Hesi Med Surg Study Guide - Hematemesis Information Nursing Processes

HESI MED SURG STUDY GUIDE - HEMATEMESIS INFORMATION NURSING PROCESSES Please use this guide as such, a guide however remember to utilize the basics, the nursing process, ABCs and prioritize accordingly. Hematemesis (vomiting blood) - typically upper GI bleed a. What to assess? i. Remember ABCs (pt having diff breathing?), check vital signs first* ii. Assess stool (blood present? - if so, what color. Dark red = upper GI bleed, usually more serious) iii. Check if they are on iron supplements iv. Worried about hypovolemic shock 1. S/S: restlessness, agitation, inc HR and RR, cool, pale, sweaty Open vs Close angle glaucoma b. Def: condition characterized by inc intraocular pressure (IOP > 22 mmHg) r/t aqueous fluid being inadequately drained from eye gradual painless vision loss. Generally asymptomatic in early stages (seen in reg eye exam) i. No cure, can be treated pharmacologically and surgically c. Patient teaching i. Develop a teaching plan that includes the following: (p. 131) 1. Careful adherence to eye-drop regimen can prevent blindness 2. Vision already lost cannot be restored 3. Eyes drops are needed for rest of life a. Eye drops used to cause pupillary constriction - mvmt 4. ***Proper eye-drop instillation technique. Obtain