabolic rates
- Levothyroxine (Synthroid) T
- Adverse Reactions a. Anxiety b. Insomnia c. Tremors d. Tachycardia e. Palpitations f. Angina g. Dysrhythmias
- Nursing Implications a. Give in the early morning before meals. b. Check serum hormone levels routinely. c. Check BP and pulse regularly. d. Weigh daily. e. Report side effects to the health care provider. f. Avoid foods and products containing iodine. g. Initiate cautiously in clients with cardiovascular disease.
- Advanced hypothyroidism - Inadequate ventilation and sleep apnea can occur with severe hypothyroidism; pleural effusion, pericardial effusion, and resp muscle weakness may also occur.
- Myxedema coma - pt initially shows signs of depression, diminished cognitive status, lethargy, somnolence a. ICU admission with IV levothyroxine b. Watch CV/Lungs Diverticulosis signs and symptoms- Description: Diverticulosis: bulging pouches in the GI wall (diverticula), which push the mucosa lining through the surrounding muscle. Nursing Assessment S/S A. Left lower quadrant pain B. Increased flatus C. Rectal bleeding D. Signs of intestinal obstruction
- Constipation alternating with diarrhea
- Abdominal distention
- Anorexia
- Low-grade fever E. Barium enema or colonoscopy positive for diverticular disease: obstruction, ileus, or perforation confirmed by abdominal radiograph (barium not used during the acute phase of illness) DM poor compliance-
- To detect poor DM compliance, the patient may use a urine dipstick (Ketostix or Chemstrip UK) to detect ketonuria.
- If the reagent pad on the strip turns purple, it means ketones are present; it shows unmanaged diabetes or a lack of control over DM.
vi. Weakness vii. Hepatomegaly i. Ascites Small bowel obstruction actions- Nursing interventions:
- Maintain client NPO, with IV fluids and electrolyte therapy.
- Monitor I&O; a Foley catheter maintains strict output.
- Implement NG intubation.
- Attach to low suction (intermittent; 80 mm Hg).
- Document output every 8 hours.
- Irrigate with normal saline if policy dictates. NG tube (passed through the nose into the stomach; Miller-Abbott tube is used for decompression; it is passed through the nose and the stomach into the small intestines then connected to suction) placement is usually performed by the health care provider.
- NG tube a. Measure correct length of tubing to be inserted by measuring from the tip of the client's nose to the client's earlobe to the xiphoid process. b. Advance decompression tube every 1 to 2 hours. c. Do not secure to nose until tube reaches specified position. d. Reposition the client every 2 hours to assist with placement of the tube. e. Connect tube to suction. f. Irrigate NG tube with normal saline; irrigate Miller-Abbott tube with air only. g. Note amount, color, consistency, and any unusual odor of drainage. h. Assess for signs of dehydration (skin turgor, amount and color of urine). i. Monitor electrolyte values.
- Document pain; medicate as prescribed.
- Assess abdomen regularly for distention, rigidity, and change in status of bowel sounds.
- If conservative medical interventions fail, surgery will be required to remove obstruction. Pneumonia action- A. Assess sputum for volume, color, consistency, clarity, and distinct odors like Pseudomonas. B. Assist client to cough productively by
- Deep breathing every 2 hours (may use incentive spirometer)
- Using humidity to loosen secretions (may be oxygenated)
- Suctioning the airway, if necessary
- Chest physiotherapy C. Provide fluids up to 3 L/day unless contraindicated (helps liquefy lung secretions). D. Assess lung sounds before and after coughing. E. Keep client sitting up
- PCV13: >65, >19 with conditions that weaken immune system
- PPSV23: >65, 19-64 year olds who smoke/have asthma COPD oxygen flow rate - Administer O2 at 1 to 2 L per nasal cannula. Diverticulitis NPO-
- Withhold oral intake,
- Administer IV fluids, and
- If vomiting or distended, institute nasogastric (NG) suctioning.
- These are used to rest the bowel.
area, causing interstitial overhydration; may also be seen with ascites and third-spacing. Hypertonic solutions a. 5% dextrose in lactated Ringer’s (D5LR) b. 5% dextrose in 0.45% saline c. 5% dextrose in 0.9% saline (D5NS) d. 3% Na e. 5% NaCl f. 10% dextrose in water (D10W) g. 20% Dextrose in water (20W) acts as osmotic diuretic h. 50% Dextrose in water (50% DW) Rheumatoid arthritis diagnosis- A doctor will use blood tests, X-rays, and ultrasound to determine if you have RA. The goal of treatment at all phases of the RA disease process is to
- Decrease joint pain and swelling,
- Achieve clinical remission,
- Decrease the likelihood of joint deformity,
- Minimize disability. Initial treatment delays have been implicated in greater long-term joint deformity. Once the diagnosis of RA is made, treatment should begin with either a nonbiologic or biologic Disease-Modifying Antirheumatic Drug (DMARD). The goal of using DMARD therapy is to prevent inflammation and joint damage. Implement pain relief measures.
- Use moist heat. A. Warm, moist compresses (Realize It says alternate cold and hot) B. Whirlpool baths
C. Hot shower in the morning
- Use diversionary activities. A. Imaging B. Distraction C. Self-hypnosis D. Biofeedback
- Administer medications and teach the client about medications (NSAIDs)
- Methotrexate PUD NGT- During surgery and postoperatively, the stomach contents are drained using an NG tube. The nurse monitors fluid and electrolyte balance and assesses the patient for localized infection or peritonitis (increased temperature, abdominal pain, paralytic ileus, increased or absent bowel sounds, abdominal distention). Confirmation that obstruction is the cause of the discomfort is accomplished by assessing the amount of fluid aspirated from the NG tube. A residual of more than 400 mL suggests obstruction. Prostatic hyperplasia- Benign prostatic hyperplasia (BPH)—also called prostate gland enlargement—is a common condition as men get older. An enlarged prostate gland can cause uncomfortable urinary symptoms, such as blocking urine flow out of the bladder. It can also cause bladder, urinary tract, or kidney problems. Treatments: There are three treatment approaches:
- Active surveillance (watchful waiting),
- Drug therapy with 5-alpha-reductase inhibitors such as finasteride (Proscar) and alpha-adrenergic receptor blockers (tamsulosin), or
- Surgery.
Symptoms a. Tenderness b. Distension c. Rigidity d. Anorexia e. N/V f. Fever Asthma triggers - Airway irritants (air pollutants, occupational exposure); Food (shellfish, nut); hormonal factors; medications; viral respiratory tract infections. A. Infections like sinusitis, colds, and the flu. B. Allergens such as pollens, mold, pet dander, and dust mites. C. Cockroaches D. Irritants like strong odors from perfumes or cleaning solutions E. Air pollution F. Tobacco smoke G. Exercise H. Cold air or changes in the weather, such as temperature or humidity. I. Gastroesophageal reflux disease (GERD) J. Strong emotions such as anxiety, laughter, sadness, or stress Ulcerative colitis symptoms- The predominant symptoms of ulcerative colitis include diarrhea, with the passage of mucus, pus, or blood; left lower quadrant abdominal pain; and intermittent tenesmus. The bleeding may be mild or severe, and pallor, anemia, and fatigue result. The patient may have anorexia, weight loss, fever, vomiting, dehydration, cramping, and the passage of six or more liquid stools daily. Nursing Assessment
A. Diarrhea B. Abdominal pain and cramping C. Intermittent tenesmus (anal contractions) and rectal bleeding D. Liquid stools containing blood, mucus, and pus (may pass 10 to 20 liquid stools per day) E. Weakness and fatigue F. Anemia (I don't see how this question can be anything other than the fact that UC has bloody diarrhea associated with it) Arterial insufficiency diabetic - Diabetes affects the lining around cells in the blood vessels. Blood vessels are not as flexible as needed to help blood flow smoothly. PAD happens when buildup on the walls of blood vessels causes narrowing, commonly affecting diabetics prone to hyperlipidemia and heart disease. Nursing Interventions A. Monitor extremities at designated intervals.
- Color
- Temperature
- Sensation and pulse quality in extremities B. Schedule activities within the client's tolerance level. C. Encourage rest at the first sign of pain. D. Encourage the client to keep extremities elevated (if venous) when sitting and to change position often. E. Encourage client to avoid crossing legs and to wear nonrestrictive clothing. F. Encourage client to keep the extremities warm by wearing extra clothing, such as socks and slippers, and not to use external heat sources such as electric heating pads.
