NCLEX-RN: Medical–Surgical Nursing

Medical–Surgical Nursing: Surgical Intervention

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: General Preoperative Care

Focus topic: Medical–Surgical Nursing

Assessment
A. Follow general assessment modalities for preoperative care.
B. Observe and record neurological symptoms relative to site of problem (clot, lesion, aneurysm, etc.), for example:

  • Paralysis.
  • Seizure foci.
  • Pupillary response.

Implementation
A. Provide psychological support to client and family.
B. Prep and shave cranial hair (save hair).
C. Apply scrub solution to scalp, as ordered.
D. Avoid using enemas unless specifically ordered; the strain of defecation may lead to increased intracranial pressure.
E. Explain postoperative routine orders such as neurological checks and headaches.
F. Administer steroids or mercurial diuretics as ordered, to decrease cerebral edema.
G. Insert NG tube and/or Foley catheter, as ordered.

Medical–Surgical Nursing: General Postoperative Care

Focus topic: Medical–Surgical Nursing

Assessment
A. Follow general assessment modalities for postoperative clients.
B. Observe neurological signs.

  • Evaluate level of consciousness.
    a. Orientation to time and place.
    b. Response to painful stimuli: Pinch Achilles tendon or test with safety pin.
    c. Ability to follow verbal command.
  • Evaluate pupil size and reactions to light.
    a. Are pupils equal, not constricted or dilated?
    b. Do pupils react to light?
    c. Do pupils react sluggishly or are they fixed?
  • Evaluate strength and motion of extremities.
    a. Are hand grasps present and equal?
    b. Are hand grasps strong or weak?
    c. Can client move all extremities on command?
    d. Are movements purposeful or involuntary?
    e. Do the extremities have twitching, flaccid, or spastic movements (indicative of a neurological problem)?

C. Observe vital signs.

  • Keep client normothermic to decrease metabolic needs of the brain.
  • Observe respirations for depth and rate to prevent respiratory acidosis from anoxia.
  • Observe blood pressure and pulse for signs of shock or increased intracranial pressure.

D . Evaluate reflexes.

  • Babinski—positive Babinski is elicited by stroking the lateral aspect of the sole of the foot, backward flexion of the great toe, or spreading of other toes.
    a. Most important pathological reflex in neurology.
    b. If positive, indicative of pyramidal tract involvement (usually upper motor neuron lesion).
  • Romberg—when client stands with feet close together, he or she falls off balance. If positive, may have cerebellar, proprioceptive, or vestibular difficulties.
  • Kernig—client is lying down with thigh flexed at a right angle; extension of the leg upward results in spasm of hamstring muscle, pain, and resistance to additional extension of leg at the knee (indicative of meningitis).

E. Observe for headache, double vision, nausea, or vomiting.

Implementation
A. Maintain patent airway.

  • Oxygen deprivation and an increase of carbon dioxide may produce cerebral hypoxia and cause cerebral edema.
  • Intubate if values indicate to be necessary:
    a. PO2 below 80 mm Hg.
    b. PCO2 above 50 mm Hg.

B. Suction if necessary, but not through nose without specific order.
C. Maintain adequate oxygenation and humidification.

D. Place client in semiprone or semi-Fowler’s position (or totally on side). Turn every 2 hours, side to side (unless contraindicated by surgical procedure).
E. Maintain fluid and electrolyte balance.

  • Do not give fluid by mouth to semiconscious or unconscious client.
  • Weigh to determine fluid loss.
  • Administer IV fluids slowly; over-hydration leads to cerebral edema.

F. Record accurate intake and output.
G. Watch serial blood and urine samples; sodium regulation disturbances accompany head injuries.
H. Keep temperature down with cooling blanket if necessary. If temperature is down, the metabolic requirements of brain as well as oxygen requirements are less.
I. Take vital and neurological signs every 15–30 minutes until stable.
J. Use seizure precautions. Administer anticonvulsants as ordered.
K. Provide hygienic care, including oral hygiene.
L. Observe dressing for unusual drainage (bleeding, cerebrospinal fluid).
M. Prevent straining with bowel movements.
N. Administer steroids and osmotic diuretics to decrease cerebral edema.

O. Observe for and treat postoperative complications.

  • Increased intracranial pressure.
  • Seizures.
  • Hemorrhage.
  • Wound infection.
  • Brain abscess.
  • Meningitis.

Medical–Surgical Nursing

Medical–Surgical Nursing: Eye and Ear

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Glaucoma

Focus topic: Medical–Surgical Nursing

Definition: An eye disorder in which intraocular pressure is too high for the health of the eye—causes atrophy of the optic nerve and peripheral visual field loss.

Characteristics
A. Glaucoma classified into two main types: openangle and angle-closure.
B. Also classified by cause: primary, cause is not known; secondary, cause is known.
C. Primary open-angle (chronic) glaucoma.

  • Results from an overproduction or obstruction to the outflow of aqueous humor. Aqueous humor flows from the trabecular network, Schlemm’s canal, or aqueous veins.
  • About 60% to 70% of all glaucoma cases are of this type.

D. Primary angle-closure (narrow angle—acute) glaucoma follows an untreated attack of acute angle-closure glaucoma.

  • Results from an obstruction to the outflow of
    aqueous humor.
  • Causes of obstruction.
    a. A narrow angle between the anterior iris and the posterior corneal surface.
    b. Shallow anterior chambers.
    c. A thickened iris that causes angle closure upon pupil dilation.
    d. A bulging iris that presses on the trabecula to close the angle.
  • Caused by trauma, drugs, or inflammation.

Assessment
A. Type of glaucoma.

  • Primary open-angle—slow, progressive course.
  • Angle-closure.
  • Other glaucomas (associated with inflammation, trauma, surgery, etc.).

B. Risk conditions: over 40 years of age, diabetes, African American, hypertensive, familial history of glaucoma, and history of eye injury.
C. Results of Schiotz or Goldman’s Applanation Tonometer Test (7 to 21 mm Hg is normal) and optic-disc cupping.
D. Primary open-angle manifestations.

  • Slow loss of peripheral vision.
  • Eventual loss of central vision; tunnel vision.

E. Primary angle-closure glaucoma manifestations (accounts for 10% of all glaucomas).

  • Unilateral inflammation.
  • Pain; pressure over eye.
  • Increased intraocular pressure (24–32 mm Hg to much higher). One-sixth of clients have pressure within normal range.
  • Moderate pupil dilation, nonreactive to light.
  • Cloudy cornea.
  • Blurring and decreased visual acuity.
  • Photophobia.
  • Halos around light.
  • Nausea and vomiting.

Implementation
A. Chronic or primary open-angle glaucoma.

  • Decrease aqueous humor production through beta blockers or prostaglandins.
  • Treated first with medication. New drugs include topical α2-selective adrenergic agonists, carbonic anhydrase inhibitors and prostaglandin analogs.
  • When medication no longer controls intraocular pressure and peripheral vision is lost, prepare client for argon laser treatments.
    a. Trabeculoplasty—laser alters trabecular meshwork and facilitates aqueous humor drainage.
    b. Trabeculectomy—creates a new opening at limbus to allow drainage of aqueous humor.
    c. Seton implants (Moltemo).
    d. Photocoagulation—uses argon laser heat to destroy portions of the ciliary body.
    e. Cyclocryotherapy—freezes tissue and destroys portions of the ciliary body.

B. Acute or primary angle-closure glaucoma.

  • Treat as a medical emergency problem.
  • Administer drugs to lower intraocular pressure (IOP)—beta blockers, IV or oral carbonic anhydrase inhibitors, or topical adrenergic agonists.
  • Prepare client for laser peripheral iridotomy (definitive treatment).
    a. Allows aqueous humor to flow from posterior to anterior chamber.
    b. Administer ordered drugs: Salagen (pilocarpine), Diamox (acetazolamide), mannitol, etc.

C. Provide postoperative care.

  • Administer cycloplegic eye drops to affected eye to relax the ciliary muscle and decrease inflammation.
  • Observe unaffected eye for symptoms of acute angle-closure glaucoma if cycloplegic drops are given by mistake.

D. Instruct client to limit activities that increase intraocular pressure—straining, coughing, stooping, or lifting.

Medical–Surgical Nursing: Cataracts

Focus topic: Medical–Surgical Nursing

Definition: Clouding or opacity of the lens that leads to
blurred vision.

Characteristics
A. Opacity is due to physical changes of the fibers or chemical changes in protein of the lens—most often caused by the slow, degenerative changes of age. Leading cause of blindness worldwide.
B. The goal of cataract surgery is to restore functional vision.
C. Surgical procedure is usually based on individual needs.

  • If any inflammation is present, surgery is not performed.
  • Cataracts are usually removed under local or topical anesthesia.
  • Some simple cataracts are removed by use of alpha chymotrypsin, which weakens the zonular fibers that hold the lens in position.
  • Surgery is performed on one eye at a time.

D. Types of surgical extraction.

  • Extracapsular—the lens is lifted out without removing the posterior lens capsule.
  • Phacoemulsification (ultrasonic)—the lens is broken up by ultrasonic vibrations and extracted via extracapsular route.

E. Intraocular lens implant at time of surgery is a common alternative to sight correction with glasses.

  • Cataracts are now removed through smaller incisions to promote rapid visual rehabilitation.
  • New intraocular lens designs have helped to prevent lens epithelial cell migration.

Implementation
A. Check that client understands preoperative instructions.

  • Client must be transported to and from hospital.
  • Client must have someone at home for assistance following surgery.
  • Client should be NPO, and shampoo hair before surgery.
  • Review instructions to decrease intraocular pressure (do not bend, cough, strain, or lift).

B. Administer prescribed preoperative medications.

  • Mydriatics and cycloplegics (Cyclogyl [cyclopentolate]) to paralyze ciliary muscle—note whether pupil dilates following drug instillation.
    a. Instruct client to wear dark glasses to minimize photophobia that may occur from drugs.
    b. Monitor for signs of systemic toxicity (e.g., CNS effects and tachycardia).
  • Topical antibiotics—prevention of infection.

C. Provide postoperative care. Most procedures are done on outpatient basis.

  • Instruct client in postoperative drugs.
    a. Mydriatics are occasionally used.
    b. Steroids (prednisolone suspension) and antibiotic drops.
    c. Analgesics.
  • Instruct in ways to alleviate symptoms that could result in complications.
    a. Increased intraocular pressure may occur with nausea and vomiting, restlessness, coughing or sneezing, lifting more than 15 pounds, constipation.
    b. Observe for signs of infection: increasing redness, tearing, green drainage, or photophobia.
  • Instruct client to notify physician of sudden pain in operative eye—may be due to ruptured vessel or suture.
  • Apply dressing and shield at night to prevent injury to operative eye if ordered. Unoperative eye is usually left uncovered.
  • There is research that indicates that postop activity restrictions and nighttime eye shields are not necessary. However, many physicians still instruct clients to avoid activities that will increase IOP such as bending, coughing, stooping, or lifting, and instruct client on head positioning.
  • Reinforce instructions on dressing changes and eye drops. (Client returns to physician’s office first postoperative day for change of dressing.)
  • Inform client that temporary glasses are prescribed 1–4 weeks postoperatively if lens is not implanted.

D. Assist client with specific adjustment problems.

  • Intraocular lens implant at time of surgery is very common.
    a. This lens provides means of focusing light on the retina—approximates human lens.
    b. If no implant, the eye cannot accommodate and glasses must be worn at all times.
    c. Mydriatic drops frequently used to prevent lens displacement.
  • Cataract glasses magnify—objects appear closer. Teach client to accommodate, judge distance, and climb stairs carefully.

Ophthalmic Drugs
A. Miotics: pilocarpine HCl 1–4% solution; Carbastat, Miostat (carbachol); cholinergic agonists.

  • Action is contraction of ciliary muscle, which increases flow of aqueous humor.
  • Treatment for glaucoma and certain types of lens implants.
  • Side effects: headache, conjunctiva irritation, and inflammation.

B. Beta blockers: Timoptic (timolol); Betoptic, Kerlone (betaxolol), Betagan (levobunolol).

  • Action is to reduce intraocular pressure by decreasing formation of aqueous humor or may facilitate outflow of aqueous humor.
  • Treatment for glaucoma.
  • Side effects: eye irritation.

C. Carbonic anhydrase inhibitors: Diamox (acetazolamide), Daranide (dichlorphenamide).

  • Action is to restrict action of the enzyme necessary to produce aqueous humor—thus, decrease aqueous production.
  • Treatment for glaucoma.
  • Side effects: CNS disturbance, GI irritation, acidosis, hypokalemia.

D. Hyperosmotic agents: glycerin (oral) or mannitol (IV).

  • Action is to draw fluid from the eye (increase blood osmolarity)—reduce intraocular pressure.
  • Treatment for cataract surgery as preoperative medication.
  • Side effects: CNS—headache, confusion, blurred vision; GI irritability, nausea, dehydration.

E. Nonselective adrenergic agonists: Adrenalin (epinephrine), Propine (dipivefrin).

  • Action is to increase aqueous outflow and decrease aqueous production.
  • Topical treatment for glaucoma.

F. Topical antibiotics are used to prevent infection.

Retinal Detachment

Characteristics
A. The retina is the part of the eye that perceives light; it coordinates and transmits impulses from its seeing nerve cells to the optic nerve.
B. There are two primitive retinal layers: the outer pigment epithelium and an inner sensory layer.
C. Retinal detachment occurs when

  • The two primitive layers of the retina separate, due to the accumulation of fluid between them.
  • Both retinal layers elevate away from the choroid, due to a tumor.

D. As the detachment extends and becomes complete, blindness occurs.

Assessment
A. Opacities before the eyes.
B. Flashes of light.
C. Floating spots—blood and retinal cells freed at the time of the tear cast shadows on the retina as they drift about the eye.
D. Progressive constriction of vision in one area.

  • The area of visual loss depends on the location of detachment.
  • When the detachment is extensive and rapid, the client feels as if a curtain has been pulled over his or her eyes.
  • Painless.

Implementation
A. Provide preoperative care.

  • Keep client on bed rest.
  • Cover both eyes with patches to prevent further detachment.
  • Position client’s head so the retinal hole is in the lowest part of the eye.
  • Immediate surgery with drainage of fluid from subretinal space so that retina returns to normal position.
  • Retinal breaks are sealed by various methods that produce inflammatory reactions (chorioretinitis).
    a. Cryosurgery—cold probe applied to sclera causes a chorioretinal scar. Most common procedure.
    b. Diathermy—causes retina to adhere to choroid.
    c. Laser—seals small retinal tears before detachment occurs.

B. Provide postoperative care.

  • Maintain safe environment.
    a. Keep side rails up.
    b. Feed client.
    c. Maintain bed rest for 1 or 2 days.
    d. Give client call bell and answer immediately.
  • Prevent complications.
    a. Observe for hemorrhage, which is a common complication. Notify physician immediately of any sudden, sharp eye pain, restlessness.
    b. Cover both eyes; keep lights dim.
    c. Position so area of detachment is in dependent position. (If air bubble is present, position on abdomen.)
    d. Prevent clinical manifestations that can cause hemorrhage.
    (1) Nausea and vomiting.
    (2) Restlessness.
    e. Encourage client to do deep breathing but to avoid coughing (increases intraocular pressure).
    f. Administer good skin care to prevent breakdown.
  • Provide emotional support.
    a. Provide audible stimulation.
    b. Warn client as you enter the room and always speak before touching.
    c. Orient to surroundings.

C. Provide client instruction.

  • Convalescent period.
    a. Wear patch at night to prevent rubbing of eyes.
    b. Wear dark glasses; avoid squinting.
    c. No reading for 3 weeks.
  • Postconvalescent period.
    a. Avoid straining and constipation.
    b. Avoid lifting heavy objects for 6–8 weeks.
    c. Avoid bending from the waist.
    d. May return to more active life in 6–8 weeks.
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Medical–Surgical Nursing: Age-Related Macular Degeneration (ARMD or AMD)

Focus topic: Medical–Surgical Nursing

Definition: Macula cells fail to function and cell regeneration lessens, which causes loss of central vision.

Characteristics
A. The leading cause of new cases of uncorrectable vision loss in adults over 60 years of age.

  • Most cases are age-related.
  • Much more common in Caucasians than in African Americans.

B. There are two types.

  • Dry (atrophic)—photo receptors in the macula of the retina fail to function and are not replaced due to age.
  • Wet (exudative)—less common but more severe form in which retinal tissue degenerates, allowing fluid to leak into the subretinal space.

Assessment
A. Painless loss of central vision in one or both eyes.

  • Blurred vision.
  • Distortion of straight lines.
  • Dark spot in the central vision area.

B. Decreased ability to distinguish colors.
C. Check if client has difficulty with everyday activities— reading, driving, watching television, recognizing faces.

Implementation
A. Assist client to learn to compensate for visual deficit in the home.
B. Discuss client’s fear of blindness.
C. Discuss optical aids available, closed-circuit television, telescopic lenses.
D. Refer client to a low-vision support group.
E. If client is hospitalized with this condition, orient to room, remove clutter, assist with meals, and always identify self when entering room.

F. Alternative therapy and prevention: vitamin and nutrient supplements (lutein, lycopene, zinc, betacarotene, vitamin C, vitamin E).

Medical–Surgical Nursing: Removal of Foreign Body from Eye

Focus topic: Medical–Surgical Nursing

A. Have client look upward.
B. Expose and evert lower lid to expose conjunctival sac.
C. Wet cotton applicator with sterile normal saline, and gently twist swab over particle and remove it.
D. If particle cannot be found, have client look downward. Place cotton applicator horizontally on outer surface of upper lid.
E. Grasp eyelashes with fingers, and pull upper lid outward and upward over cotton stick.
F. With twisting motion upward, loosen particle and remove.
G. If penetrating object—do not remove. Cover with cup, do not bend, and notify physician STAT.

Medical–Surgical Nursing: Stapedectomy

Focus topic: Medical–Surgical Nursing

Characteristics
A. Surgery is performed when the client has otosclerosis.
B. Otosclerosis is a condition in which the stapes is replaced.

  • A graft is placed over the oval window and a prosthesis is positioned between the incus and covered oval window.
  • Stapes replacement surgery has a high success rate, with the client experiencing improved hearing.

C. Surgical procedure.

  • An incision is made deep in the ear canal, close to the eardrum, so that the drum can be turned back and the middle ear exposed.
  • The surgeon frees and removes the stapes and the attached footplate, leaving an opening in the oval window.
  • The client can usually hear as soon as this procedure has been completed.
  • The opening in the oval window is closed with a plug of fat or Gelfoam, which the body will eventually replace with mucous membrane cells.
  • A steel wire or a Teflon piston is inserted to replace the stapes.
    a. It is attached to the incus at one end and to the graft or plug at the other end.
    b. The wire transmits sound to the inner ear.
  • External canal is packed, covered with “eye patch” dressing over auricle.

Implementation
A. Position client in low-Fowler’s, on unoperated side, or as ordered.
B. Do not turn the client.
C. Put side rails up.
D. Have client deep-breathe every 2 hours until ambulatory, but do not allow client to cough.
E. Check for drainage; report excessive bleeding.
F. Prevent vomiting.
G. Give antibiotics as ordered.
H. Client may have vertigo when ambulatory; stay with the client and avoid quick movements.
I. Advise client not to smoke.

Medical–Surgical Nursing: Irrigation of External Auditory Canal

Focus topic: Medical–Surgical Nursing

A. Remove any discharge on outer ear.
B. Place emesis basin under ear.
C. Gently pull outer ear upward and backward for adult, or downward and backward for child.
D. Place tip of syringe or irrigating catheter at opening of ear.
E. Gently irrigate with solution at 95°F to 105°F (35°–40.5°C), directing flow toward the sides of the canal.
F. Dry external ear.
G. If irrigation does not dislodge wax, instillation of drops will need to be carried out.

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