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Therapeutic II > Exam 3 > Flashcards

Exam 3 Flashcards

1
Q

assistive device indicated for short or long term assistance

A

crutches

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2
Q

what patient would need forearm crutches

A

individuals with permanent ambulation needs, like cerebral palsy or congenital hip

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3
Q

what type of crutch would be used for persons with rheumatoid arthritis, severe osteoarthritis, or spina bifida

A

platform crutches

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4
Q

axilla pad of crutch should be how many inches below axillary fold, and degree that elbows should be

A

1 1/2 - 2 inches below axilla and 30 degree angle at elbows

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5
Q

two point gait crutch walk instructions

A

imitates normal walking with 1 crutch and opposite foot forward follow by other foot and crutch in unison

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6
Q

indications for two point gait crutch walking

A

bilateral weakness

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7
Q

three point partial weight bearing indications

A

amputee learning to use prosthetic, healing injury, partial weight bearing status

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8
Q

three point partial weight bearing instructions

A

both crutches advance with weaker leg followed by stronger leg

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9
Q

three point gait non weight bearing indications

A

amputated, disabled or injured leg

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10
Q

three point gait non weight bearing instructions

A

two crutches advance, strong leg advances while injured leg is bent and swings with step

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11
Q

four point gait crutch walking indications

A

bilateral weakness

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12
Q

four point gait crutch walking instructions

A

right crutch, left foot, left crutch, right foot

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13
Q

swing to and swing through crutch walking indications

A

good upper body strength, bilateral weakness

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14
Q

swing to and swing through crutch walking instructions

A

crutches advances, both legs swing to crutch at same time, or swing through beyond crutch

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15
Q

instructions for stair climbing with crutches

A

up: good leg, crutches, bad leg
down: bad leg and crutches, good leg

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16
Q

benefits of using a cane

A

provides support, balance, and relieves pressure on weight bearing joints

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17
Q

how canes should be measured

A

upside down, and cane should stop at the wrist crease

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18
Q

canes should be placed on what side and instructions on walking

A

the unaffected side and should advance with weaker leg

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19
Q

are instructions for stairs and canes the same as stairs and crutches

A

yes, good going up bad going down

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20
Q

canes use what leg first

A

COAL: canes opposite affected leg

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21
Q

walkers use what leg first

A

wandering wilma’s always late: walkers with affected leg

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22
Q

examples of nursing diagnoses for patients with assistive devices

A
  • impaired physical mobility, skin integrity
  • risk for injury, falls
  • acute, chronic pain
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23
Q

pulling force that is applied to part of extremity while counter force pulls in opposite direction

A

traction

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24
Q

purposes of traction

A

reduce fracture, immobilize, decrease pain, correct deformities, decrease muscle spasms, stretch tight muscles, expand joint

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25
Q

two types of traction are

A

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

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26
Q

olecranon pin traction

A

overhead arm traction, elbow is 90 degree angle

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27
Q

dunlop’s traction

A

sidearm traction, elbow is 90 degrees

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28
Q

buck’s traction

A

extension leg traction, skin traction, pulls hip and knee fully extended, not used as much anymore

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29
Q

russell traction

A

skin leg traction, usually for femur or hip fracture

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30
Q

balanced traction with thomas ring splint and pearson attachment

A

ring at groin, with canvas sling, supports high thigh, skeletal traction

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31
Q

halo vest

A

for cervical and high thoracic fractures

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32
Q

when screws placed in tibia, pelvis, ankle/foot

A

external fixation

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33
Q

what is more common external or internal fixation

A

internal as it allows for more immediate mobility and requires no hardware removal

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34
Q

what should always be applied to assist patient with movement when in traction

A

trapeze

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35
Q

how should traction ropes hang

A

freely with no friction

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36
Q

proper body alignment for pt in traction

A

positioned high so feet are not pressed against bed

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37
Q

care of pt in traction should include

A
  • check pressure points
  • CMS checks
  • bed no higher than 25 degrees
  • clean pins with normal saline and hydrogen peroxide
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38
Q

T of TRACTION

A

temperature

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39
Q

R of TRACTION

A

ropes hang freely

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40
Q

A of TRACTION

A

alignment

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41
Q

C of TRACTION

A

circulation (5 P’s)

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42
Q

T of TRACTION

A

type and location of fracture

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43
Q

I of TRACTION

A

intake of fluid

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44
Q

O of TRACTION

A

overhead trapeze

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45
Q

N of TRACTION

A

no weights on bed or floor

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46
Q

5 P’s of circulatory checks

A 
Pain
Paresthesia
Paralysis
Pulse
Pallor
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47
Q

examples of nursing diagnoses for pt with traction

A
  • impaired physical mobility, skin integrity, breathing pattern
  • peripheral neuromuscular dysfunction
  • acute pain
  • risk for injury, infection
  • decreased tissue perfusion
  • self care deficit
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48
Q

fibrous connective tissue attaches muscle to bone

A

tendon

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49
Q

fibrous connective tissue attached bone to bone

A

ligament

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50
Q

over-stretching that leads to a partial or complete tear of ligaments

A

sprains

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51
Q

first degree ankle sprain assessment findings

A

mild tenderness and slight swelling

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52
Q

2nd degree ankle sprain assessment findings

A

increased swelling and tenderness, more bruising

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53
Q

third degree ankle sprain assessment findings

A

complete ligament tear, gap may be felt or seen through skin, extremely painful due to nerve exposure

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54
Q

stretching of muscle and fascial sheath is

A

strain

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55
Q

assessment findings of strains

A

pain, edema, decreased function, bruising

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56
Q

interventions for sprains and strains

A

rest, icing area, warm moist heat, compression, elevate extremity, analgesia, muscle relaxants, NSAIDS, surgery

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57
Q

RICE stands for what for sprains and strains care

A

Rest, Ice, Compression, Elevation

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58
Q

how should ace wraps be applied

A

figure 8 motion, not circular

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59
Q

things to mind when caring for pt with leg amputation

A

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

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60
Q

post mutation pt care nursing diagnoses

A
  • chronic or acute pain, phantom pain/sensation
  • impaired physical mobility
  • disturbed body image
  • knowledge deficit
  • risk for injury
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61
Q

continuous passive motion devices indicated for

A

knee replacement, reparative knee replacement, past interarticular fractures

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62
Q

advantages of continuous

passive motion devices

A

early mobilization, enhanced healing, tissue remodeling, reduces joint effusions and associated pain, decreased LOS

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63
Q

assessment during CPM (continuous passive motion) devices

A

confirm degrees of flexion and extension w/ provider, assess neurvascular status, reports of pain

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64
Q

methods to prevent DVT

A

meds (aspirin, coumadin, heparin), SCD’s, anti-embolism stockings

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65
Q

risk factors for DVT

A
  • 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
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66
Q

minor risk factors for DVT

A

obesity, compensated heart failure, trauma, pregnancy, varicose veins, IBS, contraceptives, meds (Evista and Nolvadex)

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67
Q

definition: loss

A

experience of parting with object, person, pet or relationship which results in need for life reorganization

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68
Q

definition: grief

A

psychological, emotional, spiritual, and physiological responses by a person following a loss

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69
Q

definition: bereavement

A

state of destitution following loss

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70
Q

definition: mourning

A

socially prescribed behaviors in response to a death, can vary in different cultures

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71
Q

common elements in all models of grieving

A

holistic responses, shock, denial, acceptance, resolution

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72
Q

interventions to help aid anticipatory grieving

A
  • 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
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73
Q

interventions for dysfunctional grieving

A
  • 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
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74
Q

care of pt following death

A
  • give time for family
  • remove tubes
  • bathe, dress and position patient
  • place dressing on leaking wounds, and padding for any incontinence
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75
Q

things to offer family after death of pt

A
  • ask if they would like to assist in the care
  • preferences for clothing or care of body
  • prayer service preferences at bedside
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76
Q

what is included in spiritual assessment

A

FICA (faith, influence, community, application)

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77
Q

symptoms of imminent death

A
  • decreased urine output
  • cold and mottle extremities
  • change in vitals and noisy breathing
  • delirium
  • restlessness
  • confusion/unresponsive
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78
Q

interventions for noisy breathing, “death rattle” before death

A

raise HOB, reduce or withhold fluids, atropine to dry up secretions

79
Q

signs of death

A
  • 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
80
Q

how is ileostomy created

A

brings a portion of small intestine through opening in abdomen

81
Q

discharge from ileostomy consistency and character

A

constant, watery, with large amounts of salt and digestive enzymes

82
Q

discharge that is constant, watery and contains large amounts of salts and digestive enzymes is discharged from what type of ostomy

A

ileostomy

83
Q

output that is liquid to semi-liquid, rich in digestive enzymes and irritating to the skin around stoma is from what type of ostomy

A

ascending colostomy

84
Q

output that is liquid to semi-formed due to decrease in digestive enzyme content

A

transverse colostomy

85
Q

as stoma of transverse colostomy moves further to the left what happens to the output an why

A

it becomes more formed due to decrease in digestive enzyme content

86
Q

output is semi-formed to formed due to water being absorbed is from what kind of ostomy

A

descending colostomy

87
Q

why does output from descending colostomy become more formed

A

as waste moves through ascending and transverse colon more and more water gets absorbed

88
Q

output is normal, formed consistency in what kind of ostomy

A

sigmoid colostomy

89
Q

why is output in sigmoid colostomy normal and formed

A

because water continues to be absorbed as waste passes through large bowel

90
Q

what is involved in a conventional urostomy

A

ureters from bladder are detached and implanted into ileal segment creating and ileal conduit

91
Q

is a conventional urostomy a permanent surgical procedure

A

yes

92
Q

what does a conventional urostomy require the pt to wear and why

A

a collection bag at all times because urine flow is uncontrolled

93
Q

normal stoma appearance

A

pink to rosy red and moist

94
Q

abnormal stoma appearance

A

dark blue to purplish black in color and requires revision

95
Q

with ostomy wafer sizing what can result from an opening that is too small

A

it can restrict circulation to stoma

96
Q

how long should pressure be placed during application of the ostomy wafer in order to ensure adhesion

A

at least 30 seconds

97
Q

is the swelling, “turtle-necking” effect with durahesive ostomy wafers normal or a reason for concern

A

it is normal and does not prevent flow of urine or stool

98
Q

when applying ostomy pouch where should you start

A

start with two fingers at 6 o’clock position, and move up both sides to 12 o’clock position

99
Q

what type of water and how much should be used to irrigate an ostomy

A

500-1000 ml of lukewarm tap water

100
Q

what should you do if the pt complains of cramping while giving an enema through an ostomy stoma

A

slow the rate of fluid administration

101
Q

when should ostomy irrigation be done

A

the same time every day and preferably one hour after a meal

102
Q

potential pt problems regarding ostomies

A
  • altered body image
  • self care deficit
  • knowledge deficit r/t health maintenance
  • alteration in bowel regimen
  • impaired skin integrity
103
Q

purpose for administering an enema (6)

A
  1. cleanse lower bowel
  2. soften feces
  3. expel flatus
  4. soothe irritated mucous membranes
  5. outline colon during diagnostic x-rays
  6. treat worm and parasitic infections
104
Q

what type of fluid can be used for large volume enemas

A

tap water with soap suds or normal saline

105
Q

how does a large volume enema stimulate defacation

A

by causing distention in order to stimulate the defection reflex

106
Q

indications for large volume enema

A

to relieve constipation, or to cleanse bowel for procedures

107
Q

who are saline enemas usually reserved for

A

infants and children

108
Q

another term used for small volume enemas

A

fleets

109
Q

small volume enema indication

A

when oral or rectal laxatives are ineffective

110
Q

how does a small volume enemas work

A

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

111
Q

what is the preferred pt position for administering an enema

A

pt laying on left side

112
Q

in what direction should enema tube be initially inserted

A

towards umbilicus

113
Q

if patient complains of cramping during enema administration what should do

A

slow rate or stop administration by lowering enema bag, and resume once cramping passes

114
Q

where should enema bag be placed

A

18 inches above rectum

115
Q

what is different about technique for purging air/flatus using enema treatment as opposed to normal enema

A

use same technique as large volume enema, except bag is placed below rectum allowing water to return to the container, expelling flatus

116
Q

potential pt problems related to enemas (7)

A
  1. constipation
  2. risk for constipation
  3. perceived constipation
  4. diarrhea
  5. bowel incontinence
  6. toiling self-care deficit
  7. situational low self-esteem
117
Q

diagnostic indications for GI tubing (4)

A
  1. evaluation of upper GI bleed
  2. aspiration of gastric fluid for sampling and testing
  3. identification of esophagus and stomach on chest radiograph
  4. administration of radiographic contract to GI tract
118
Q

therapeutic indications for GI tubing (7)

A
  1. gastric decompression of fluid and gas
  2. relief of symptoms r/t small bowel obstruction or paralytic ileum
  3. lavage - aspiration of toxic gastric content
  4. med administration
  5. garage feeding
  6. bowel irrigation
  7. controlling gastric bleeding by compression or tamponade
119
Q

salem sump, levine, enteral feeding tube, miller abbott & cantor, sengstaken-blakemore & minnesota, “ewald” tube are all examples of what type of GI tubing

A

Nasogastric tubes

120
Q

gastric single lumen NG tube with air vent

A

salem pump

121
Q

gastric single lumen NG tube

A

levine tube

122
Q

NG tubing that comes in single or double lumen, gastric or gastrointestinal, weight or non-weighted, wired or un-wired

A

NG enteral feeding tube

123
Q

a salem sump tube with air vent is used to

A

decompress the stomach

124
Q

the air vent of the salem sump must be…

A

unclamped at all times and kept above level of stomach

125
Q

what type of suction is used with salem sump tubes

A

intermittent or continuous suction

126
Q

most common type of tubing for decompression

A

salem sump tube

127
Q

suction used for levine tubes

A

intermittent

128
Q

indications for levine tubes

A

remove gastric contents

129
Q

is levine tube common or rarely used

A

rarely used

130
Q

indications for NG tube feedings

A

need for intermittent or continuous enteral feedings and med admin.

131
Q

where is NG tube inserted to

A

either the stomach or duodenum

132
Q

what is the hesitation to using miller-abbott or cantor tubes

A

they are mercury weighted and therefore they are handled as hazardous waste

133
Q

alternative to mercury weighted tubes

A

anderson tube which is tungsten weight, safer than mercury

134
Q

miller abbott is ____ lumen
anderson is ____ lumen
cantor is ____ lumen

A

double
double
single

135
Q

indications for miller abbott, cantor and anderson tubes

A

decompression or relieve intestinal obstruction

136
Q

in order to prevent esophageal and gastric bleeding with sengstaken blakemore or minnesota tubing what should be done

A

pressure should be applied to esophageal veins and gastric varices

137
Q

what can happen if sengstaken blakemore or minnesota tubing balloon ruptures arm igrates

A

can lead to respiratory distress or arrest due to airway obstruction

138
Q

what should be kept at bedside in case of balloon rupture or migration with sengstaken blakemore and Minnesota tubes

A

pair of scissors to cut tube below bifurcation in order to remove

139
Q

when are gastric varies tubes used (linton-nachlas)

A

when endoscopy was unsuccessful or when tubing can be lifesaving despite risk for complications

140
Q

tube that is a temporary measure and is removed 24 hrs post insertion

A

esophageal tamponade

141
Q

patients ta high risk for malpositioned nasogastric tubes (6)

A
  1. unconscious or heavily sedated
  2. have endotracheal tube or tracheostomy
  3. uncooperative during section
  4. depressed or absent gag and cough reflex
  5. confusion or debilitated
  6. craniofacial trauma or surgery
142
Q

absolute contraindications for NG tubes (2)

A
  1. severe facial trauma

2. recent nasal surgery

143
Q

relative contraindications for NG tube (4)

A
  1. coagulation abnormality
  2. esophageal varices or stricture
  3. recent banning or cautery of esophageal varies
  4. alkaline ingestion
144
Q

NG tube measuring (NEX)

A

n - nose
e - earlobe
x - xiphoid process

145
Q

what can misplacement of NG tubes lead to:

A
  • aspiration pneumonia
  • severe lung damage
  • permanent lung damage leading to organ dysfunction or death
146
Q

placement of NG tube definitely increases what

A

LOS, morbidity, mortality

147
Q

if patient is experiencing weight loss, or inadequate weight gain, dumping syndrome or diarrhea following NG tube placement what should be considered

A

NG tube migration or dislodgment

148
Q

when should residual checks be done with NG tube feedings

A

before feedings

149
Q

in order to avoid fluid and electrolyte imbalance and keep up nutritional requirements with NG feedings what should be done

A

residuals should be re-fed and only discarded if there is blood

150
Q

how often should oral care be done with NG tube feedings

A

minimum of every shift

151
Q

NG placement should be checked when

A

initially and continuously

152
Q

patient position for NG tube feeding

A

HOB at least 30 degrees

153
Q

gold standard for checking NG tube placement and when should be done

A

chest x ray with radio-opaque tube, should be done on initial insertion

154
Q

other methods besides chest x ray for confirming NG tube placement especially used after initial insertion at bedside

A

observation and characteristics of aspirate, and pH of gastric versus intestinal aspirate

155
Q

non scientific method for NG tube placement

A

auscultating air bolus through tube near gastric funds/epigastric region

156
Q

color of aspirate if NG tube properly placed in gastric region

A

green, clear/colorless, or brown

157
Q

bile stained aspirate means NG tube is most likely placed where, what will pH of aspirate be as well

A

small intestine, greater than 6

158
Q

things to note with NG continuous feedings

A
  • patient tolerance

- adult should have residuals less than 50 mls

159
Q

provider should be noticed if adult residuals are greater than what

A

150 ml

160
Q

continous suction should be generally used with vented or unvented NG tube

A

unvented, but can cause irritation and get flecks of blood in drainage

161
Q

intermittent suction should be used with vented or unvented NG tube and why

A

vented to prevent irritation

162
Q

in adults intermittent suction pressure should be set at

A

20-40 , max 60 mm Hg

163
Q

when is NG tube clamped with intermittent suction

A

clamped for 30 minutes after med admin., and clamped when pt ambulating

164
Q

aspirate pH less than or equal to 5 placement is in

A

GI tract

165
Q

aspirate pH greater than or equal to 6 placement is in

A

respiratory tract

166
Q

complications of NG tube intubation (9)

A
  1. aspiration leading to asphyxia
  2. aspiration pneumonia
  3. abscess formation
  4. trauma injury including perforation
  5. pulmonary hemorrhage, pneumo, empyema, pneumothorax, pleural effusion
  6. nosebleeds
  7. secondary infection
  8. tracheal-esophageal fistula
  9. erosion or tissue necrosis
167
Q

types of trans-abdominal gastric tubs

A

gastrostomy tube, jejunostomy tube, PEG, MIC-key button

168
Q

indication for gastronomy and PEG tubes

A

for long term delivery of nutrition and meds when pt has no gag or swallow reflex or who aspirates

169
Q

what is malecot feeding tube

A

used for children where gastrostomy tube is too big

170
Q

reason why PEG tube is preferred

A

less expensive, safer to insert, and no anesthesia is required, feedings can begin 24 hrs after placement

171
Q

gastric feeding tube used in pediatrics

A

MIC-Key (LPGD)

172
Q

gastric tube used in patients who aspirate frequently

A

J tube (jejunostomy) along with gastrostomy tube –> GJ tube

173
Q

food and meds are given through what with a GJ tube

A

feedings through J tube and meds through G tube

174
Q

what is needed with J tubes to prevent occlusions

A

flushing

175
Q

predigested formulas need to be given with what tubes and why

A

with J tubes because its location is further along in the digestive process

176
Q

enteral nutrition via bolus

A

volume of 250-400 cc formula over 30 min or less, 4-6 times a day

177
Q

enteral feeding via intermittent

A

240-400 cc formula over 30-60 minutes 4-6 times a day

178
Q

enteral feeding via cyclic

A

continuous nourishment for 8-12 hours with 12-16 hour pause

179
Q

indications for cyclic enteral feeding

A

to wean patient from tube feedings and for those fed overnight

180
Q

enteral feedings via continuous

A

continuous with no interruption at rate of 1.5 ml per minute (50-75 ml/hour)

181
Q

to prevent infection with enteral tube feedings

A
  • change tubing q 24 hrs
182
Q

to prevent air during bolus enteral feedings what should be done

A

gravity flow instillation should be done on angle

183
Q

when should placement be checked with GI tubes

A

before initial use using x ray, and before feeding by aspirating gastric contents and checking tube placement at nares

184
Q

to maintain tube potency and prevent obstructions what must nurse do with GI tubes

A
  • flush with sterile water before and after feedings (intermittent)
  • flush q 4-6 hrs with sterile water (continuous)
185
Q

call provider guideline for GI feeding residuals

A

greater than 150 ml

186
Q

with continuous feedings what should nurse do when suctioning, turning, positioning or transferring patient

A

place feeding on standby every time

187
Q

complications of enteral feedings (6)

A
  1. obstruction
  2. perforation
  3. tube migration
  4. regurgitation and aspiration of feeding
  5. diarrhea, nausea, vomiting
  6. abdominal distention, cramping, discomfort
188
Q

potential pt problems related to enteral feedings (7)

A
  1. imbalanced nutrition less than body requirements
  2. self care deficit
  3. paired swallowing
  4. aspiration risk
  5. impaired oral mucous membranes
  6. diarrhea
  7. constipation
189
Q

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

A

d. pair of scissors

190
Q

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

A

c. Clamp the nasogastric tube for 30 minutes following administration of the medication

191
Q

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

A

b. Reinstill the amount and continue with administering the feeding

192
Q

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

A

d. Pull back on the tube and wait until the respiratory distress subsides

193
Q 
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
A

C. Assess patency of the NG tube

Therapeutic II (6 decks)

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