Exam 3 Flashcards
assistive device indicated for short or long term assistance
crutches
what patient would need forearm crutches
individuals with permanent ambulation needs, like cerebral palsy or congenital hip
what type of crutch would be used for persons with rheumatoid arthritis, severe osteoarthritis, or spina bifida
platform crutches
axilla pad of crutch should be how many inches below axillary fold, and degree that elbows should be
1 1/2 - 2 inches below axilla and 30 degree angle at elbows
two point gait crutch walk instructions
imitates normal walking with 1 crutch and opposite foot forward follow by other foot and crutch in unison
indications for two point gait crutch walking
bilateral weakness
three point partial weight bearing indications
amputee learning to use prosthetic, healing injury, partial weight bearing status
three point partial weight bearing instructions
both crutches advance with weaker leg followed by stronger leg
three point gait non weight bearing indications
amputated, disabled or injured leg
three point gait non weight bearing instructions
two crutches advance, strong leg advances while injured leg is bent and swings with step
four point gait crutch walking indications
bilateral weakness
four point gait crutch walking instructions
right crutch, left foot, left crutch, right foot
swing to and swing through crutch walking indications
good upper body strength, bilateral weakness
swing to and swing through crutch walking instructions
crutches advances, both legs swing to crutch at same time, or swing through beyond crutch
instructions for stair climbing with crutches
up: good leg, crutches, bad leg
down: bad leg and crutches, good leg
benefits of using a cane
provides support, balance, and relieves pressure on weight bearing joints
how canes should be measured
upside down, and cane should stop at the wrist crease
canes should be placed on what side and instructions on walking
the unaffected side and should advance with weaker leg
are instructions for stairs and canes the same as stairs and crutches
yes, good going up bad going down
canes use what leg first
COAL: canes opposite affected leg
walkers use what leg first
wandering wilma’s always late: walkers with affected leg
examples of nursing diagnoses for patients with assistive devices
- impaired physical mobility, skin integrity
- risk for injury, falls
- acute, chronic pain
pulling force that is applied to part of extremity while counter force pulls in opposite direction
traction
purposes of traction
reduce fracture, immobilize, decrease pain, correct deformities, decrease muscle spasms, stretch tight muscles, expand joint
two types of traction are
skin - attached to skin or soft tissues and provides light pull for short term stabilization
skeletal - directly attached to bone, pins inserted and provides strong continuous pull
olecranon pin traction
overhead arm traction, elbow is 90 degree angle
dunlop’s traction
sidearm traction, elbow is 90 degrees
buck’s traction
extension leg traction, skin traction, pulls hip and knee fully extended, not used as much anymore
russell traction
skin leg traction, usually for femur or hip fracture
balanced traction with thomas ring splint and pearson attachment
ring at groin, with canvas sling, supports high thigh, skeletal traction
halo vest
for cervical and high thoracic fractures
when screws placed in tibia, pelvis, ankle/foot
external fixation
what is more common external or internal fixation
internal as it allows for more immediate mobility and requires no hardware removal
what should always be applied to assist patient with movement when in traction
trapeze
how should traction ropes hang
freely with no friction
proper body alignment for pt in traction
positioned high so feet are not pressed against bed
care of pt in traction should include
- check pressure points
- CMS checks
- bed no higher than 25 degrees
- clean pins with normal saline and hydrogen peroxide
T of TRACTION
temperature
R of TRACTION
ropes hang freely
A of TRACTION
alignment
C of TRACTION
circulation (5 P’s)
T of TRACTION
type and location of fracture
I of TRACTION
intake of fluid
O of TRACTION
overhead trapeze
N of TRACTION
no weights on bed or floor
5 P’s of circulatory checks
Pain Paresthesia Paralysis Pulse Pallor
examples of nursing diagnoses for pt with traction
- impaired physical mobility, skin integrity, breathing pattern
- peripheral neuromuscular dysfunction
- acute pain
- risk for injury, infection
- decreased tissue perfusion
- self care deficit
fibrous connective tissue attaches muscle to bone
tendon
fibrous connective tissue attached bone to bone
ligament
over-stretching that leads to a partial or complete tear of ligaments
sprains
first degree ankle sprain assessment findings
mild tenderness and slight swelling
2nd degree ankle sprain assessment findings
increased swelling and tenderness, more bruising
third degree ankle sprain assessment findings
complete ligament tear, gap may be felt or seen through skin, extremely painful due to nerve exposure
stretching of muscle and fascial sheath is
strain
assessment findings of strains
pain, edema, decreased function, bruising
interventions for sprains and strains
rest, icing area, warm moist heat, compression, elevate extremity, analgesia, muscle relaxants, NSAIDS, surgery
RICE stands for what for sprains and strains care
Rest, Ice, Compression, Elevation
how should ace wraps be applied
figure 8 motion, not circular
things to mind when caring for pt with leg amputation
avoid fowlers and semi-fowlers position for long periods of time, sit in chair no more than 30 mins twice a day 24 hrs post op, avoid standing with limb in dependent position for more than 30 mins until stump heals
post mutation pt care nursing diagnoses
- chronic or acute pain, phantom pain/sensation
- impaired physical mobility
- disturbed body image
- knowledge deficit
- risk for injury
continuous passive motion devices indicated for
knee replacement, reparative knee replacement, past interarticular fractures
advantages of continuous
passive motion devices
early mobilization, enhanced healing, tissue remodeling, reduces joint effusions and associated pain, decreased LOS
assessment during CPM (continuous passive motion) devices
confirm degrees of flexion and extension w/ provider, assess neurvascular status, reports of pain
methods to prevent DVT
meds (aspirin, coumadin, heparin), SCD’s, anti-embolism stockings
risk factors for DVT
- prior DVT or PE
- malignancy
- hypercoaguable state
- 60 yrs or older
- prolonged immobility or paralysis (> 72 hrs)
- central venous access
- MI, heart failure, sepsis, stroke
minor risk factors for DVT
obesity, compensated heart failure, trauma, pregnancy, varicose veins, IBS, contraceptives, meds (Evista and Nolvadex)
definition: loss
experience of parting with object, person, pet or relationship which results in need for life reorganization
definition: grief
psychological, emotional, spiritual, and physiological responses by a person following a loss
definition: bereavement
state of destitution following loss
definition: mourning
socially prescribed behaviors in response to a death, can vary in different cultures
common elements in all models of grieving
holistic responses, shock, denial, acceptance, resolution
interventions to help aid anticipatory grieving
- active listening to grief
- maintain hope
- building and creating memories
- encourage family to talk and touch loved one and to give loved one permission to die
- referral to bereavement supports
- planning funeral, burial, etc.
- assess emotions, responses, and suffering
interventions for dysfunctional grieving
- encourage expression of feelings
- assist with focusing on reality and changes due to loss
- promote self-help activities
- identify coping strategies
- encourage reminiscing
- referral to bereavement and support groups
care of pt following death
- give time for family
- remove tubes
- bathe, dress and position patient
- place dressing on leaking wounds, and padding for any incontinence
things to offer family after death of pt
- ask if they would like to assist in the care
- preferences for clothing or care of body
- prayer service preferences at bedside
what is included in spiritual assessment
FICA (faith, influence, community, application)
symptoms of imminent death
- decreased urine output
- cold and mottle extremities
- change in vitals and noisy breathing
- delirium
- restlessness
- confusion/unresponsive
interventions for noisy breathing, “death rattle” before death
raise HOB, reduce or withhold fluids, atropine to dry up secretions
signs of death
- no heartbeat, blood pressure, respirations
- pupils dilate or fixed
- pale to waxen
- body temp drops (cold to touch)
- sphincters relax (stool or urine release)
- eyes may be open, jaw may relax and fall open
how is ileostomy created
brings a portion of small intestine through opening in abdomen
discharge from ileostomy consistency and character
constant, watery, with large amounts of salt and digestive enzymes
discharge that is constant, watery and contains large amounts of salts and digestive enzymes is discharged from what type of ostomy
ileostomy
output that is liquid to semi-liquid, rich in digestive enzymes and irritating to the skin around stoma is from what type of ostomy
ascending colostomy
output that is liquid to semi-formed due to decrease in digestive enzyme content
transverse colostomy
as stoma of transverse colostomy moves further to the left what happens to the output an why
it becomes more formed due to decrease in digestive enzyme content
output is semi-formed to formed due to water being absorbed is from what kind of ostomy
descending colostomy
why does output from descending colostomy become more formed
as waste moves through ascending and transverse colon more and more water gets absorbed
output is normal, formed consistency in what kind of ostomy
sigmoid colostomy
why is output in sigmoid colostomy normal and formed
because water continues to be absorbed as waste passes through large bowel
what is involved in a conventional urostomy
ureters from bladder are detached and implanted into ileal segment creating and ileal conduit
is a conventional urostomy a permanent surgical procedure
yes
what does a conventional urostomy require the pt to wear and why
a collection bag at all times because urine flow is uncontrolled
normal stoma appearance
pink to rosy red and moist
abnormal stoma appearance
dark blue to purplish black in color and requires revision
with ostomy wafer sizing what can result from an opening that is too small
it can restrict circulation to stoma
how long should pressure be placed during application of the ostomy wafer in order to ensure adhesion
at least 30 seconds
is the swelling, “turtle-necking” effect with durahesive ostomy wafers normal or a reason for concern
it is normal and does not prevent flow of urine or stool
when applying ostomy pouch where should you start
start with two fingers at 6 o’clock position, and move up both sides to 12 o’clock position
what type of water and how much should be used to irrigate an ostomy
500-1000 ml of lukewarm tap water
what should you do if the pt complains of cramping while giving an enema through an ostomy stoma
slow the rate of fluid administration
when should ostomy irrigation be done
the same time every day and preferably one hour after a meal
potential pt problems regarding ostomies
- altered body image
- self care deficit
- knowledge deficit r/t health maintenance
- alteration in bowel regimen
- impaired skin integrity
purpose for administering an enema (6)
- cleanse lower bowel
- soften feces
- expel flatus
- soothe irritated mucous membranes
- outline colon during diagnostic x-rays
- treat worm and parasitic infections
what type of fluid can be used for large volume enemas
tap water with soap suds or normal saline
how does a large volume enema stimulate defacation
by causing distention in order to stimulate the defection reflex
indications for large volume enema
to relieve constipation, or to cleanse bowel for procedures
who are saline enemas usually reserved for
infants and children
another term used for small volume enemas
fleets
small volume enema indication
when oral or rectal laxatives are ineffective
how does a small volume enemas work
the hypertonic solution draws water via osmosis from colonic mucosa to cause water retention in the lower colon, this increases peristalsis and stimulates defamation reflex
what is the preferred pt position for administering an enema
pt laying on left side
in what direction should enema tube be initially inserted
towards umbilicus
if patient complains of cramping during enema administration what should do
slow rate or stop administration by lowering enema bag, and resume once cramping passes
where should enema bag be placed
18 inches above rectum
what is different about technique for purging air/flatus using enema treatment as opposed to normal enema
use same technique as large volume enema, except bag is placed below rectum allowing water to return to the container, expelling flatus
potential pt problems related to enemas (7)
- constipation
- risk for constipation
- perceived constipation
- diarrhea
- bowel incontinence
- toiling self-care deficit
- situational low self-esteem
diagnostic indications for GI tubing (4)
- evaluation of upper GI bleed
- aspiration of gastric fluid for sampling and testing
- identification of esophagus and stomach on chest radiograph
- administration of radiographic contract to GI tract
therapeutic indications for GI tubing (7)
- gastric decompression of fluid and gas
- relief of symptoms r/t small bowel obstruction or paralytic ileum
- lavage - aspiration of toxic gastric content
- med administration
- garage feeding
- bowel irrigation
- controlling gastric bleeding by compression or tamponade
salem sump, levine, enteral feeding tube, miller abbott & cantor, sengstaken-blakemore & minnesota, “ewald” tube are all examples of what type of GI tubing
Nasogastric tubes
gastric single lumen NG tube with air vent
salem pump
gastric single lumen NG tube
levine tube
NG tubing that comes in single or double lumen, gastric or gastrointestinal, weight or non-weighted, wired or un-wired
NG enteral feeding tube
a salem sump tube with air vent is used to
decompress the stomach
the air vent of the salem sump must be…
unclamped at all times and kept above level of stomach
what type of suction is used with salem sump tubes
intermittent or continuous suction
most common type of tubing for decompression
salem sump tube
suction used for levine tubes
intermittent
indications for levine tubes
remove gastric contents
is levine tube common or rarely used
rarely used
indications for NG tube feedings
need for intermittent or continuous enteral feedings and med admin.
where is NG tube inserted to
either the stomach or duodenum
what is the hesitation to using miller-abbott or cantor tubes
they are mercury weighted and therefore they are handled as hazardous waste
alternative to mercury weighted tubes
anderson tube which is tungsten weight, safer than mercury
miller abbott is ____ lumen
anderson is ____ lumen
cantor is ____ lumen
double
double
single
indications for miller abbott, cantor and anderson tubes
decompression or relieve intestinal obstruction
in order to prevent esophageal and gastric bleeding with sengstaken blakemore or minnesota tubing what should be done
pressure should be applied to esophageal veins and gastric varices
what can happen if sengstaken blakemore or minnesota tubing balloon ruptures arm igrates
can lead to respiratory distress or arrest due to airway obstruction
what should be kept at bedside in case of balloon rupture or migration with sengstaken blakemore and Minnesota tubes
pair of scissors to cut tube below bifurcation in order to remove
when are gastric varies tubes used (linton-nachlas)
when endoscopy was unsuccessful or when tubing can be lifesaving despite risk for complications
tube that is a temporary measure and is removed 24 hrs post insertion
esophageal tamponade
patients ta high risk for malpositioned nasogastric tubes (6)
- unconscious or heavily sedated
- have endotracheal tube or tracheostomy
- uncooperative during section
- depressed or absent gag and cough reflex
- confusion or debilitated
- craniofacial trauma or surgery
absolute contraindications for NG tubes (2)
- severe facial trauma
2. recent nasal surgery
relative contraindications for NG tube (4)
- coagulation abnormality
- esophageal varices or stricture
- recent banning or cautery of esophageal varies
- alkaline ingestion
NG tube measuring (NEX)
n - nose
e - earlobe
x - xiphoid process
what can misplacement of NG tubes lead to:
- aspiration pneumonia
- severe lung damage
- permanent lung damage leading to organ dysfunction or death
placement of NG tube definitely increases what
LOS, morbidity, mortality
if patient is experiencing weight loss, or inadequate weight gain, dumping syndrome or diarrhea following NG tube placement what should be considered
NG tube migration or dislodgment
when should residual checks be done with NG tube feedings
before feedings
in order to avoid fluid and electrolyte imbalance and keep up nutritional requirements with NG feedings what should be done
residuals should be re-fed and only discarded if there is blood
how often should oral care be done with NG tube feedings
minimum of every shift
NG placement should be checked when
initially and continuously
patient position for NG tube feeding
HOB at least 30 degrees
gold standard for checking NG tube placement and when should be done
chest x ray with radio-opaque tube, should be done on initial insertion
other methods besides chest x ray for confirming NG tube placement especially used after initial insertion at bedside
observation and characteristics of aspirate, and pH of gastric versus intestinal aspirate
non scientific method for NG tube placement
auscultating air bolus through tube near gastric funds/epigastric region
color of aspirate if NG tube properly placed in gastric region
green, clear/colorless, or brown
bile stained aspirate means NG tube is most likely placed where, what will pH of aspirate be as well
small intestine, greater than 6
things to note with NG continuous feedings
- patient tolerance
- adult should have residuals less than 50 mls
provider should be noticed if adult residuals are greater than what
150 ml
continous suction should be generally used with vented or unvented NG tube
unvented, but can cause irritation and get flecks of blood in drainage
intermittent suction should be used with vented or unvented NG tube and why
vented to prevent irritation
in adults intermittent suction pressure should be set at
20-40 , max 60 mm Hg
when is NG tube clamped with intermittent suction
clamped for 30 minutes after med admin., and clamped when pt ambulating
aspirate pH less than or equal to 5 placement is in
GI tract
aspirate pH greater than or equal to 6 placement is in
respiratory tract
complications of NG tube intubation (9)
- aspiration leading to asphyxia
- aspiration pneumonia
- abscess formation
- trauma injury including perforation
- pulmonary hemorrhage, pneumo, empyema, pneumothorax, pleural effusion
- nosebleeds
- secondary infection
- tracheal-esophageal fistula
- erosion or tissue necrosis
types of trans-abdominal gastric tubs
gastrostomy tube, jejunostomy tube, PEG, MIC-key button
indication for gastronomy and PEG tubes
for long term delivery of nutrition and meds when pt has no gag or swallow reflex or who aspirates
what is malecot feeding tube
used for children where gastrostomy tube is too big
reason why PEG tube is preferred
less expensive, safer to insert, and no anesthesia is required, feedings can begin 24 hrs after placement
gastric feeding tube used in pediatrics
MIC-Key (LPGD)
gastric tube used in patients who aspirate frequently
J tube (jejunostomy) along with gastrostomy tube –> GJ tube
food and meds are given through what with a GJ tube
feedings through J tube and meds through G tube
what is needed with J tubes to prevent occlusions
flushing
predigested formulas need to be given with what tubes and why
with J tubes because its location is further along in the digestive process
enteral nutrition via bolus
volume of 250-400 cc formula over 30 min or less, 4-6 times a day
enteral feeding via intermittent
240-400 cc formula over 30-60 minutes 4-6 times a day
enteral feeding via cyclic
continuous nourishment for 8-12 hours with 12-16 hour pause
indications for cyclic enteral feeding
to wean patient from tube feedings and for those fed overnight
enteral feedings via continuous
continuous with no interruption at rate of 1.5 ml per minute (50-75 ml/hour)
to prevent infection with enteral tube feedings
- change tubing q 24 hrs
to prevent air during bolus enteral feedings what should be done
gravity flow instillation should be done on angle
when should placement be checked with GI tubes
before initial use using x ray, and before feeding by aspirating gastric contents and checking tube placement at nares
to maintain tube potency and prevent obstructions what must nurse do with GI tubes
- flush with sterile water before and after feedings (intermittent)
- flush q 4-6 hrs with sterile water (continuous)
call provider guideline for GI feeding residuals
greater than 150 ml
with continuous feedings what should nurse do when suctioning, turning, positioning or transferring patient
place feeding on standby every time
complications of enteral feedings (6)
- obstruction
- perforation
- tube migration
- regurgitation and aspiration of feeding
- diarrhea, nausea, vomiting
- abdominal distention, cramping, discomfort
potential pt problems related to enteral feedings (7)
- imbalanced nutrition less than body requirements
- self care deficit
- paired swallowing
- aspiration risk
- impaired oral mucous membranes
- diarrhea
- constipation
A nurse is preparing to care for a patient with esophageal varices who has just has a Sengstaken-Blakemore tube inserted. The nurse gathers supplies, knowing that which of the following items must be kept at the bedside at all times?
a. An obturator
b. Kelly clamp
c. An irrigation set
d. A pair of scissors
d. pair of scissors
A nurse is preparing to administer medication through a NG tube (Salem sump) that is connected to suction. To administer the medication, the nurse would do which of the following?
a. Position the patient supine to assist in medication absorption
b. Aspirate the nasogastric tube after medication administration to maintain patency
c. Clamp the nasogastric tube for 30 minutes following administration of the medication
d. Change the suction setting to low intermittent suction for 30 minutes after medication administration
c. Clamp the nasogastric tube for 30 minutes following administration of the medication
A nurse checks for residual before administering a bolus tube feeding to a patient with a NG tube (Duotube) and obtains a residual amount of 100 mL. What is appropriate action for the nurse to take?
a. Hold the feeding
b. Reinstill the amount and continue with administering the feeding
c. Elevate the client’s head at least 45 degrees and administer the feeding
d. Discard the residual amount and proceed with administering the feeding
b. Reinstill the amount and continue with administering the feeding
A nurse is inserting a NG
tube in a patient. During the procedure, the patient begins to cough and has difficulty breathing. Which of the following is the appropriate nursing action?
a. Quickly insert the tube
b. Notify the physician immediately
c. Remove the tube and reinsert later subsides
d. Pull back on the tube and wait until the respiratory distress subsides
d. Pull back on the tube and wait until the respiratory distress subsides
A patient who underwent abdominal surgery who has a NG tube in place begins to complain of abdominal pain that is described as "feeling full and uncomfortable." Which assessment should the nurse perform first? A. Measure abdominal girth B. Auscultate bowel sounds C. Assess patency of the NG tube D. Assess vital signs
C. Assess patency of the NG tube
