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NSO424 Introduction to nursing assessment skills > Emesis and Sputum > Flashcards

Emesis and Sputum Flashcards

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1
Q

Define Emesis and its significance

A

Vomiting (emesis)- the forceful movement and elimination of the contents of the stomach by the constant action of the abdominal muscles with the opening of the gastric cardia.

The presentation may be acute or chronic and range from mildly annoying symptoms to a condition that impairs the patients’ quality of life or is a marker of a life-threatening disease, emotional distress, memory (defensive) or an adverse reaction to treatments.

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2
Q

What are the most frequent and severe effects of vomiting?

A
  • Dehydration
  • Nutritional deficiencies
  • Electrolyte and acid-base imbalance
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3
Q

Why is the pathophysiology for vomiting complex? What centres are involves and how?

A

The act of emesis is associated with 2 main centres located in the medulla oblongata (the brain stem)
• the vomiting centre
• the chemoreceptor trigger zone (CTZ)

Vomiting is ultimately controlled by the vomiting centre which receives input from a wide range of sources. Some of these inputs are directly connected to the vomiting centre but most are directed via the CTZ.

The CTZ is an area of the brain not fully separated from the blood by the blood brain barrier so it can detect chemicals in the blood and cerebrospinal fluid and initiate vomiting. The CTZ is also stimulated by signals from the gut and inner ear.

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4
Q

what is the CTZ?

A
  • AKA Chemoreceptor zone
  • The CTZ is an area of the brain not fully separated from the blood by the blood brain barrier so it can detect chemicals in the blood and cerebrospinal fluid and initiate vomiting. The CTZ is stimulated by signals form the gut and inner ear.
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5
Q

what are the main 2 mechanisms for emesis?

A

1) neurological stimulation where the medulla oblongata “senses” noxious chemical agents (like poison, chemotherapy agents and (Digoxin) which then causes nausea and the emesis reflex.
- Diseases based on the CNS like infections and tumours can also stimulate nausea etc.
2) Peripheral diseases like diseases in the Gastrointestinal tract. Brain centres where nausea is perceived will stimulate vomiting.
- Tumours etc and drugs in the periphery may cause local dysfunction in diff organs that when sensed can cause vomiting

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6
Q

Examples of toxins that can trigger Emesis?

A
  • Medications/drugs (e.g. cytoxics, opiods, NSAIDs, antibiotics, anticonvulsants, iron and many others)
  • Poisoning
  • Substance Abuse
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7
Q

Examples of Metabolic conditions can trigger Emesis?

A
  • Hypercalcaemia
  • Hyponatremia
  • Ketoacidosis
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8
Q

Examples of Organ failure / disorders of viscera that can lead to Emesis?

A
  • Liver
  • Renal
  • Obstruction (e.g. gastric outlet, bowel, biliary, pancreatic)
  • Severe constipation
  • Gastroparesis
  • Inflammation or irritation (e.g. gastroenteritis, hepatitis, cholecystitis, NSAID, chemotherapy, radiation)
  • Malignancy
  • Ascites
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9
Q

Examples of Neurological conditions that can lead to vomiting?

A
  • Increased intracranial pressure (e.e malignancy, haemorrhage, cranial irradiation or abscess)
  • Meningeal infiltration
  • Vestibular (e.g. labyrinthitis or effects of medications or drugs)
  • Anxiety
  • Pain
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10
Q

what is Nausea?

A

Subjective experience of feeling sick, Unpleasant feeling, often leading to vomiting.

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11
Q

what is retching?

A

Movements associated with vomiting without the expulsion of gastrointestinal contents.

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12
Q

what is Haematemesis?

A
  • Presence of blood in vomit, bright pink or ‘coffee ground’
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13
Q

what is Copraemesis?

A

Odour or presence of faeces in vomit

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14
Q

what is Emesis/vomiting?

A

Forceful emptying of stomach contents through the mouth

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15
Q

what is Anticipatory nausea and vomiting?

A

Where a person has emetic symptoms to a conditioned stimulus before treatment is commenced

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16
Q

what is Emetogenic potential?

A

Ability of a treatment, eg chemotherapy, to cause nausea, retching and vomiting

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17
Q

what are Antiemetics?

A

Medication used to treat nausea, retching and vomiting

18
Q

what is projectile vomiting?

A

Spontaneous vomiting not preceded by nausea or retching.

19
Q

what is Chemotherapy-induced nausea and vomiting?

A

Acute nausea and vomiting/Delayed nausea and vomiting after Chemotherapy

20
Q

what are emetic symptoms?

A

Nausea, retching and vomiting

21
Q

Nursing care of the patient who is vomiting: outline the pre-procedure and justify.

9 steps

A

1)Introduce yourself, explain, discuss procedure and gain consent

why- so feel at ease, understand and give valid consent

2)Ensure they’re in a safe place and position so they don’t fall etc

why- patient safety

3)Decontaminate hands and wear PPE

why- Clean procedure

4)Close the door or draw curtains around their bed

why- maintain privacy and dignity

5) provide patient with (2) vomit bowls and tissues

why-reduce risk of spillage and cross infection

6)Remain with patient

why-provide reassurance and maintain safety

7)Once done vomiting, remove bowl and offer warm water and towels for them wash their face and hands

why-infection prevention and control AND patient comfort

8)Assist the patient to find a comfortable position and leave the second, clean vomit bowl with them.

why-ensure the comfort

9)Take 1st vomit bowl to a dirty utility (sluice) room and if necessary, measure the volume and note characteristics.

why- characteristics could help determine cause of vomiting

22
Q

Nursing care of the patient who is vomiting: post procedure.

Outline the procedure and justify

A

1)Dispose contents safely and place vomit bowl in washer/disposal unit.

why- infection prevention and control.

2)Remove PPE. Wash hands with soap and water.

why- infection prevention and control

3) Record the volume and any notable characteristics in the patient’s notes.

why- maintain accurate documentation

4)Administer any prescribed antiemetics

why- to prevent any further episodes of nausea or vomiting and to help control symptoms.

5) Return to patient and assess them at regular intervals, evaluating the effectiveness of any interventions.

why-monitor patient and maintain their safety and comfort.

23
Q

what is sputum?

A

Sputum is a term used to describe mucus that has been expectorated (coughed up) consisting of secretions and other matter from the lungs and large airways.

24
Q

Is sputum always unhealthy?

why is sputum analysis important?

what 3 things should nurses always record>

A
  • Sputum is always abnormal because health people swallow bronchial secretions
  • Sputum analysis is important as it enables diagnosis of conditions such as pneumonia, tuberculosis (TB), lung abscess and lung cancer
  • The nurse should record the colour, amount and consistency of sputum
  • Specimens should be sent to the laboratory for further analysis
25
Q

what does Purulent, yellow or green, malodorous sputum and perhaps intermittently blood stained sputum indicate?

A

Bronchiectasis

26
Q

what might sputum for lung cancer look like?

A

Repeatedly blood stained

27
Q

what might sputum for Pulmonary tuberculosis look like?

A

Purulent, intermittently bloodstained

28
Q

what might sputum for for a lung abscess look like?

A

Copious, purulent and malodorous, may be blood stained

29
Q

what might sputum for Pneumococcal pneumonia look like?

A

• Purulent, stained with rusty red blood

30
Q

what might pink or white frothy sputum indicate?

A

Pulmonary oedema

31
Q

what might sputum for Pulmonary embolus look like?

A

bright red

32
Q

what will sputum for a blood clotting abnormality look like?

A

bright red

33
Q

what kind of sputum might indicate trauma from intubation, tracheostomy, lung contusion or following tracheal suction?

A

blood stained

34
Q

what will sputum for Chronic obstructive pulmonary disease look like?

A

Mucoid (clear, grey or white like raw egg white)

35
Q

what does sputum for infection for dehydration look like?

A

thick, tenacious

36
Q

what will sputum indicating that infections, allergies and/or secretions have not been expectorated?

A

Purulent, yellow or green- happens when immune cells arrive, fight, die and are carried off in the mucus turning it yellow.

37
Q

what does sputum for Asthma look like?

A

sputum plugs or stringy sputum

38
Q

what does sputum indicating the presence of eosinophils (indicative of an infection) look like?

A

Green or yellow

39
Q

what kind of sputum indicates a Pseudomonas infection?

A

Thick, green, musty smelling and sticky

40
Q

what is haemoptosis?

A

coughing up blood

41
Q

what equipment do you need to collect a sample of sputum?

A

– Alcohol gel, depending on local policy.

– Sterile gloves.

– A disposable apron.

– Protective eyewear.

– Sterile 0.9% sodium chloride solution for inhalation via a nebuliser if required

  • Sputum specimen collection container.

– Clinical waste bin.

42
Q

Describe the procedure for gaining a sample of sputum?

A

1) Explain the procedure to the patient and gain informed consent
2) Decontaminate hands
3) Position the patient in an upright position in a chair, on the edge of the bed or well-supported by pillows in bed (high Folwer position) as this will ensure max lung expansion
4) The patient’s mouth should be rinsed with water before the sample is collected, to avoid contaminating the sample with food residue. It can also be helpful to removed dentures.
5) Adminster prescribed sodium chloride 0.9% nebuliser to help to loosen secretions if they’re thick and difficult to expectorate.
6) Decontaminate hands and put on PPE to reduce the risk of contamination and the risk of cross infection.
7) Wear eye protection
8) Ask the patient to take several deep breaths- breathing through the nose and exhaling through the mouth- to help loosen secretions.
9) Ask the patient to force a deep cough to ensure a sample is obtained from the lower respiratory tract.
10) The patient should expectorate into the specimen pot and secure the lid to prevent contamination. Ensure the specimen is sputum rather than saliva, as samples contaminated with oropharyngeal secretions and saliva are difficult to interpret and can be misleading.

11) Doff PPE and decontaminate hands.
12) Label the sample and complete microbiology forms

13) Send the sample to the laboratory ASAP (within four hours)
14) Document the procedure in the patient’s notes

NSO424 Introduction to nursing assessment skills (10 decks)

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