378 Medical-surgical – Exam (76 To 100)

Frequent turning and positioning is the single most important nursing intervention to prevent ulcer formation. Skins are massaged but once the areas are reddened already [ CLASS I Ulcer ], It is not anymore massaged as not to prevent further breakdown. Lotions and Oils are not use in clients skin because it will further enhance skin breakdown. Water matress are used in BURN patients to limit the pressure on the skin by his own body weight. An alternating-inflatable air matress is much more compatible in periodic distribution of pressure in clients with prolong immobility. Keeping skin clean and dry is important but not as important as frequent turning and positioning.

If the client's right side is weak, the affected lobe is the LEFT LOBE which is where the broca's area is located. Client will exhibit expressive aphasia, careful and slow movements and right sided weakness. Judging distance and proprioception is usually impaired in clients with RIGHT sided stroke. Telling that the clients orientation to time and space will be much affected is a blind shot analysis. This is seen on clients with severe and massive hemorrhagic stroke with recovery failure related to aneurysms producing long term and permanent coma. Mr. Franco right side is weak, not paralysed, meaning, some functions are still left intact.

Hallucinations and delusions are part of DEMENTIA and is termed as ORGANIC PSYCHOSES. The daughter needs further teaching when she try to bargain, explain, dissprove or advice a client with dementia. The client has an impaired judgement, concentration, thinking, reasoning and memory and has inability to learn that is why institutional care for clients with dementia is always required. The disease is progressive and is not preventable.

Airway is always a priority in an unconscious client. Refer to maslows hierarchy of needs for prioritization. Although this is not absolute, knowledge with pathophysiology will best lead you to the correct option.

WBC increases with inflammation and infection.

Peritonitis will cause all of the above symptoms. The peritoneum has a natural tendency to GUARD and become RIGID as to limit the infective exudate exchange inside the abdominal cavity. Hypovolemia and F&E imbalance are caused by severe nausea and vomiting in patients with peritonitis because of acute pain. As inflammation and infection spreads, fever and chills will become more apparent causing elevation in temperature, weakness and sweating. If peritonitis is left untreated, Client will become severely hypotensive leading to shock and death.

Client will be on NGT once comatose, A is removed first. Client with CVA MAY have seizures, but it is RARE enough that it must require a frequent mouth care, B is eliminated next. Knowing that tactile stimulation is done by touching the patient and not by peforming mouth care will lead you to letter D. Comatose patient uses the mouth to breathe predisposing himself to drying, cracking and infections.

Probanthine on its own already cause severe dizziness and drowsiness. Addition of alcohol will further depress the CNS and might lead to potentiation of the side effects of probanthine. A,B,C are not contraindicated when taking probanthine EXCEPT when the disease entity itself do not permit intake of such drugs like in Pancreatitis, NSAID is not use. Pain is controlled using probanthine and meperidine [ demerol ] in cases of acute pancreatitis.

Drug compliance is the most important teaching for Mr. Dela Isla to prevent the symptoms of psychoses and to control behavioral symptoms.

Paralytic Ileus is a mechanical bowel obstruction where in, the patients intestine fails to regain its motility. It is usually caused by surgery and anesthesia. Intusussusception, Appendicitis and Peritonitis also causes paralytic ileus.

NGT after appendectomy is used not to deliver nutrients but to decompress the GI tract because of the absence of peristalsis after appendectomy. The stomach and intestines are not sterile, Clean technique is sufficient during irrigation. NGT is placed and not anymore advanced as long as it already reach the stomach. Naso enteric tubes are the one that are advanced periodically until obstruction is reached in the intestine. The client still needs assessment and confirmation of the return of peristalsis before anything is given per orem. Irrigations are done to prevent obstruction in the tube.

When flatus is expelled, it means that peristalsis has returned and theres is no need for continuing the NGT.

Probanthine is use in PUD to decrease gastric acid secretion. It is also used in Pancreatitis to rest the pancreas from over secretion of pancreatic enzyme and to prevent pain and spasm. Probanthine is contraindicated in clients with UC, Glaucoma. Since this is an anti spasmodic drug, Urinary retention will be a side effect

CVA patients has impaired swallowing ability and if not absent, depressed gag reflex. Client is at the highest risk for aspiration when eating or drinking that is why NGT is initiated early in the hospitalization. B prevent EXTERNAL ROTATION in hip or leg fracture. Footboards and splint prevents FOOTDROP seen in clients that has a severed peroneal nerve or prolonged immobilization usually due to fractures that eventually puts pressure on the peroneal nerve. A is not specific to clients with CVA.

Probanthine alters the ability of the body to secrete sweat. Telling the client to avoid hot weathers to prevent heat stroke is appropriate. Chlorinated pool is discouraged for patients undergoing skin radiation for skin cancer to prevent breakdown. Limiting fluid intake and avoiding cold weather are unecessary teachings.

Chronic brain syndrome tends to be progressive and irreversible. Organic brain syndrome is acute and irreversible or reversible depending on the causative factor.

Probanthine reduces glandular secretion of the different organs of the body. It is an anti-cholinergic / anti spasmodic drug and still, not approved by the FDA for treatment with various disorders. Probanthine exerts benifits for treatment of severe diaphoresis, Ulcers due to over secretion of HCl, Spasms, PANCREATITS [ Please take note ] and other conditions of over secretion.

Refer to ABDOMINAL ASSESSMENT : STORY TOWARDS MASTERY

Talk as normally as possible. The client has dementia and is not deaf, although hearing might be impaired progressively as the client ages, the nurse should not alter his voice, shout or over enunciate the words. Client will preceive this things as belittling and direspectful.

Like other anti cholinergics/ anti spasmodics, Probanthine causes dizziness, blurred vision and drowsiness. Patients are advised not to drive, operate heavy machineries etc. Probanthine should be taken with a full glass of water but is contraindicated with inflammatory bowel diseases like ulcerative colitis and chrons disease. Drug is taken with meals to prevent irritation of the gastric mucosa and client is advised not to take double dose in case the previous dose is missed

B, C and D are all behaviors that results from organic psychoses. The questions seems to ask EXCEPTION which is A. MEMORY DEFICIT. Organic psychoses is the same as the usual psychoses except that the causative factor of organic psychoses is evidently caused by a disease process of the brain or affecting the brain. Example are patients who suffer stroke suddenly experience hallucinations and delusions. Organic psychoses is simply a psychoses that has an IDENTIFIED CAUSE. Knowing this will lead you to understand that psychoses is manifested by B,C, and D but NOT MEMORY DEFICIT.

Client's peristalsis will return in 48 to 72 hours post-op therefore, Fluid and food are witheld until the bowel sounds returns. Remember that ALL PROCUDURES requiring GENERAL and SPINAL anesthesia above the nerves that supply the intestines will cause temporary paralysis of the bowel. Specially when the bowels are traumatized during the procedure, it may take longer for the intestinal peristalsis to resume.

Spinal anesthesia is the most common method used in appendectomy. Using this method, Only the area affected is anesthetized preventing systemic side effects of anesthetics like dizziness, hypotension and RR depression.

Organic psychoses is a broad and collective term used for psychoses and schizophrenia that has an organic cause. [ Due to Creutzfeldt jakob disease, huntington, hydrocephalus, increase ICP, dementia, stroke etc. ] Manifesting signs and symptoms like hallucination, delustions, illusion, ideas of reference etc. that is similar to schizophrenia and psychoses in absence of organic causes.

Pain is not reduced in appendicits. Clients are not given pain medication as to assess whether the appendix ruptured. A sudden relief of pain indicates the the appendix has ruptured and client will have an emergency appendectomy and prevent peritonitis. Demerol and Atropine are used to allay client's anxiety pre operatively.