Understanding Medical Surgical Nursing Ch 27
Terms
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- epistaxis
-
nosebleed
anterior bleeds (originating from Kiesselbach plexus) most common -
Which of the following positions is recommeded for a pt experiencing a nosebleed?
a. lying down w/feet elevated
b. sitting up w/neck fully extended
c. lying down w/a small pillow under the head
d. sitting up le - d. sitting up leaning slightly forward
-
Which of the following is the best explanation by a nurse for why a physician did not prescribe antibiotics for influenza?
a. "Most cases of influenza are caused by antibiotic resistant bacteria."
b. "Influenza is cau - b. "Influenza is caused by viruses."
-
Which of the following responses is correct when a pt asks why her physician didn't order that new antiviral drug for her flu?
a. "The antiviral drugs are for AIDS, not the flu."
b. "The side effects of the antiviral - d. "These drugs only work if you start them within 48 hours after flu symptoms start."
-
After a laryngectomy, which of the following assessments takes priority?
a. Airway patency
b. Nutritional status
c. Lung sounds
d. Patient acceptance of surgery - a. Airway patency
-
Which of the following communication methods will not work for the pt w/a laryngectomy?
a. placing a finger over the stoma
b. providing a special valve that diverts air into the esophagus
c. obtaining a picture board
- a. placing a finger over the stoma
-
Which of the following statements best explains why the nurse is careful when administering narcotics to a laryngectomee?
a. Most laryngectomees have been drug addicts in the past.
b.Even low doses of narcotics may cause respiratory - c. Narcotics can depress the cough reflex
- Other causes of epistaxis are . . .
-
- trauma
- hypertension
- anticoagulants - Treatment options for epistaxis include:
-
- sit in chair & lean forward
- pressure to nares for 5 to 10 min
- ice packs to nose area
- local application of vasoconstrictive agent
- electrical cauterizing
- nasal packing for 2-4 days
- nasal balloon catheter - nasal polyps
-
grapelike clusters of mucosa in nasal passages
usually benign but can obstruct nasal passage
more common in people w/allergies
"triad dx" = nasal polyps + asthma + ASA allergy - Symptoms of a deviated septum include:
-
- stuffy nose
- blocked sinus drainage
- headaches
- epistaxis - nasoseptoplasty
-
incision made through mucous membrane covering septum
deviated portion of septum removed
AKA submucous resection (SMR) - rhinoplasty
- surgical reconstruction of the nose
- sinusitis
-
inflammation of the mucosa of one or more sinuses
maxillary & ethmoid sinuses usually affected
most common infecting organisms are Streptococcus pneumoniae & Haemophilus influenzae - Treatment for sinusitis includes:
-
- decongestants
- hot packs
- saline irrigation
- humidification
- surgical drainage
- antibiotics -
viral rhinitis
(AKA common cold) -
S/S are congestion, sneezing discharge
treat symptoms - pharyngitis
-
inflammation of the pharynx
usually related to bacterial/viral infection
most commonly caused by beta-hemolytic streptococci (strep throat)
if not treated, can lead to rheumatic fever - S/S of pharyngitis include:
-
- sore throat
- dysphagia
- red, swollen throat
- exudate may be present (usually means bacteria present)
- fever
- malaise - dysphagia
- difficulty swallowing
- exudate
- drainage or pus
- laryngitis
-
inflammation of the mucous membrane lining the larynx
S/S cough, dysphagia, fever, hoarseness - tonsillitis
-
occurs when filtering function of tonsils becomes overwhelmed w/a virus or bacteria & infection results
most common organisms are Streptococcus species, Staphylococcus aureus, Haemophilus influenzae, & Pneumococcus species - S/S of tonsillitis include:
-
- sore throat
- fever
- pain on swallowing
- exudate
- malaise
- myalgia - myalgia
- muscle pain
- influenza
-
viral infection of respiratory tract
transmitted via droplets or physical contact from infected individuals or objects
incubation period from time of exposure to onset of symptoms is 1 to 3 days -
influenza prevention
-who needs it?
-how is it done? -
who? people 50+ yrs old - residents of extended care facilities - those w/chronic illness
how? shot - immunization doesn't have live virus - 2 wks for antibodies to develop - 4 months until effective - Cancer of the larynx usually develops in the 1_____ 1_____. It is usally a 2_____ cancer and can spread to the 3_____, 4_____, or 5_____ 5_____. The prognosis for a patient with laryngeal cancer is often poor because 6_____ may have occurred prior to pat
-
1 mucosal epithelium
2 primary
3 lungs
4 liver
5 lymph nodes
6 metastasis - S/S of cancer of the larynx:
-
- hoarseness
- change in voice
- pain
- dysphagia
- airway obstruction -
Acute Pain Related to Infections Process
interventions: -
- assess for cause of discomfort
- offer pain relief
- encourage rest -
Hyperthermia Related to Infectious Process
interventions: -
- monitor temp (q4h if febrile)
- monitor for dehydration
- encourage oral fluids
- give antipyretic if temp higher than 102.5 F -
Risk for Infection: Transmission to Others Related to Presence of Infectious Disease
interventions: -
- teach good handwashing
- assess pt's understanding of infection transmission