exam 3 Flashcards
Preparation and discharge teaching for surgical patients (fractures)
○ Preparation: Before fracture reduction and immobilization:
■ Consent
■ Analgesics
■ Anesthesia may be used.
■ Education: How to assess neurovascular symptoms, IS, Controlling edema and pain.
○ Medical Management:
■ Reduction is the restoring of fracture fragments (taking pieces and putting them back together)
● Closed Reduction: anatomic alignment through manipulation and manual traction (Taking our hands and putting the bones back together), Extremity held while a cast, splint, or traction is used.
○ Healing may take 6-8 weeks
● Open Reduction: Surgical approach to anatomic alignment. Surgical incision to put the bones back together.
○ Use of internal fixation devices (pins, wires, screws, plates, nails, rods) during surgery.
■ Immobilization: Bones fragments will be positioned and aligned until union occurs.
● Immobilization may be accomplished by external or internal fixation. Methods of external fixation include bandages, casts, splints, continuous traction, and external fixators.
■ Maintaining and Restoring Function: Primary Nursing Assessment)
● Neurovascular status (circulation, motion, and sensation) monitored routinely: Numbness, tingling, blood flow, pulses, pain
● Edema controlled by elevating injury and applying ice
● Pain control through analgesics and position changes
● Isometric exercises
Priority assessment and nursing interventions for fractures and surgical patients
■ Priority Assessment:
● Neuro Checks
● Pain level
● Vitals signs
● Labs
■ Emergency Management:
● Closed Fracture: Immobilize!!! Splint wrapped in ace wrap to keep it from moving or displacing further.
● Open Fracture: Immobilize (Splint) Wound Care, cover with sterile dressing
● Neuro Checks: Done before and after you splint or immobilize
○ Check sensation
○ Check vascular status (numbness, tingling, temperature, look for pallor or color
○ Check pulses distal (below) fracture site to see if the area is getting blood flow
■ Nursing Management:
● Control edema with elevation and ice; RICE: Rest, Ice, Compress, Elevate
● Control pain with medications and nonpharmacologic techniques
● Monitor neurovascular status
● Exercises to maintain the health of unaffected limbs
● Use of assistive devices
● Educate on self-care, medications, monitoring potential complications
● Monitor and prevent infection (Open Fractures): Sterile!!
Compartment syndrome – clinical manifestations, priority nursing assessment and interventions, treatment
■ Compartment pressure is so high the blood cannot get to the extremity.
■ Develops quickly, but presents 48 hours after
■ Manifestations: 5 P’s
● Pain: Crucial in early recognition
● Paresthesia: Numbness, tingling, pinprick sensation
● Pallor: Late sign, no blood getting to extremity
● Pulselessness: BAD SHAPE, should always have a pulse distal to the fracture
● Paralysis: Very late sign
■ Nursing Management:
● Frequently assess pain and neurovascular status
● Report any negative changes to doctor immediately
● Pain management- opioids
● Educate pt on s/s at discharge: 5 P’s
● Prompt management is essential
● Conservative measures to restore tissue perfusion and relieve pain first
■ Treatment: If other measures do not work a fasciotomy is performed.
● Fasciotomy: Incision and diversion of the muscle fascia to relieve muscle constriction
○ After the wound is left open covered with a moist, sterile saline dressing.
Fat embolism syndrome – clinical manifestations, priority nursing care for prevention, treatment
■ Fat globules go into circulation and occlude small blood vessels that supply blood to vital organs.
■ Rapid onset
■ Manifestations: tripod of ss hpn
● Hypoxia: FIRST SIGN
● Petechial Rash (Chest and mucous membranes)
● Neurologic Compromise: Restless, agitated, seizures, focal deficits, encephalopathy
■ Prevention: As little movement of fracture as possible
● Immediate Immobilization
● Minimal fracture manipulation
● Support of fracture bones during turning and positioning.
● Fluid/Electrolyte balance
■ Treatment: Supportive
Stable vs unstable pelvic fractures and what is priority nursing assessment and interventions
■ Pelvic Fracture:
● CM’s:
○ Ecchymosis: Bruising
○ Tenderness over fracture site
○ Local edema
○ Numbness or tingling of pubis, genitals, proximal thighs
○ Inability to bear weight without pain/discomfort
○ Severe back pain
○ Alterations in neurovascular status of lower extremities
● Hemorrhage and shock are two of the most serious consequences!!
● Priority Nursing Assessment:
○ Assess for bleeding: VS (Blood pressure) and labs (Hemoglobin)
● Stable Pelvic Fracture: Won’t move a whole lot and will heal spontaneously
○ Treatment:
■ Bed rest and symptom management
■ Fluids, dietary fiber, ankle and leg exercises, anti embolism stockings, logrolling, deep breathing (IS), and skin care.
■ Monitor Bowel Sounds
● Unstable Pelvic Fracture: Results in rotational instability, having the potential to move or rotate the pelvis.
○ Treatment:
■ Stabilize the pelvic bones and compress bleeding with pelvic girdle.
■ Surgery with open reduction and internal fixation.
Hip fractures – clinical manifestations, priority nursing assessment and interventions, treatment, bucks traction
■ Hip Fracture: Fracture of the upper femur ● Older adult, women, osteoporosis ● Predisposes the older adult to: ○ Atelectasis Pneumonia Sepsis ○ VTE ○ Pressure ulcers ○ Delirium ○ Dehydration/poor nutrition ○ Loss of muscle strength ● CM’s: ○ Leg Shortening ○ Leg adducted (middle of body) and externally rotated (Toes point toward the wall) ○ Pain in hip and groin ○ Immobility of affected leg ○ Muscle spasms of affected leg ● Medical Management: ○ Buck’s Traction (Skin traction): Does not fix the fracture, but helps relieve symptoms such as muscle spasm, immobilize the extremity, and relieve pain. ● Surgical Treatment ● Nursing Priorities: ○ Hydration ○ Respiratory Support ○ Circulation Checks: Neuro Checks ○ Pain Control ○ Prevention of immobility Complications ○ Hx of chronic conditions and medications ● Nursing Management After Surgery: ○ Reposition: ■ Turn on uninjured side ■ Use of abduction pillow ○ Promote Exercise: ■ Use of over bed trapeze ■ Up to chair POD #1 ■ Consult physical therapy ■ Use of walker/cane ■ Modifications to home environment ○ Monitoring and Managing Potential Complications: ■ Monitor Neuro status of affected leg. ■ Prevent VTE: SCD’s, ted hose, lovenox, increase fluids ■ Pulmonary complications: Deep breaths, coughing, IS, change positions ■ Skin breakdown: Monitor
Internal vs external fixation
■ Internal Fixation: Stabilization of the reduced fracture by the use of Metallic pins, wires, screws, plates, nails, rods.
■ External Fixation: Use of bandages, casts, splints, continuous traction.
○ Phantom pain – understand what it is and priority nursing interventions
■ Phantom limb pain: Pain perceived in the amputated section, caused by severing of the peripheral nerves. Pain in a body part that is no longer there. Crushing, cramping, twisting pain. ■ Relieve Pain ● Use of analgesic medications ● Position change ● Acknowledge phantom pain as real ■ Limb Shrinkers- To help with Edema
○ In general – what is the priority nursing assessment and interventions w/ amputations
■ Uses:
● Relieve symptoms
● Improve function
● Save/improve quality of life
■ Goal of surgery is to conserve as much limb length as needed to preserve function and achieve a good prosthetic fit.
■ Complications:
● Hemorrhage: Bleeding
● Infection
● Skin breakdown
● Joint contracture
■ Medical Management
● Achieve healing of the amputation wound
● Edema control with limb shrinkers
■ Nursing Management:
● Promoting Wound Healing
○ Residual limb should be measured once every 8-12 hours for edema
○ Frequent neuro checks
○ Dressing changes as ordered
○ Monitor s/s of infection
● Enhancing Body Image
○ Establish trusting relationship
○ Encourages to look at, feel, and care for residual limb
○ Help regain independence in self-care
● Help Patient Resolve Grieving
○ Create an accepting and supportive atmosphere
○ Encourage patient to express and share feelings
○ Encourage family support
○ Educate patient on realistic rehab goals and future independent functioning
○ Refer to support groups
● Promoting Independent Self-Care
○ Encourage patient to be active participant
○ Provide supportive, relaxed, not rushed environment
○ Maintain positive attitude
○ Consult physical and occupational therapy
● Help Patient to Achieve Physical Mobility
○ Frequent position changes to prevent contractures
○ Consult physical therapy
○ Increase activity gradually
○ Use assistive devices
○ Remove environmental barriers
○ Prepare patient for prosthesis
● Monitoring and Managing Potential Complications
○ Hemorrhage
■ Monitor for s/s of bleeding
■ Monitor VS: BP
■ Monitor lab results (Hgb)
○ Infection
■ Administer antibiotics as prescribed
■ Monitor incision, dressing, and drainage
○ Skin Breakdown
■ Assess for breaks in skin
■ Perform careful skin hygiene
■ Assess skin for erythema, pressure areas, dermatitis, and blisters
■ Use of residual limb sock
Explain the factors that affect the severity of burn injury- depth/degree, total body surface area (TBSA), and rule of palm (measure the size)
● Depth: First degree, second degree, third degree ○ First degree: ■ Involves only epidermis ■ Skin is red, painful, blanches with pressure, dry ■ A few days to heal ■ Minimal or no residual scarring ■ Causes: ● UV radiation ● Scald ● Brief flash ○ Second degree: ■ Partial thickness injury: Involves epidermis & part of dermis ■ Skin: red, blistered, swollen, painful ■ May or may not heal in 2-3 weeks ■ May or may not produce scarring ■ Causes: ● Flash/flame: ● Scald: ● Contact: ○ Third degree: ■ Full thickness injury: Involves all of epidermis & dermis ■ Whitish or charred appearance. Tough, leathery ■ Sensation is lost. ■ Takes several weeks to heal. ■ Will result in scarring ■ Causes: ● Flame ● Chemical/Tar ● Scald ● Contact ● Electrical ● Total Body Surface Area (TBSA) Will be a calculation on the exam. ○ Head: 9% ○ Chest: 18% ○ Back: 18% ○ Each Arm: 9% ○ Each Leg: 18% ○ Groin: 1% ○ First degree burn is NOT calculated in TBSA. ● Rule of Palm (Measure the size) ○ Client’s palm = 1% TBSA ○ Used to estimate the extent of burns in those with scattered burns ● Location: ○ Face, hands or feet ● Treatment ● Age: Young children and older adults have increased morbidity and mortality ● Past medical history
Use the nursing process as a framework of care for the patient with burns (chemical burn) in the emergent/resuscitative
○ Chemical
■ Severity of the injury depends on the mechanism of action of the substance, the penetrating strength and concentration, and the amount of skin exposed to the agent
■ Immediately flush the skin with running water from a shower, hose, or faucet
● Note: Lye or white phosphorus should be brushed off the skin dry
■ Protect healthcare personnel from the substance
■ Determine the substance
■ Some substances may require prolonged flushing or irrigation
■ Follow-up care includes reexamination of the area at 24 hours, 72 hours, and 7 days
■ ACIDS:
● Cleaning solvents, hydrofluoric acid, hydrochloric acid, muriatic acid, oxalic acid, & sulfuric acid
● Hydrofluoric acid burns are unique:
○ Treat w/calcium: topical calcium gluconate & water soluble lubricant
○ IV & intrarterial for severe hypocalcemia
■ ALKALINE:
● Alkalis lye, cement, lime, drain openers
● Combines w/lipids & dissolves tissue. Almost turns skin into gel-like substance.
● Etiologies:
○ Work-related
○ Assault
○ improper use of household products
● Treat:
○ Dilute w/ copious amounts of water irrigation (15-20 minutes)
○ pH test of skin until the result is neutral
○ Do NOT attempt to neutralize with other substances
○ This causes an exothermic reaction & thermal injury
Compare priorities of care and potential complications for each phase of burn recovery.
● Initial Care ○ Stop the burning ○ Cool the burn ● Emergent/Resuscitative ○ From onset of injury to completion of fluid resuscitation ○ Primary survey: A, B, C, D ■ Airway ■ Breathing ■ Circulation ■ Disability ■ Environment/Exposure ■ Fluids ■ Head-to-toe Assessment ■ Labs. History. Tubes. Drains. IV lines. Meds. Dressings ○ Priorities: Replacing fluids is the main thing with burns!! ■ Prevent of shock ■ Prevent respiratory distress ■ Detect & treat concomitant injuries ■ Wound assessment ■ Initial care ● Acute/Intermediate phase ○ From beginning of diuresis to near completion of wound closure ○ Priorities: ■ Wound care & closure ■ Prevent or treat complications, including infection ■ Nutritional support ● Rehab ○ From major wound closure to return to optimal level of physical & psychosocial adjustment ○ Priorities: ■ Prevent & treat scars, contractures ■ Physical, occupational, & vocational rehab ■ Functional & cosmetic reconstruction ■ Psychosocial counseling
Plan fluid replacement requirements during the emergent/resuscitative phase of a burn injury.
● Factors to consider: ○ Burn size/depth ○ Inhalation injuries ○ Associated injuries ○ Age (children need more; older adults need less) ○ Escharotomies ○ Delay in resuscitation ○ Alcohol/drug involvement ● Over resuscitation: ○ Pulmonary edema ○ Peripheral edema ○ Compartment syndromes ● Under resuscitation: ○ Inadequate perfusion ○ Renal failure ○ Conversion ● Adults w/ in 24 hours post-thermal or chemical burns: ○ 2 mL LR x wt in kg x % TBSA 2nd, 3rd, & 4th degree burns ● Adults w/ electrical burns: ○ 4 mL LR x wt in kg x % TBSA 2nd, 3rd, & 4th degree burns ● The infusion is regulated so that one half of the calculated volume is administered in the first 8 hrs. ● Adjust rate of fluid resuscitation to: ○ Urine output: ■ ½ mL/kg/hr for adults ■ 1 mL/kg/hr for children ● Only a guideline! Fluid resuscitation must be tailored to specific needs!
Discuss the nurse’s role in burn wound management during the acute/intermediate phase of burn care.
Nonsurgical wound management
○ Drug Therapy:
■ Topical antimicrobials
■ Topical/systemic antibiotics
■ Pain management
■ No single topical medication is universally effective. Different agents may be used at different times post-burn.
○ Wound Dressing:
■ Cover in several layers of dressing (lighter dressing over joints to promote mobility)
■ Apply circumferential dressings distally to proximally: promote return of excess fluid
■ Fingers & toes wrapped individually: promote function while healing
■ Burns to face usually left open to air
■ Occlusive dressings for skin grafts: protect the graft
■ Use water to gently remove dressings
■ Documentation
● Surgical wound management
○ Wound debridement: Remove devitalized tissue
■ Goals: Remove devitalized tissue or burn eschar to prepare for grafting or wound healing. Remove tissue contaminated by bacteria, foreign bodies
○ Natural: Devitalized tissue separates from viable tissue spontaneously
■ May take weeks to months
○ Mechanical: Use of surgical tools to separate & remove eschar
○ Chemical: Topical enzymatic agents to promote debridement of burn wounds
○ Surgical: Removal of full thickness burned skin down to fascia or shaving of burned skin layers down to freely bleeding, viable tissue
● Cleaning a wound
○ Goals: Debride nonviable tissue. Remove previously applied topical agents. Apply new topical agents.
○ Methods:
■ Mild soap & water: prevent infection of the wound surface
■ Ambulatory clients may clean burn wounds in the shower
■ Nonambulatory clients have burn wounds washed at the bedside
○ Comfort:
■ Client participation is encouraged to promote exercise of extremities
■ Nurse inspects skin/wounds for any signs of infection or breakdown
■ Continuously assess for hypothermia
■ Maintain temperature of water at 100o F & temperature of the room 80-85o F
■ Assess fatigue, changes in hemodynamic status, pain control
Liver Function Tests:
· When the liver has a problem, ALT, AST, Ammonia will be elevated!
· Alanine aminotransferase (ALT): Know 40
o Normal:8-40 U/mL: Elevated in liver cell damage.
o Used to monitor course of hepatitis, cirrhosis
· Aspartate aminotransferase (AST): Know 40
o Normal: 10-40 U/mL: Elevated in liver cell damage.
· Gamma-glutamyl transferase (GGT): elevated with alcohol abuse
· Alkaline phosphatase (ALP)
o Injury to biliary tree (i.e. obstruction, tumors)
· Serum bilirubin: 0.3-1 mg/dL, Know 1, associated with Jaundice
o Associated with jaundice
· Serum albumin: 3.5-4.8 mg/dL, Know 4
o Affected in cirrhosis, chronic hepatitis, edema, and ascites.
o Albumin will be lowered, shows malnutrition
· Prothrombin:
o Normal: 9.0-11.5 sec: Prolonged in liver disease
· INR: 0.9-1.1
· Ammonia: Know 40
o Normal: 15-45 mcg/dL: Rises in liver failure
o Elevation causes mental status confusion (hepatic encephalopathy), this can lead to comatose.
jaundice
Jaundice: Patho: Increased bilirubin in the blood (Exceeds 2mg/dL)
· S/S: All body tissues, including the sclerae and the skin become tinged yellow or greenish-yellow, skin becomes very itchy.
Management: Putting mittens, fingernails trimmed. Very important because the skin will be itchy and we don’t want them to scratch themselves.
Hemolytic Jaundice: Increased destruction of RBC’s
Hepatocellular Jaundice
● Damaged liver cells cannot clear bilirubin from blood
● AST, ALT, and Bilirubin elevated.
S/S:
* Mild or severely ill
* Lack of appetite, nausea or vomiting, weight loss
* Malaise, fatigue, weakness
* Headache, chills, fever, infection
Obstructive Jaundice
● Occlusion of bile duct
● Biliruben, AST, ALT elevated
S/S:
* Dark orange-brown urine, clay-colored stools
* Dyspepsia and intolerance of fats, impaired digestion
* Pruritus
Portal Hypertension:
Patho: Obstructed blood flow through the liver results in increased pressure throughout the portal venous system
· Results in
o Ascites
o Esophageal varices
· All of these are related.
● Portal htn you want to decrease the pressure:
○ Low sodium diet to decrease edema
○ Diuretic, fluid restriction (1500 mL), I/O
○ Can lead to ascites which means they need paracentesis
■ Sign consent, monitor drainage, measure drainage
■ Monitor insertion site
■ Lot more drainage than thoracentesis
■ Monitor respiratory status because pressure causes SOB
■ Elevate HOB, need to sit up to help them breathe
■ Watch for F/E imbalances
● Add fluid restriction (1500mL) to management
● Daily weights
● I&O, VS, Labs
Ascites: Collection of fluid in peritoneal cavity.
· Manifestations:
o Increased abdominal girth & rapid weight gain
o Shortness of air
o Fluid & Electrolyte imbalances
· MEDICAL MANAGEMENT
o Low-sodium diet
o Diuretics, rid body of sodium. Monitor I&O
o Bed rest
o Administration of salt-poor albumin
o Transjugular intrahepatic portosystemic shunt (TIPS): Applied to drain out fluid
o They cannot lay flat at all, at least semi-fowlers.
o Paracentesis:
Purposes:
· Remove ascites (palliative)
· Dx: peritonitis, cancer, trauma
Pre-procedure:
· Consent
· VS
· Have pt void, don’t want pressure on the abdomen
· Position HOB , sitting upright in chair
During procedure:
· VS q 15 min. & PRN
· Help pt maintain position
Post-procedure:
· VS q 15 min. x 4; q 30 min. x 2 then q 4 hrs.
· Assist w/fluid collection, sending to lab
· Puncture site for leakage, bleeding
· Weigh pt
Complications:
· Vasodilation, shock
· Depletion of protein: Admin. salt-poor IV albumin
· Elect. Imbalances
· NURSING MANAGEMENT:
o Strict I&O.
o Restrict fluids to less than 1500 mL/day
o Restrict sodium to less than 2000 mg/day
● Smaller more frequent meals, high calorie. Reduce fluid retention.
o Abdominal girth measurements daily or B.I.D.
o Daily weights. Should not gain or lose more than 0.5 kg/day.
o Close monitoring of respiratory status.
o Monitor lab values including serum ammonia, creatinine, electrolytes.
o These patients should not lay flat
Esophageal Varices:
o Hematemesis, melena
o Deterioration in mental/physical status
o S/S of shock- life threatening!
· Treatment:
o Pharmacologic therapy
o Endoscopic therapies
o Balloon tamponade: Stop Bleeding
o Transjugular Intrahepatic Portosystemic shunting (TIPS): Decrease the pressure
· Nursing Management:
o Maintain safe environment; prevent injury, bleeding and infection
o Administer prescribed treatments and monitor for potential complications
o Encourage deep breathing and position changes.
o Education and support of patient and family
o If patient goes into shock and is intubated:
#1: Maintain airway, prevent aspiration of blood
#2: Insert Central line for fluid and blood transfusion
Medication: Vasopressor: Control blood pressure
Closely monitor VS, I&O, s/s of blood, GI bleed
Hepatic encephalopathy
Patho: Accumulation of ammonia & other toxins in blood r/t liver failure
· Early Signs: mental changes and motor disturbances
· Assessment:
o EEG: Look at neuro function
o Changes in LOC
o Potential seizures
o Asterixis: Flopping Hand
o Fetor hepaticus
o Monitor fluid, electrolyte, and ammonia levels
· Medical Management:
o Reduce ammonia level: from GI tract by gastric suction or enema
o Treat cause
o Monitor
o Medications
o Lactulose: watch for hypokalemia and SE (bloating cramps). This is for ammonia
o IV Glucose to minimize protein catabolism
o Safety: Discontinue sedatives, analgesics, and tranquilizers
· Nursing Management:
o Maintain a safe environment.
§ Prevent injury, bleeding, and infection.
o Administer prescribed treatments.
§ Lactulose
§ Treat diarrhea after
o Monitor for potential complications.
§ Coma: reduce ammonia level (lactulose)
§ Seizures: Seizure precautions
§ Electrolyte imbalance
o Encourage deep breathing/position changes for respiratory status.
o Communicate with and support the patient’s family.
Imbalanced Nutrition
If no ascites or edema ● High protein, high CHO/calories ● Supplemental vitamins ● Small, frequent meals ● Protein supplements ■ If steatorrhea ● Vit A, D, E ● Folic acid and iron needed ■ If impending coma ● Decrease protein ■ With ascites ● Limit sodium >2g/day ● Restrict fluids to 1500mL/day ■ Calories and protein ● If ammonia levels are normal, need adequate amounts ● If ammonia levels high, decrease protein · Nursing Interventions o Glucose: monitor hyper & hypoglycemia o Bleeding risk § monitor PT/INR § limit invasive procedure: even an IV § varices-risk for bleeding § S/S of bleeding (stool for blood, petechia) § hold pressure 5 mins or more o Toxin buildup: monitor mental status, check reflexes, hand flapping o Nutrition: § high lean protein, (low protein when ammonia level elevated or confusion happens) § low sodium- reduces ascites § NO ETOH or raw seafood § fluid restriction, PO vitamins o FVO: Fluid Volume Overload § strict I & O, § measure abd. Girth and edema, daily weight, § turning q2h (skin breakdown & risk of infection), § NO supine, activity intolerance
Viral Hepatitis (A, B, C)- transmission
Patho: Viral hepatitis: a systemic viral infection that causes necrosis and inflammation of liver cells with characteristic symptoms and cellular and biochemical changes
o Transmission:
§ A: fecal–oral route
§ B and C: bloodborne
· Nursing Care:
o Acute Stage: Physical & psychological rest
o Symptom management (N/V/anorexia, fever)
o Diet:
§ High CHO & kcal w/mod. amts of fat & protein
§ Small, freq. meals
§ Supplemental vitamins
o Medications (Drugs are used sparingly!)
§ Antiemetics
§ Antiviral medications
§ Immunomodulators
o Educate:
§ Hand hygiene, quit drinking, eat low fat, high carb diet
§ Don’t share personal hygiene products, use separate bathrooms, small frequent meals
· Hepatitis A: Transmission: Fecal-oral
o Spread by poor hand hygiene
o Manifestations:
§ Mild flu-like symptoms, low-grade fever, anorexia, later jaundice and dark urine, indigestion and epigastric distress, enlargement of liver and spleen
o Management:
§ Prevention:
· Good handwashing, safe water, and proper sewage disposal.
· Vaccine
· Immunoglobulin for contacts to provide passive immunity.
· Bed rest during acute stage
· Nutritional support
· Hepatitis B: Transmitted through blood, saliva, semen, and vaginal secretions; sexually transmitted, transmitted to infant at the time of birth
o Risk Factors: Unprotected sex, contact with infected blood, needles, infant born to infected mother.
o Manifestations:
§ Insidious and variable; similar to Hepatitis A
§ Loss of appetite
§ Dyspepsia
§ Abdominal pain
§ Generalized aching
§ Malaise
§ Weakness
§ Jaundice may or may not be present
o Management:
§ Medications:
· Alpha interferon and antiviral agents: entecavir (ETV) and tenofovir (TDF)
§ Acute stage: Bed rest and nutritional support
§ Vaccine:
· Passive immunization for those exposed
· Standard precautions and infection control measures
§ Screening of blood and blood products
· Hepatitis C: Transmitted by blood and sexual contact, including needle sticks and sharing of needles
o Management:
§ Antiviral medications: Interferon SQ
§ Alcohol potentiates disease; medications that effect the liver should be avoided
§ Prevention: Public health programs to decrease needle sharing among drug users
§ Screening of blood supply
§ Safety needles for health care workers, wear gloves.
o When they get to chronic stage, liver cancer and transplant may happen
Hepatic Cirrhosis
Most commonly associated with alcohol abuse and scar tissue. · Manifestations: o Liver enlargement o Portal obstruction o Ascites o Infection and peritonitis o Varices, GI varices o Edema, o vitamin deficiency o Anemia o Mental deterioration · Nursing Management: o Promoting Rest o Improving nutritional status: High carb, calories, and protein (unless ammonia elevated). o Provide skin care, skin will be irritated o Reduce risk of injury o Monitor and manage potential complications · Complications: o Bleeding and hemorrhage o Hepatic encephalopathy o Fluid volume excess
Plan care for the patient who has undergone liver transplant
Liver Transplant: o Indications § Advanced chronic liver disease § Fulminant hepatic failure § Metabolic liver diseases § HCC § Hepatocellular disorders (viral hepatitis, drug or alcohol induced liver disease) § Cholestatic diseases (interruption in bile flow) o Process § Multidisciplinary process § Assessment of pt. § Organ matching § Placed on List § Priority based on Model of ESLD o Procedure § Remove disease liver § Replace with good liver § Vascular anastomoses of good liver to recipient § Biliary reconstruction § Long surgery § High blood loss likely o Nursing Management: § Preoperative · Support · Education § Postoperative · Infection control: Immunosuppressant meds · Monitoring · Education: Medication regimen, t-tube: how to manage the tube, drainage, and skin care § Complications · Bleeding, · Infection · Rejection, · Delayed graft function · Thrombosis
Describe principles of emergency care, including triage, assessment and intervening.
● TRIAGE: sorts patients by hierarchy based on:
○ Severity of health problems
○ Immediacy with which these problems must be treated
● Triage nurse collects data and classifies the illnesses/injuries to ensure the patients most in need of care do not needlessly wait
● Protocols may be initiated in the triage area
● ED triages differ from disaster triage in that patients who are the most critically ill receive the most resources, regardless of potential outcome
● Three categories:
○ Emergent: Highest priority
○ Urgent: Serious health problems but not life threatening
○ Nonurgent: Episodic illness
● Emergency severity index (ESI) assigns patients to five levels:
○ Level 1 (most urgent) to Level 5 (least urgent)
○ Level 1: Immediate life saving interventions
● Assessment:
○ Primary Survey: Focus on stabilizing life-threatening conditions:
■ A: airway: establish patent airway
■ B: breathing: provide adequate ventilation
■ C: circulation: evaluate and restore cardiac output; control hemorrhage, prevent and treat shock
■ D: disability: determine neurologic status; AVPU mnemonic (alert, verbal, pain, unresponsive), patient has neuro problem not able to communicate or unresponsive
■ E: exposure: undress to assess wounds or areas of injury. Make sure we don’t miss any areas
○ Secondary Survey
■ Health history: Very important
● History including current trauma, indoor and outdoor, what happened leading up to these injuries. Patients status before the injury or illness
■ Head-to-toe assessment: reassess airway, breathing, VS
■ Diagnostic and lab testing
■ Monitoring devices: ECG, arterial lines, urinary catheters
■ Splinting of suspected fractures
■ Cleansing, closure, dressing wounds
■ Performance of other interventions based on patients condition
Discuss priority and specify the similarities and differences of the emergency management of patients with:
. Airway Obstruction: ● Partial and complete obstruction ● Oropharyngeal or nasopharyngeal airway insertion ● Endotracheal intubation ● King tube or laryngeal mask ● Cricothyroidotomy ● Maintain Ventilation: ○ Ensure that the patient has equal bilateral breath sounds ○ Monitor pulse ox
b. Hemorrhage: Control Bleeding
· Fluid replacement: IV access
· Monitor VS, neuro, circulation and pulses
· External: Easier to control
· Internal: May need dx testing to find out where the bleed is
c. Trauma: Chest
· Injury prevention:
o Education
o Legislation
o Automatic protection
· Multiple trauma: Single catastrophic even that causes life-threatening injuries to at least 2 distinct organs or organ systems
· Injuries interfering with vital physiologic function have highest priority: Brain and spinal cord
· Chest Trauma
o Blunt: Caused by impact or force from an object
o Penetrating: Body is pierce by an object
o Pneumothorax
o Cardiac Tamponade
o Subcuteneous Emphysema
o Pathologic states:
§ Hypoxemia
§ Hypovolemia
§ Cardiac Failure
o Life threatening: Impaired ventilation and perfusion leading to acute renal failure, hypovolemic shock, and death
o Assessment:
§ Rapid Assessment- ABCDE
· Airway:
· Breathing:
· Circulation:
· Disability:
· Exposure:
§ General assessment: Undress patient completely to avoid missing injuries
· CXR, CT scan
· Lab: CBC, clotting studies, electrolytes
· O2 sat, ABGs
· ECG
o Medical Management:
§ Goal: Restore & maintain cardiopulmonary function
§ Establish airway & ventilation
§ Treat shock with colloids, crystalloids, blood
§ Chest tube often needed to achieve rapid and continuing re-expansion of lungs, drains fluid, blood, and air.
§ May require exploratory surgery if management isn’t enough
Pain management to help with chest expansion
Gastrointestinal: Ostomy
● Ostomy
○ Colostomy vs ileostomy - how they differ in characteristics and nursing care
■ Colostomy:
● surgical opening into the colon to allow drainage of contents through a stoma (large intestine: sigmoid, transverse, descending, ascending)
● Depending on placement, determines the type of fecal matter
● Permanent or temporary
● Can be trained
■ Ileostomy:
● surgical opening into the ileum of the small intestine
● Large amounts of digestive enzymes are found in the waste
● Permanent of temporary
● Continuous output, so there should never be constipated
● Nursing care of both Ostomy types
○ Empty the pouch when it is 1/3-1/2 full
○ Empty before activity and bedtime
○ Never put anything in the stoma unless instructed by provider
○ Change appliance system 1-2 times a week and prn, in the morning another gathering all supplies
○ Always wipe the tail of the pouch after emptying
○ May use lubricating deodorizer
○ Clean stoma and peri-stomal skin with warm water only w/ wash cloth or paper towels
○ Apply barrier ring (if needed), then wafer (cut to size), then apply pouch to wafer
● Post-operative ostomy assessment, nursing care, and priority interventions
○ Assessment
■ Monitor Ostomy output
● Occurs in 24-48 hours after surgery for ileostomy
● 3-6 days after surgery for colostomy
■ Monitor stoma
● Pink to bright red
● Shiny
○ Nursing care
■ Monitor fluid loss (large volume lost in this early period)
■ Record I&O
■ Monitor electrolyte and lab values
■ Administer electrolyte replacement
■ Bloody drainage initially
■ May still have stool and mucous from rectum initially
■ Monitor/manage gas pain
■ Manage NG suction
■ Provide emotional support
○ Priority interventions
■ Determine a regular schedule for changing the pouch to avoid leakage
■ Reinforce ostomy care education
■ Management of drainage from stoma and monitoring the nature of the drainage
■ How to use stoma appliances
■ Monitor for Peri-stomal skin irritation
● Caused by leakage due to pouching system that does not fit will
● Apply a solid skin barrier component
■ Diarrhea
● Can lead to dehydration and electrolyte imbalance, so monitor lab values
● Replacement of fluids and electrolytes when needed
● Use of anti-diarrheal agents
■ Ensure the pouching system is fitted properly to prevent leakage and skin irritation
■ Stoma stenosis
● Monitor for circular scar tissue that forms at stoma site
● May be surgically release
● Monitor for complications
○ Discharge education for colostomy and ileostomy
■ Patient is able to empty, change and apply
■ Education on when to call the doctor
● s/s of infection/complications
● Bowel Obstruction
Bowel Obstruction: Focus on the NG tube here!!
○ Small bowel obstruction clinical manifestations
■ Initial symptoms
● Cramps pain (wavelike and colicky)
● Hypoactive/absent bowel sounds
● Vomiting
● Dehydration
● Abdominal distention
● Complete blockage
○ Reverse direction of intestinal contents
○ Large bowel obstruction clinical manifestations
■ Symptoms develop and progress much slower than small bowel obstruction
● Constipation may be ONLY symptom
■ As it progresses
● Obvious distention
● Crampy lower abdominal pain
● Understand nasogastric (NG) tubes – why we use them, nursing care associated with them, and assessment that is involved
■ Used to decompress the stomach when there is an intestinal obstruction/lieu’s
■ Hooks up to suction to remove gastric contents when needed
■ Used to administer nutrition or medication when oral intake is not tolerate
○ NG nursing care
■ Assess/monitor output
■ Monitor function of NG
■ Assess fluid and electrolyte imbalances
■ Monitor nutritional status
■ Assess for resolution
■ Frequent oral care (every 4 hours)
■ Can also offer water or mouth wash to swish every hour
■ Keep nostrils clear
■ Lubricant can be applied to mouth and nose to help with discomfort of the tube
■ If the NG tube comes out DO NOT put it back in!! Call the provider
○ NG assessment
■ To check placement attach an empty syringe and instill air, then pull back to withdraw stomach contents and us a pH strip to double check that it is stomach contents
● If it is positive, indicates correct placement
● Inflammatory bowel disease
○ Know clinical manifestations of Crohn’s and ulcerative colitis
■ Crohn’s disease clinical manifestations
● Insidious onset
● RLQ abdominal pain that is NOT relieved with a BM
● Chronic diarrhea
● Cramps abdominal pain after meals
● Abdominal tenderness and spasms
● Steatorrhea
● Anorexia, weight loss, nutritional deficiencies
■ Ulcerative Colitis clinical manifestations
● LLQ pain
● Chronic diarrhea
● Stool with mucus, pus, or blood
● Frequent stools, 6+ a day
● Intermittent tenesmus (feeling of Im-complete defection)
● Anorexia, weight loss
○ Client education (discharge teaching) for Crohn’s and UC
■ Maintain normal elimination patterns
■ Determine relationship between BM and certain foods/activities/emotional stressors
■ Determine frequency, character, consistency, and amount of BM
■ Administer anti-diarrheal
○ Relieving pain
■ Assess character and onset of pain
■ Administer analgesic
■ Encourage non-pharm interventions
○ Maintain optimal nutrition
■ May need parenteral nutrition
■ Record I&O and DW
■ Encourage small, frequent, low-residue food
○ Promote rest
■ Intermittent rest periods and activity as tolerate
■ Passive exercises and joint ROM if needed
○ Reduce anxiety
■ Encourage expression of feelings and questions
■ Provide education about medical management/surgery
○ Prevent skin breakdown
■ Assess skin frequently
■ Provide perianal care (apply skin barrier prn)
■ Use pressure relieving devices
■ Consult with wound care prn
○ Monitor and manage potential complications
■ Monitor lytes, dysrhythmias, change in LOC, hypotension, rectal bleeding, s/s or perforation and obstruction
○ Know potential complications associated with inflammatory bowel disease and how to monitor/manage
■ Malnutrition and dyhydration
■ Increase risk of colon cancer
■ Bowel obstruction and perforation
■ Ulcers and fistula
■ Anal fissures
■ Cancers
● Know the risk factors, clinical manifestations, and ways of prevention associated with colorectal cancer
○ Risk factors of colorectal cancer
■ Older age (65-75)
■ Family history
■ Men
■ African American or Ashkenazi
○ Clinical manifestations
■ Determined by location, stage, and function of affected intestinal segment
■ Change in bowel habits (most common)
■ Blood in stool
■ Dull abdominal pain, melena (R side)
■ Obstruction, bright red blood in stool (L sided)
■ Tenesmus, rectal pain, alternating constipation and diarrhea, blood in stool (rectal)
○ Prevention: She said to remember that screening is very important!
■ EARLY SCREENING
■ All adults begin periodic colonoscopy screening at age 50
■ Home test kits
■ Smoking cessation
■ Physical activity, diet, weight reduction
● Know risk factors of oral cancer
○ Any form of tobacco use ○ Excessive ETOH use ○ HPV infection ○ Hx of head and neck cancer ○ Men
nursing management post-op esophagectomy
○ Nursing management ■ Prevention of aspiration pneumonia ■ Low Fowler/Fowler position ■ Use of IS 10x/day ■ Sitting up in chair when able ■ Nebulizer treatments ■ Assess for regurgitation and dyspnea ■ Maintain NG tube ● Usually to low intermittent suction ● DO NOT manipulate ● DO NOT replace if displaced ■ NPO ■ Maintaining Adequate Nutrition ● Diet advanced as tolerated ● After meals, remain un right for at least 2 hours ● Encourage food intake, appetite may be poor ● Avoid Boost of Ensure (promotes dumping syndrome)
● Priority care post-op neck dissection
○ Maintains airway clearance ○ Fowler position ○ Assess for s/s of resp distress (She said this is the main thing, knowing that we just took out part of the neck and need to assess breathing and swallowing!) ○ Removal of secretions to prevent pneumonia ○ Cough and deep breathing ○ Suction PRN ○ Relieve pain ○ Assess pain level (PCA if needed) ○ Providing wound care ○ Management of wound vacs and dressings and s/s of infection ○ Maintaining adequate nutrition ○ Assess ability to chew ○ Diet modification PRN ○ Oral care after eating to prevent infection ○ Maintaining physical mobility ■ Weakness of shoulder ■ Exercise to promote maximal shoulder function and neck motion ○ Monitor/manage potential complications ■ Hemorrhage ○ Frequent VS ○ Avoid valsalva maneuver ○ Chyle fistula ○ Assess chest tube drainage
○ Nerve injury
■ Assess for lower facial paralysis and difficulty swallowing ○ Speech therapy ■ Promote effective communication ■ Establish communication plan pre op ■ SLP therapy ■ Supporting patient self esteem and needs of caregivers ○ Pre op teaching ○ Support change in body image ■ Coping skills ■ Support groups
