185 - med surg exam 2 Flashcards by Alayna Johnson

When a client with a second degree burn injury in the acute stage of recovery, which finding would the LPN report immediately to the registered nurse?

A) Urine output of 70 mL/hr
B) Foul oder from the wound
C) Client reports pain 3/10
D) Client reporting no bowel movement for the past 2 days

B) Foul oder from the wound

RATIONALE: Foul oder may indicate infection and should be reported immediatly to the RN for a follow up

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Tissue injury caused by thermal/chemical/ect. burns

Severity is based on size, debth, location, age, gender, health status, & mechanism of injury

Classified by size & debth of tissue injury
* Partial or full thickness
* reevaluate frequently
* Size often defined as % of area effected (Wallace Rule of 9)

Leading cause of accidental death

Burns

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Affects ONLY epidermis - mildest

S/S:
* Pink/red
* Painful, minor swelling
* Dry w/o blisters
* Blanches
* No vesicles

Healing time:
* 3-6 days
* Superficial layer overskin may peel off in 1 or 2 days

Ex: Sunburn

Superficial Burn (1st Degree)

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Affects epidermis & dermis

S/s:
* Painful
* Large, moist, weepy blister
* Pale, pink, red

Ex: severe sunburn, large blister

Superficial partial thickness burn (2nd degree)

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Exposed dermis
* Skin, fat, muscle

S/s:
* Large, thick walled blister/edema
* weeping, cherry red
* Painful, sensative to cold air

Tx:
* Hospitalization
* monitor for shock
* Keep covered

Deep partial thickness burn

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Involves epidermis, dermis, & underlying tissues including fat, muscle, & bone

S/s:
* Dry, leathery, eschar
* May be red, brown, black, or white
* Lacks sensation

Tx:
* Hospitalization
* monitor for shock
* Keep covered

Full thickness burn

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What are the percentages of each body part involved in the rule of nine?

Head (Front & back)
Arms (Front & back)
Abd (2 sections - upper/lower (Front & back))
Legs (Front & back)
Groin (Front & back)

Head (Front & back) - 4.5%

Arms (Front & back) - 4.5%

Abd (2 sections - upper/lower (Front & back)) - 9%

Legs (Front & back) - 9%

Groin (Front & back) - 1%

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Predicts the probability or morality d/t burns

Baux score

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When is fluid resuscitation the most critical in a burn pt?

24-48 hrs after injury

I/O’s strictly monitored to prevent shock

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What is the most common skin infection for a burn patient that is found in the U.S?

Methicillin-resistant staphylococcus aureus (MRSA)

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Releases chemicals that cause increased capillary permeability

Permits excess Na to enter the cell & allows K to escape into the extracellular compartment

Shift causes edema & decreases cardiac output, & decline in blood volume (Olguria, hypovolemic shock)
* 18-36 hrs after injury, capillary permeability normalizes & reabsorption of edema fluid begins. Cardiac o/p normalizes & increases to meet increased metabolic demands

Decreased blood flow a ileus may occus

Stress ulcer may occur (Curling ulcer)

Pathophysiology of Burn injuries

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What is the most common skin infection for a burn patient that is found OUTSIDE of the U.S?

Acinetobacter

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What lab should you draw for a military pt who has returned to the U.S for treatment?

Culture on admission to rule out any infection (Acinetobacter / MRSA)

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Begins when burn starts & ends when fluid shifts stabilize
* First 12-48 hrs critical

S/s:
* Hemoconcentration (Increased Hct)
* Acute renal failure (ARF), olguria
* Hyperkalemia, hyponatremia
* Hypovolemic shock
* Metabolic acidosis
* Risk of cardiac dysrhythmias

Tx:
* ABCs, ABGs
* Start IV (PIV/central)
* Insert cath. & NGT, tetanus prophylaxis
* Pain managment/assessment & tetanus
* Clean/debride wounds, topical antibiodics
* Blood for baseline blood studies (Hct, electrolytes)
* Assess for smoke inhalation injury - intubate if needed
* Hydrotherapy (softens eschar), escharotomy
* ROM, skin graft

Emergent / hypovolemic stage of burn injury

(1st of 3 stages of burn injuries)

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Begins 48-72 hrs after fluids stabilize
* Some marked when all but 10% of burn wounds are closed or until all wounds are closed

S/s:
* Hemodilution (decreased Hct)
* CHF risk
* Metabolic acidosis
* Hypokalemia, hyponatremia
* Circulatory overload / hypervolemia (Main concern)
* Polyuria (kidney problem - Insert fowly cath)

Acute/Diuretic stage of burn injury

(2nd of 3 stages of burn injuries)

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Goal: Prevent infection & return pt to “normal”
* Can take months

Overlaps w/ acute stage
* Starts when pt is stable

PT/OT begin tx

Interventions:
* Restore independence
* Adjusting to body image
* Preventing contractures
* Coping

Rehabilitation stage of burn injury

(3rd of 3 stages of burn injuries)

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Which burn may blister, peel & heal w/ minimal long-term effects?

A) Partial-thickness
B) Full-thickness
C) Deep Partial-thickness

Chpt 57 pg 1165

A) Partial-thickness

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Which burn is often covered by a thick, leathery layer of burned tissue/eschar that shelters microorganisms & inhibits healing?

A) Partial-thickness
B) Full-thickness
C) Deep Partial-thickness

Chpt 57 pg 1165

B) Full-thickness

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Removal of debris & necrotic tissue from a wound
* Eschar must be removed or healing will not take place

Types:
* Surgical excision: Escharotomy

Mechanical: Removing eschar/ necrosis w/ scissors/ forcepts
Enzymatic: Use of topical medications containing enzymes capable of dissolving necrotic tissue. (Cause pain & bleeding)

Debridement

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What is the goal of wound care after a burn injury?

Promote healing

Prevent infection

Controll heat loss

Retain function

Minimize disfigurement

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What are the 2 standard wound care treatments for patients w/ burns?

Open care method:
* Topical antimicrobials but no dressings
* Less restrictive & simpler but provides increased opportunity for loss of fluid & heal through wounds surface

Closed care method:
* Topical antimicrobials but covered by dressings

Examples of Topical medications:
* Silvadiazine (Silvadene)
* Mafenide acetate (Sulfamylon)

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What is the preferred solution for burn patients?

Lactated Ringers (LR)

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Where would a LPN start an IV?

Peripheral IV (PIV)

TIP: LPN can insert IV 3in into AC and below

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Surgical procedure done by making an incision through the eschar to relieve underlying pressure, measuring the pressure in the compartment, closed space nerves, muscle tissue, & blood vessels

Used to relieve circulatory construction

Escharotomy

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A burn **covered by the pts own skin** * *preferred sites are thigh or butt* removed by **dermatome** (tool used to remove graft)

Autograft (skin graft)

A type of **skin graft applied to a thin layer of skin** May be an intact layer of skin or meshed graft * *Meshed grafts have multpile tiny slits to allow skin to be stretched to cover a large area*

Split-thickness graft

A type of **skin graft used for deep burns to face, neck, & hands** *Include subq tissue & skin* Cosmetically provied better results

Full thickness graft

What are some nursing interventions for a pt w/ a skin graft?

Assess site for bleeding *Immobilization of affected area for 3-7 days to ensure attachment of the graft* Remove dressings and allow wound to air dry 24 hrs after surgery - Can use heat lamp to dry area * While site dries, a fine-mesh gaze or Zeroform will lift off of the skin

What vitals s/s should you notify the HCP immediatley for in a client w/ burn injuries?

**Take vitals first** & report: * Restlessness, Tachypnea (**Hypoxia**) * Bounding pulse, HTN (**Fluid volume excess**) * Tachycardia, hypotension (**Hypovolemia**) * Fever, Tachycardia (**Infection**)

What intervention should be done ASAP during an inital assessment of a stable pt w/ a burn injury?

Height & weight

Occurs w/ flame burns or from being trapped in an enclosed space filled w/ smoke Pts *can have pulmonary edema resulting in resp. failure* S/s: * *Facial burns* * Redness, **swelling of pharynx** * Restlessness, Tachypnea (**Hypoxia**) * *Dyspnea, sooty sputum* * Death Interventions: * **Protect airway** (intubate) and *evaluate for resp. distress syndrome* * Apply O2 * *pulmonary function studies* done before discharge to complete lung function

Smoke inhalation

Carbon monoxied displaces O2 on _____ , so the blood is unable to transport O2 into the tissues A) Hgb B) Hct C) WBC D) platelets

A) Hgb

What type of pain meds would you give to a burn pt?

Morphine, fentanyl, & other opioids * Pre-medicate priot to any procedure (Required)

What do the letters stand for in R.A.C.E?

**R**: Rescue **A**: Alarm **C**: Contain fire **E**: Extinguish/ Evacuate

What do the letters in P.A.S.S stand for when operating a fire extinguisher?

**P**: Pull **A**: Aim **S**: Squeeze **S**: Sweep

2 Types: * **Aesthetic (cosmetic)** procedures: Performed to improve apperance * **Reconstructive** procedures: Performed to correct abnormalities/ disfigured scars Ex: * **Rhytidectomy** (*facelift*): Remove wrinkles & tightens sagging tissue * **Blepharoplasty**: Removal of excess tissue arround the eyes imparing vision, aesthetic procedure * **Chin implants**: Done by placeing a prosthesis to correct a receding chin * **Rhinoplasty**: Nose job, alters shape/size * **Abdominoplasty**: Excess skin & adipose tissue are removed & abd. muscles are tightned * **Breast augmentation**: Breast enlargment * **Breast reduction**

Plastic surgery

What is the purpose of a reconstructive procedure?

Repair disfigured scars Restore body contours after radical surgery (Mastectomy) Restore features damaged from trauma/disease Correct developmental defects

How could you educate a burn patient?

Practice *good hygiene & avoiding others w/ infections* **Eat 6 small frequent meals a day plus supplements** * Make sure to eat all food on plate *Change positions, exercise, & use splints to **help prevent stiffening of the joints, skin breakdown, & blood clots in legs*** Pain managment * Contact HCP if pain is uncontrolled Protect grafts from pressure & shearing Clothing, make-up, hairpieces, & prostheses can be used to conceal scars & improve apperance *Adaptive devices are avalible to compensate for disabilities* *Rehabilitation resources will be provided once the acute phase has passed*

A burn pt on the unit is showing signs and symptoms of inadequate circulation. What signs and symptoms would you see?

S/s: * **Hypotension** d/t blood volume not being maintained causing *impaired tissue perfusion* * **Tachycardia**, *decreased urine o/p* (blood volume) * *Cool, pale, cyanotic skin* (impaired tissue perfusion) * **Restlessness**, *confusion* (impaired tissue perfusion)

what interventions would be in place for a burn pt who is showing signs and symptoms of inadequate circulation?

Monitor vital (BP & HR especially) Monitor cardiac o/p (Pulmonary artery cath) Monitor I/O, strict I/O Admin IV fluids as ordered w/ close continuous monitoring of fluid status Neuro assessment / skin assessment

A burn pt on the unit is showing signs and symptoms of fluid volume excess. What interventions would the nurse perform?

Monitor vitals for HTN, dyspnea, & full, bounding pulse (increased risk for heart failure) Measure urine o/p & compare to intake Aminister IV fluids as ordered & monitor pt closely Document data collected during assessments

what interventions would be in place for a burn pt on who's temp is declining?

Monitor temp to detect changes Keep room about **76 degrees on the floor an 85 degress or higher on ICU** Attempt to *limit body surface exposure during wound care* Body heat loss may increase is pt is on *air-fluisized bed* - **monitor temp of the bed**

what interventions would be in place for a burn pt who is showing S/s of inadequate nutrition?

**Consult w/ dietitian** about nutritional needs & preferences * *Calorie needs may be as much as twice the pts baseline needs* Try to create an environment conductive to eating & encourage the pt to eat all food served *Provide tube feeding or total parenteral nutrition (TPN)* to meet calorie needs if needed Encourage pt to drink *protein drinks rather than water* Calorie count at bedside to ensure pt is consuming enough calories to meet increased metabolic needs associated w/ burns

what interventions would be in place for a burn pt who is showing S/s of infection?

Monitor for local infection * Pus, foul odor, increased redness Strict handwashing from anyone who enters the room * Infection can come from anywhere/anyone *Shave body hair around wound w/ exception of eyebrows (can grow back disorganized)* *Carry out wound care as ordered or according to specialty unit*

What are some potential complications that could occur w/ a rhytiedctomy (facelift)?

Hematoma Hemorrhage Temoprary / permanent facial nerve damage Wound infection Bruising, edema Skin necrosis Hair loss

What are some potential complications that could occur w/ a blepharoplasy?

Hematoma Ectropion Corneal injury Visual loss (rare) Wound infection (rare)

What are some potential complications that could occur w/ a rhinoplasty?

Hematoma Hemorrhage Temporary bruising Edema Wound infection Septal perforation Minor skin irritataion

What are some potential complications that could occur w/ an augmentation mammoplasty?

Hematoma Hemorrhage Wound infection Phlebitis Capsule formation & contraction

What are some potential complications that could occur w/ an reduction mammoplasty?

Hematoma Hemorrhage Infection Fat necrosis Wound dehiscence Necrosis of nipple, areola, & skin flap

Used to avoid / treat skin infections in patients with burns Side effects: * Back, leg, or stomach pain * *Blistering, peeling, lossening skin* * **Blue/green to black skin discoloration** (*dark urine*) * Increased light sensitivity (especially w/ burns on large areas) * **Light colored stools** * Lower back pain

Silver Sulfadiazine

Used to treat severe/serious bacterial infections Side effects: * **Hearing loss**, roaring sound in ear * Severe/ongoing **dizziness** * Weak, shallow breathing * **Numbness**/ tingling * Muscle tightness/contraction

Garamycin

Opiod / narcotic Relieves acute/ chronic / mod-severe pain **Can be used for pre-op or supplement to anesthesia** Side effects: * *Noisy breathing, sighing, shallow breathing, sleep apnea* * Confusion, extreme happiness or sadness * *Severe weakness or drowsiness* * *Light-headedness, dizziness* * *Vomiting, anorexia* Adverse effects: * **Resp. depression** * **Urinary retention** * *Excessive use / abuse* * *Increased effect w/ CNS depression*

Dilaudid

**Beta-blocker** Affects the heart & circulation (blood flow through arteries & veins) Used to treat: * Tremors * **Angina (CP)** * **HTN** * Heart rhythm disorders * Heart / circulatory conditions Side effects: * **Bradycardia** * **Hypotension** * *Light-headedness* * Wheezes * Liver problems Interventions: * **Always take BP** before admin.

Propranolol (Inderal)

**Opioid** - **IV, TD** (patch), nasal spray, buccal (Gums/cheek) Used for *mod-severe pain* Side effects: * **Bradycardia** * Euphoria * Sedation, **resp. depression** * Dizziness * **Hypotension**

Fentanyl (Subliminze)

**Isotonic solution - IV** Contains electrolytes **Prefurred solution for burn pts**

Lactated Ringers (LR)

When *water is less than normal amount in the body* S/s: * *Hypotension* * *Weak, rapid pulse* * Decreased temperature * Weight loss * *Decreased urine output* Tx: * Correct the cause * Fluid replacement & electrolyte replacement * Daily weights * **Monitor I/O** * Encourage oral fluids

Fluid volume deficit (FVD) / Hypovolemia

When there is **too much water in the body** S/s: * Edema and or pulmonary edema * Weight gain * *Pupils will be sluggish to light* * **Hypertension** * **Increased respiration (crackles)**

Fluid volume excess (FVE) / Hypervolemia

Decreased sodium Causes: * excessive intake of H2O * **loss of sodium, diarrhea, vomiting** S/s: * headache, fatigue, * *muscle weakness, cramps, weakness* * confusion * *hypotension* Tx: * fluid restriction * **NS or LR, Lasix** * increased sodium in diet * Monitor I&O, lab results, & VS * Safety precautions

Hyponatremia

Increased sodium S/s: * thirst * flushed skin, * dry mucous membranes, low urine output * Increased heart rate * convulsions *flushed skin Tx: * IV or fluid replacement * Low Na diet * Monitor IV infusion * Reinforce diet (Na restriction) * Monitor Renal function tests

Hypernatremia

Decreased K Causes: * Vomiting, diarrhea * NG-tube suction * DKA * Diuretics S/s: * Vomiting, diarrhea * Muscle cramps * Dysrthythmias * Abdominal distention * Hypotension Tx: * Correct the problem * Replace K (Give PO/IV) * Monitor heart rate & rhythm * High K diet

Hypokalemia

Increased K Causes: * Decreased renal function * Metabolic acidosis * Burn patients S/s: * Bradycardia, then tachycardia * Cardiac arrest * Muscle cramps * Weakness Tx: * K restriction * IV calcium gluconate * IV insulin * Kayexalate (PO) * Place on heart monitor * Monitor labs New drugs used: * Veltassa * Zirconium

Hyperkalemia

Low Ca S/s: * Neuromuscular irritability * Tingling sensation to face, hands & lips * Muscle twitches, muscle cramps

Hypocalemia

T/F: Hypercalcemia is a complication of certain cancers

True

A systemic inflammatory response to a documented/ suspected infection S/s: * **Hypotension, tachycardia** * Fever, elevated WBCs * Lethargic * **S**hivers/very cold * **E**xtreme pain/general discomfort * **P**ale/discolored skin * **S**leepy/*difficult to arrouse, disoriented* * "**I** feel like i might die" * **S**OB, **tachypnea** Tx: * **IV antibiodics** * *NS bolus (over an hour)* * Antipyretics (*Tylenol & Ibuprofen*)

Sepsis

Inadequate tissue perfusion resulting in impaired cellular metabolism Derives cells of essential oxygen & nutrients forcing cells to rely on anaerobic metabolism Stages: **1. Preshock** * Tachycardia & peripheral vasoconstruction may maintain BP * Mild elevation of lactic acid levels (Observe tachycardia & slight BP increase) **2. Shock** * S/s of organ dysfunction become apparent as compensatory mechanisms become overwhelmed **3. End-organ-dysfunction** * Multiple organ failure and death will occur if not corrected * Blood vessel constricts & prevents blood flow to organs

Shock

What are S/s of the End-Organ Dysfunctional stage of shock?

Decreased mental status Hypotension Tachycardia Elevated temp Cyanosis, Necrosis Decreased urine O/P

Occurs when the **circulating blood volume is inadequate to maintain the supply of oxygen & nurtients to body tissue** Results from blood loss or extreme dehydration Causes: * **GI loss d/t severe diarrhea, blood loss, or vomiting** * Diuresis (urinating) from diabetes insipidus or too much diuretic * DKA S/s: * Tachycardia * Hypotension * Tachypnea * Decreased urine output * Decreased central venous pressure Tx: * IV fluids (**NS/LR**) replacement * *If blood loss, may have transfusion of blood or blood products* * Correct the cause * *If dehydration is cause, replace electrolytes & fluid replacement* * Oxygen

Hypovolemic shock

Caused by ***pathogens (bacteria, fungi, viruses) that release toxins that case blood vessels to dilate**, thereby decreasing vascular resistance & increasing capillary permeability* S/s: * Hypotension * Olguria * **Metabolic acidosis** * Acute encephalopathy * Coagulation disorders * Extreme elevated temperature * *Elevated lactic acid* * **Multiple organ dysfunction syndrom (MODS - worst case)** Tx: * IV antibiodics (**Zosyn, meropenem**) * Fluids (NS) * Corticosteroids * **Antipyretics (Tylenol)** * **Vasopressors (Epinephrine, norepinephrine & dopamine)**

Septic Shock

Heart fails as a pump **Decrease in myocardial contractility results in decreased cardiac output & impaired tissue perfusion** Difficult to treat Causes: * Malignancies, uremia, idiopathic pericarditis, infectious disease S/s: * Fluid collects in pericardial sac, causing compression of the myocardium resulting reduced cardiac output & iscemia

Cardiogenic shock

*Severe allergic reaction that results in relase of chemicals that dilate blood vessels* & increase capillary permeability Causes: * Food * Drugs * Mold * Pollen * Insects * Vaccines * Contrast Media S/s: * SOB, unable to swallow * **Hives, itchy rash** * **Redness, swelling** * Cramps, N/V/D * **Drop in BP** * **Increased tachycardia, weak pulse** * Feeling faint

Anaphylactic shock

*Vasoconstriction* in skin, viscera, & mucous membranes * Relaxation of bronchi * **Given IV/IM** Use: * Anaphylactic shock * Hypotension * Bronchial construction Side effects: * Hypertension * Tachycardia * Dysrthymias Interventions: * Monitor vitals * Monitor IV site

Epinephrine (Adrenaline)

Catercholamine * **Given IV** Use: * **Shock (Cardiogenic/septic)** Side Effects: * Palpitations * Hypotension * N/V/D/H * Anxiety Nursing interventions: * Vital signs Q15 min * Cardiac monitor * Monitor I/O * monitor angina/ HF

Dopamine

Anti-infective (broad spectrum) * **Given IV** Uses: * Resp. Infection * UTIs * E-coli Side effects: * Lethargy * N/V * Rash * **Liver damage** * **Steven-Johnson-syndrome** Interventions: * Monitor vitals * **Monitor labs: AST, ALT, Renal function**

Zosyn (Piperacillin)

Anti-infective Use: * Multiple Infections Side effects: * N/V * Rash * Hepatotoxicity * Gastritis * Jaundice Interventions: * CBC * Monitor liver function * Monitor vital signs

Meropenem (Merrem)

What are the antidotes for the following medications? Warfarin/Coumadin Heparin Tylenol/Acetominophen Opioids Lovenox

Warfarin/Coumadin - **Vitamin K** Heparin - **Protamine Sulfate** Tylenol/Acetominophen - **Mucomyst** Opioids - **Narcan** Lovenox - **Protamine Sulfate**

**Passage & dispelling of stool** through the intestinal tract by means of intesinal smooth muscle contraction

Bowel Elimination

**Passage of urine** out of urinary tract through urinary sphincter & urethra

Urinary Elimination

Growths found in **sigmoid & rectal regions of colon** * Third most common cancer in the U.S Cause remains unknown Risk factors: * Adenomatous polyps * *UC, Diverticulitis* * Heredity * High fat, low fiber diet * Smoking S/s: **Right side** * Right sided abd. pain * Vage cramping until advances * Anemia, unexplained blood loss * Weakness & fatigue **Left Side** * Diarrhea or constipation * Blood in stool * May report feeling full or pressure in the abd. or rectum Medical Tx/Interventions: * Surgery - depending on location * **If rectum is removed, permanent colostomy will be created** * **Chemotherapy done post-op, radiation** * IV antibiodics * Treat pain * Assess & monitor vitals * coping w/ change * Sexual dysfunction

Colorectal Cancer

An artificial opening into a body cavity They bypass the affected portion of the bowel or urinary tract

Ostomy

What are some ways to prevent colon cancer?

High fiber, low fat diet Stop smoking Exercise Yearly colonoscopy screening

Opening in the colon through which fecal matters is eliminated Bringing a loop or an end of the intestine thorugh the abd. wall & creating a stoma for passage of fecal matter

Colostomy

Where are colostomies placed & what type of stool do they collect?

Ascending colon - Liquid stool Transverse colon - Pasty stool Descending & sigmoid - Semi-formed

How would you perform nursing care for a pt with a colostomy?

Perform focus assessment Assess the capatability to manage colostomy self-care Irrigate the colostomy everyday to mantain regular & controlled elimination Administer prescribed medications Monitor labs Help with coping

Opening in the ileum Distal portion of the small intestine that empties into the large intestine that empties into the large intestine *Occurs when colon is bypassed or removed* *High risk of fluid & electrolye imbalance* Nursing care: * Focus assessment * Vital sign * Assess stoma for bleeding & color (Beefy red) * **Monitor labs (electrolytes), ABGs (may go into metabolic acidosis)**

Ileostomy

What does a normal stoma look like?

Beefy red (not pale) Constant output from stoma

What dietary teachings would you teach a for a pt w/ an ostomy?

Avoid Cabbage, alcohol, onions, & eggs * Cause gas Avoid corn, popcorn, seeds, & nuts * Especially w/ ileostomies

Most common malignancy of the urinary tract Causes: * Chemical carcinogens, smoking, aniline dyes found in industrial compounds, & tryptophan all have been implicated in the development of bladder cancer S/s: * Painless (most common) * Intermittent hematuria * Bladdered irritability * infection w/ dysuria * Frequency & urgency * Decreased stream of urine

Bladder cancer

What tests would you run to Dx bladder cancer?

Urinalysis with urine cytology Cystoscopy to visualize the bladder & obtained biopsy CT/MRI Intravenous pyelogram (IVP) CT-urogram Chest radiography Radionuclide bone scan

How would you medically treat bladder cancer?

Malignancy is present * Cystectomy is surgery of choice Laser photocoagulation * Intense beam of light (argon laser) that destroy tissue Chemotherapy, radiation Immunotherapy Urinary diversion

Brings ureter to the abd. surface Urine eliminated through stoma

Ureterostomy

What are nursing interventions for a post-op pt who underwent elimination surgery?

**Assess bowel sounds & abdomen in general** *Assess stool* *Assess stoma site for s/s of infection, bleeding & pain* Monitor & chart I/O Teach pt about coping Cleans site daily & as needed Empty pouch & irrigating bag Change pouch daily or as needed per order Splinting the incision Antibiodics **Ambulation after surgery** *Splinting w/ pillow while coughing* **Irrigating the stoma can help train the bowel**

Antibiodic * **Vesicant** 2 toxicities: * **Nephrotoxic** - Toxic to kidneys * **Ototoxic** - Can't hear well Should monitor peak & trough **Monitor BUN/Cr** Side effects: * Nephrotoxcicity * Red man syndrome Assess for hearing problems (ototoxicity)

Vancomycin

**Used for diarrhea** Combinations meds: * *Atropine* = anticholinergic, can be used to dry things * *Diphenoxylate* = decrease spasms & slows the gut Know it works when there is no diarrhea

Lomotil (Atropine/Diphenoxylate)

Antibiodic Used for skin, vaginal, & GI infections Side effects: * Dark urine * Metallic taste * GI upset (No alc. puts GI in distress) * Diarrhea

Flagyl (Metronidazole)

**Used to prep the bowel** for colonoscopy or surgical procedure * NPO at midnight Tips: * *Make icy cold - don't freeze* * Do NOT use straws * Clear liquid diet

Golytely (Polyethylene Glycol)

Give SubQ in fatty tissue Stimulates production of RBCs Use: * Treats anemia * Anemia related to chemo

Procrit /Epogen (Epoetin Alpha)

Given SubQ Stimulates production of neutrophilic white cells * Reduces neutropenia interval in bone marrow transplantation

Neupogen (Filgramtim)