Exam 4 Flashcards
Identify risk factors that affect a client’s response to surgery
o Full assessment.
o Smoking: respiratory problems. Can cause atelectasis and pneumonia, poor wound healing. Increases thickness and amount of secretions
o Diabetes: increase risk wound infection and mortality. Decrease of perfusion.
o Resp. disease: anesthesia reduce resp. func. Reduces ot ability to compensate for acif base changes
o Immunosuppression: at risk for developing infection. Impaire tissue perfusion
o Morbid obesity: as wt increases cardiac and resp. func decrease increasing risk for postop atelectasis, pneumonia, and death. Risk VTE
o Impaired mobility: increase chances developing VTE
o Heart disease: anesethesia depresses cardiac output. Heart has to be able to pump on its own.
o Chronic pain: at risk poor healing b/can’t manage pain. Result in higher tolerance
o Age: hypothermia. General inhibits shivering and causes vasodilation, results in heat loss.
o Malnutrition: normal tissue needs nutrients to repair itself. When too thin or obese often lack needed nutrients.
o Anxiety
o Confusion
o Pre-op use of anticoagulants
• Explain the role and responsibilities of the RN in the preoperative surgical phase
o Full assessment: ID risk factors, allergies, etc.
o Provide information on what to expect
o Plan care
Describe priority pre-operative assessments
Health History Sensory aids Previous surgery Physical assessment Preop pain Emotional state going into surgery Cognitive Family support, use of tobacco products, alcohol, occupation, culture All medications o Prescription, over the counter, and herbal: 4 G’s garlic, gingko, ginger, ginseng Medication and latex allergies
Explain risks associated with aspirin or anticoagulant therapy
o Increase risk of hemorrhaging
Identify herbal supplements that may increase risks associated with surgery
o 4 G’s garlic, gingko, ginger, ginseng
o Client education
Client must understand complications and benefits. Pt. must have clarity of mind Qs Time/Loc. Surgery Intraoperative Pain management Immediately postop Ongoing postop Discharge needs Advance directives Informed consent
Informed Consent
Adequate disclosure Sufficient comprehension Voluntary consent If pt is not able; family member, next of kin, or durable power of attorney Documented medical necessity
• Differentiate between diagnostic, palliative, ablative, constructive, cosmetic, and reconstructive surgeries
o Palliative: to improve symptoms. Ex. Remove part bowel
o Diagnostic: to figure out what’s going on
o Ablative: removing something that is sick and is curative. Ex. appendix
o Cosmetic: client desires enhancement. Nothing is wrong
o Reconstructive: surgery to restore to original or normal function. Cleft palet.
o Procurement: transplant
• Explain the role and responsibilities of the RN in the intraoperative surgical phase
o Circulating Nurse
Does not scrub in. Manages pt care
Manage pt positioning, skin prep, medications, implants, IPC device, specimens, warming devices, surgical counts
Keep family informed
o Scrub Nurse
Understand procedure and anticipate surgeons needs
o Identify interventions to prevent injury to the client
Positioning
Extremities supported, alignment maintained, bony prominences padded, “grounded”, modesty, restrained in place
Prevention of hypothermia
Warming blankets, intraoperativewarm pt, prewarm OR
Airway management and effects of anesthesia
Lower BP, lower vitals in general,
Sponge counts
Describe basic principles of surgical aseptic technique
Describe basic principles of surgical aseptic technique
Don’t turn your back on sterile field. Make it nonsterile. Anything above or below waist is nonsterile
Sterile to sterile. 1 inch of edges is not sterile.
• Explain the role and responsibilities of the RN in the postoperative surgical phase
o Explain how clear communication contributes to client safety.
Gives postop team ability to anticipate possible clinical problems be sure that special equipment needed for nursing care is available.
o Prioritize client care after anesthesia (ABCs)
ABCs, I&O, Pain/Comfort, Neuro function, position, skin, pt safety needs, neurovascular status: extremeties, surgical dressing and lines etc., drainage?, muscular response and strength/mobilitym fluids, procedure specific assessments
Identify potential respiratory postoperative complications
o Cause: anesthetic agents cause resp. depression, smoking thicken mucous
o Atelectasis: most common cause of hypoxia postoperative, hear diminished lung sounds
o Pneumonia: hear rhonchi, productive cough
o Hypoventilation: inadequate ventilation
o Hypoxia: hear nothing. Client is restless, bradycardic, anxious
o Pulmonary embolism: blood clot to lungs
Explain early signs of hypoxia and why a post-surgical client is at risk for this.
o Decrease in O2 sats. o POST OP CONFUSION o Increased RR and work of breathing o SOB with activity o Tachycardia o Increased HR and extra beats
Identify respiratory breath sounds associated with atelectasis and pneumonia
o Atelectasis: diminished lung sounds
o Pneumonia: crackles
Resp: Explain interventions to prevent complications
o Obstruction Appropriate positioning: position on side until airways clear o Atelectasis/pneumonia Coughing and deep breathing: Q1-2h Incentive spirometry: Q1-2h Hydration Early ambulation Suctioning o Hypoxemia Oximetry monitoring: continuous oximetry monitering until done receiving IV Opioids Oxygen therapy: supplement O2 in order to keep airway open Sedation monitoring
Identify and explain circulatory postoperative complications
o Cause: blood loss, side effect anesthesia, electrolyte imbalances, depression normal mechanisms, ischemia
o Assessments: HR, rhythm, BP
o Hemorrhage: blood loss. Maintain IV fluids. Monitor vitals
Watch for increase HR, RR. Thready pulse, drop in BP.
o DVT: pooling blood extremity, leading to clot that can travel and occlude major arteries
o Postural hypertension: fall risk
o Hypotension: related to loss of blood, can lead to shock
Identify s/s bleeding or hemorrhage
o Clammy skin, drop BP, increase HR and RR.
o Explain interventions when these s/s occur
Monitor vitals, maintain fluids, O2 therapy, notify surgeon, blood counts
o Prioritize care for the client receiving blood products.
Client ID. 2 RN perform.
Pre transfusion assessment. Vital qh
Ensure IV Acess and obtain supplies.
Initiate w/in 30 min of receiving blood. Must be infused w/in 4 hrs.
Prime w/ normal saline. Stay in room for first 15 min.
Recheck qh after transfusion discontinued.
o Identify signs and symptoms of a hemolytic transfusion reaction
Febrile: Headache, tachycardia, tachypnea, fever, chills, anxiety,
Hemolytic: low BP, high RR, chest pain, low back pain, apprehension, chills, fever. Tachycardia
Allergic: hives, rash, face flush, scratch
Thrombus formation: Explain the purpose for the following interventions
o Early ambulation: keeps blood from pooling and client moving/
Identify priority assessments
• Vitals. Hypotension or arrhythmias.
o Antiembolic stockings/sequential compression device: prevent DVT’s by keeping blood from pooling
o Leg exercises: Q1H
o Hydration: prevent accumulation of formed blood elements
o Heparin or enoxaparin : anticoagulants prevent bloods clots
Identify priority nursing assessments and interventions to prevent and identify fluid and electrolyte abnormalities
o Compare lab values with pt baselin. o I&O o daily wts o Edema and crackles in lungs o BP
Review intravenous fluids (isotonic, hypertonic, hypotonic) and how they relate to the surgical client
o Isotonic: fluid w/ same tonicity as blood
o Hypertonic: soln is more concentrated then normal blood
o Hypotonic: soln is more dilute then normal blood. Sodium travels outside the veins and water into the veins
Explain malignant hyperthermia
Increase in intracellular calcium. complication of anesthesia. Causes hypercarbia, tachyonea, tachycardia, premature ventricular contractions, unstable BP, cyanosis, skin mottling, musclular rigidity
Explain the significance of an elevated temperature
Could be sign of advanced malignant hyperthermia
Mild temp is less then 100.4. Moderate is more then 100.4.
Over 48-72 hours AND high fever then consider infection
o Identify additional assessments when a post-op client demonstrates an elevated temperature
o Monitor pt end tidal volume CO2, Ca+, Labs, cardiac rhythem, HR
o Labs, RR, skin(surgical site)
Neurological function
Identify priority nursing assessments
Identify priority nursing interventions
o Reorient pt, deep breathing and coughing,
o Level of orientation, reflexes, muscle strength, CMS
o Reorient pt, deep breathing and coughing,
Review concepts of wound assessment and care
Infection: warm, red, tender skin around incision. Fever and chills with purulent drainage.
Wound Dehiscence: separation of wound at suture line: increased drainage and appearance of underlying tissues
Wound evisceration: protrusion of internal organs and tissues after surgery
Skin Breakdown: result pressure or shearing
Demonstrate interventions to prevent dehiscence and evisceration
Splinting: prevent body part from moving. Bindings
Identify s/s infection of an infected wound
Warm, red, tender skin around incision. Fever and chills with purulent drainage.
GI function and nutrition
Identify priority assessments:
General anesthesia slow GI motility and often causes nausea Passing gas? Bowel sounds Last BM Palpate abdomen
Explain paralytic ileus:
nonmechanical obstruction of the bowel caused by physiological, neurogenic, or chemical imbalance associated with decreased peristalsis. Causes abdominal distension after surgury
Explain diet progression after being NPO
ice chips, clear liquids. Normal diet after passing gas and first postop bowel movement. Also depends on pt chart.
Explain the benefit of early ambulation:
stimulate return of peristalisis
Identify methods for enhancing appetite and decreasing nausea and vomiting
antiemetic drugs. Avoid moving suddenly and help into comfortable position during mealtime. Manage pain.
Explain the effects of anesthesia on the bladder
Anesthetic prevents pt from feeling bladder fullness for 6-8hrs. W/ urinary catheter continuous flow
Identify priority assessments Urinary Elimination
I&O
Palpate to feel for bladder fullness. Distension
Bladder scan
Observe color and order of urine
Review principles of pain assessment and analgesic administration
Use scale to assess pain. Administer smallest amt of analgesic possible. Move up the scale. If pt will be in cont. pain consider a PCA
Discuss relationship of pain to function and complications of immobility
If someone is in pain, surgical recovery is slowed.
Serum Creatinine:
0.6-1.3 mg/dL
Serum Blood Urea Nitrogen (BUN)
6-20 mg/dL
Specific Gravity
1.005-1.030
• Identify how these factors affect urinary elimination: Aging
Older adult has decrease in size of bladder capacity, increase bladder irritability
Increase risk urinary incont b/ chronic illnesses that affect mobility, cognitinan, and manual dexterity
The ability and desire to void decreases
• Identify how these factors affect urinary elimination: Diet
Caffeine can promt unsolicited bladder contractions
Alcohol decreases ADH, increasing urine production
Increase in Na+ lead to increased urination
• Identify how these factors affect urinary elimination: Immobility
Can cause incontinence
• Identify how these factors affect urinary elimination: Pain
Interferes with timely access to a toilet
Can cause to suppress urge to urinate when there is pain
• Identify how these factors affect urinary elimination: Surgery
anesthetics can decrease bladder contractility/ sensation bladder fullness causing urinary retention
Decrease urine output
Decreases sensation of knowing how full toilet is
• Identify normal hourly urinary output.
o Over 30ml. 1ml/kg/hr.
Explain sig. urine output under 30 ml
Urinary retention. Inability to partially or completely empty the bladder
o Causes feelings of pressure, discomfort, pain, restlessness, diaphoresis, distention
Consider inserting a catheter intermittently. Blockage in the ureters/kidneys, change in pH, infection.
• Define oliguria, polyuria, dysuria, and hematuria
o Oliguria: low urine output
o Polyuria: lose too much urine
o Dysuria: burning,
o Hematuria:
• Describe signs/symptoms of urinary retention
o Inability to empty bladder all the way, feel pressure, discomfort/pain, restlessness, incontinence
o Explain post void residual
Urine left behind in bladder after voiding. Can be measured by bladder scan.
o Explain the use of a bladder scanner
Ultrasound. Detects approximate volume of urine in the bladder or postvoid residual
Pt supine position. Gel. Gender. Pressure. Aim. Clean. May be delegated
o Urge Inct.
Involuntary passage urine assoc. with storng sense urgency related to an overactive bladder caused by neuro problems, bladder inflam or obstruct. Ideopathic.
Urgency, frequency, nocturia, unable to hold urine, leak on way to bathroom, strong urge leaks with running h2o
Interventions
UTI?
Bladder irritants avoid
Pelvic muscle exercises, bladder training
Drugs
o Transient Incontinent:
caused by medical conditions and is usually reversable. Ex. UTI, mobility impairement
o Functional incontinence
b/ causes outside urinary tract. Related to functional deficits such as altered mobility and manual dexterity.
Result caregivers not making it in time to help
Ex. Altered mobility, sensory and/or cognitive impairments
Interventions
Adequate lighting in bathroom, mobility aides, clear access to toilet, pants with no zipper
o Overflow Urinary Inct
Caused by overdistended bladder related to bladder outlet obstruction or poor bladder emptying b/ of weak bladder contractions
Distended bladder on palpation, high postvoid residual, involuntary leakage, nocturia
Interventions: Timed voiding, double voiding, catheterization
o Stress Urinary INct.
Leakage small volm urine assoc. w/ increased intraabdomina pressure related to wither urethral hypermobility or an impoetent sphincter ex. Weak pelvic floor, childbirth
Urethra cannot stay closed as pressure increases in the bladder
Small volm. Loss of urine w/ coughing, laughing, walking, etc.
Interventions: Pelvic muscle exercises
o Reflex Urinary Inct.
Loss urine occurring at predictable intervals whent pt. reaches specific bladder V.
Related to spinal cord damage
Diminshed awareness bladder filling and urge to void
Interventions
Prescribed pee schedule
Urine containment products
UTI moniter
ph urine
4.6-8
Color urine
o Dark Red: bleeding from kidneys or ureters
o Bright Red: bleeding from bladder or urethra or rectum
o Dark Amber: Liver Dysfunction
o Explain the significance of the presence of WBCs, RBCs, or protein
WBC: 0-4 elevated numbers indicate inflammation or infection
RBC: up to 2 traumas, disease, surgery. Damage to glomeruli or tubules.
Protein: up to 8mg/100 ml damage to the glomerular membrane. Protein is a large molecule thus normally cant make it through the glomerular filter. Kidney disease
• Explain the procedure for a 24-hour timed urine specimen collection
o Collect for 24 hours. Discard the first voiding. Collect all other urine.
• Explain the procedure for obtaining a clean-voided urine specimen
o Sterile urine cup.
o Provide pericare
o Have pt initiate stream while holding open and then begin collecting mid-stream.
o Remove specimen cont. before they are done and put bedpan instead.
o STERILE cap
• Explain the procedure for obtaining a urine specimen from an indwelling catheter
o Sterile process. Obtain from port with sterile syringe and container.
• Describe interventions to prevent a UTI
o adequate hydration, peri-care, promoting complete bladder emptying, cranberry juice
• Identify priority assessments for a client with an indwelling catheter
o Allergies, assess bladder for fullness, inspect peri area, assess prior knowledge of cathedars, pain, burning, debris/crusting, urine, change in mental status, inflammation, UTI
o Discuss routine catheter care
Routine peri care daily and after soiling using antiseptic wipes
Obtain urine from sampling port
o Explain interventions to prevent catheter-associated infection
Insert aseptically
Secure indwelling catheers
Maintain a closed urinary drainage system
Bag below level of bladder at all times
Avoid loops and dragging on floor.
Empty bag before transfers and when ½ full
• Explain the purpose of continuous bladder irrigation (CBI)
o Prevent blood clots in the bladder after surgury
o Identify priority assessments during CBI
o Assess kinks/clots, Leakage of urine around catheter, blood clots, changes in color, I&O, Pain, burning
Unexpected outcome CBI
o Review unexpected outcomes and related interventions (see Skill 46-4)
1. Irrigration does not return or is less amt irrigation then was put in.
Look for clots, sediments, kinks
Inspect urine for presense of or increase in blood clots or sediment
Evaluate pt for pain or distended bladder
2. Bright red bleeding with irrigation is wide open. Assess for hypovolemic shock
3. Pt experiences pain w/ irrigation. Look for blood clots or sediment
• Different between upper and lower urinary tract infection signs and symptoms
o Lower: hematuria, dysuria, urgency, frequency, bright red bleeding
o Upper: flank pain, systemic type symptoms, dark red blood
o Review atypical signs and symptoms in the elderly client
Confusion, smell
• Explain the purpose of pelvic floor training (Kegal exercises)
o Help strengthen pelvic floor
K+
3.5-5
Na+
135-145
Ca2+
8.6-10.2
Mg2+
1.5-2.5
• Identify priority assessments prior to administering diuretics
o BP, dizziness, lightheadedness, hyponatremia, hypokalemia, daily wts, I&O, lung sounds, level of consciousness
• Discuss priority nursing actions when administering diuretics
o Administer in the morning
o Promote adherence
o Minimize adverse effects
• Discuss the action and effects of loop diuretics (ie. Furosemide(Lasix- after surgery, etc.) and Bumatanide).
o Action: blocks reabsorption of sodium and chloride in the loop of Henle. Prevents passive reabsorption of H20.
o Effect: Rapid/massive mobilization of fluid out of the body. Water follows salt. Affects K+ as well. Usually prescribed w/ potassium sparing(spironaloctone) as well t ocounterbalance.
o Assess: I&), Na, Cl, K levels, symptoms dehydration: fall in BP, fall HR, dry mouth, oliguria, weight loss.
o Explain how loop diuretics affect potassium levels
May cause hypokalemia. Lost through secretion in the distal nephron.
• Discuss the action and effects of thiazide diuretics (hydrochlorothiazide)
o Action similar to loop diuretics (Furosemide). Increase secretion of Na, Cl, K, and H20. Used in hypertension. Block reabsorption in the distal convoluted tubule. Dependent on kidney function.
o Effects: may cause hyponatremia, hypochloremia, and dehydration. May cause hypokalemia.
Daily I&O
Watch out for S/S extreme thirst, large loss of weight, fall in BP, and oliguria
o Explain how thiazide diuretics affect potassium levels
May cause hypokalemia from excessive K excretion. K should be measured periodically
• Discuss the action and effects of potassium sparing diuretics (Spironolactone).
o Explain how potassium sparing diuretics affect potassium levels
Keep K from being excreted. Blocks actions of aldosterone in the distal nephron. Leads to increased secretion Na and decreased K.
• Discuss the action and effects of osmotic diuretics (Mannitol)
o Action: inhibits passive reabsorption of H20. Urine flow increases b/ H20 is not getting reabsorbed. Used for renal failure, reduction intracranial pressure, reduction intraocular pressure.
o Effects: can cause edema, headache, nausea
• Explain the potential side effects of a potassium wasting diuretic for a client taking digoxin
o In presence of low potassium, may cause digoxin induced toxicity as side effect hypokalemia. Increase risk of dysrhythmias.
• Define ototoxicity
o Damage of the BV in the ears that causes edema in the inner ear leading the an increase of pressure.
o Identify symptoms associated with ototoxicity
Hearing loss as a result of the drug. Timitus
• Discuss priority education for client’s prescribed diuretics
o Orthostatic hypotension: get up slowly if dizzy or lightheaded. Dangle feet.
o Nocturia: diuretics in morning. Keep path clear and well lit.
o Potassium intake: OJ, bananas, spinach, potatoes
Serum Albumin
3.5-5g/dL
Serum Prealbumin
15-36mg/dL
• Discuss the relationship of malnourishment with a client’s risk for poor health outcomes.
o Greater risk of arrhythmias, sepsis, or hemorhidge, poor wound healing
• Identify clients at risk for nutritional problems.
o Poor dentition: no teeth, Improper fitting dentures o Socioeconomic status and access o Cognitive disorders o Altered sensory perception o Impaired swallowing o Lack of knowledge o Medical condition
• Differentiate between various therapeutic diets
o Clear Liquid: you can see through it o Full liquid Diet o Pureed Diet o Soft Diet o Mechanical Soft Diet o Dysphagia Diet Textures of solids Liquid consistency Thin Nectar Honey Spoon-thick o Diabetic Diet: carbohydrate exchange o Renal Diet: Na+, K+, P3-, protein, and fluid restriction diets. o Anemia Diets: increased iron intake(meat/fish), dried beans and fruid, Vit. C & B, Tannins(wine, tea. DO NOT TAKE IRON WITH TANNINS) o Cardiac: cholesterol, Na+, caffeine
• Identify foods high in protein
Legumes/Beans, eggs, peanut butter,
o Dysphagia Diet
Textures of solids Liquid consistency Thin Nectar Honey Spoon-thick
o NPO diet
NG Tubes TPN Ice chips, mouth rinse, hand candy: always ask docter IV Fluids Sign in or outside room Advancing diet?
o Nausea Diet
“White foods”
Dry food
Control nausea with medication
Indications enteral nutrition
nutrients into GI when pt is unable to swallow. Via NG tube. Risk gastric reflux. When pt is unable to swallow or take in nutrients but has a func. GI tract.. Cancer, critical illness, neurological disorders, Parkinsons, GI disorders, Resp failure
Parenteral Indications
Provided via PICC or CVC. When disuse GI tract. Pt unable to absorb or benefit from PN. Highly stressed physiological states. Non functional GI tract. Extended bowel rest. Preoperative nutritian
• Identify benefits of enteral feedings vs parenteral nutrition
o Enteral: sepsis, reduces hypermetabolic response, decreases hosp. mortality, maintains intestinal structure and function
o Parenteral: gives GI rest, provide total nutrition.
• Identify potential complications of total parenteral nutrition
o Infection, metabolic alterations, pneumothorax,
• Describe methods for preventing complications of total parenteral therapy
o Electrolyte imbalance: check TPN for supplemental electrolyte levels. I&Os
o Hypercapnia: provide 30-60% of energy req. per provider order
o Hypoglycemia: do not abruptly discontinue TPN, taper rate down. Admin. Dextrose if needed
o Cheange TPN tubing q24h
o Check for occlusion
o Moniter for infection: BP, temp., labs
o Explain why it is essential to confirm placement of the catheter before starting the infusion
Catheter is supposed to be placed in one of the major veins. If placed in the wrong spot can lead to infection.
• Explain the procedure for initiating parenteral nutrition using a central catheter
Label the port for TPN, don’t infuse with other medications or solutions
Confirm placement with an X-ray
Stabilize PICC with sterile tape
Verify health care provider’s order and inspect the solution for particulate matter or break in fat emulsion
• Discuss potential complications of enteral feeds
o Pulmonary Aspiration o Diarrhea o Constipation o Tube occlusion o Tube displacement o Abdominal Cramping o Delayed gastric emptying o Fluid overload or serum electrolyte imbalance o Hyperosmolar dehydration
o Identify essential steps in introducing liquid feedings through an indwelling feeding tube
1. Verify order
2. Assess nutritional astatus. Obtain baseline wt and review lab values. Assess food allergies. Physical assessment abodoment.
3. Prepare container and formula. Room temp. Connect tubing to container, shake well.
4. Pt in high fowlers positions. Elivate bed.
5. Verify tube placement
6. Check gastric vesidual volume before each feeding for bolus,
7. When done flush tubing
o Explain the rationale for:
X-ray before first enteral feeding:
Checking for gastric residual volumes
Checking gastrointestinal aspirate pH:
o Explain the rationale for:
X-ray before first enteral feeding: verifies if tube is in stomach. Can cause serious injury if tube is in the wrong place.
Checking for gastric residual volumes indicates if there is delayed gastric emptying. Should never be more then 250ml
Checking gastrointestinal aspirate pH: to confirm correct placement before first feeding
o Describe interventions to prevent aspiration
Dysphagia screening
Measure O2Sat
Assess oral cavity
Assess swallowing reflex before initiating feeding by placing fingers at level of larynx and asking pt to swallow saliva
Take tongue blade on tongue and ask to say ah.
Assess swallow
o Explain why enteral feedings are started at slow rates
in order to check for intolerance
o Identify interventions to prevent/treat diarrhea associated with enteral feedings
Slow rate continuously
Check pancreatic insufficiency; use low fat, lactose-free formula and continuous feedings.
Check expiration date
ID factors that can influence bowel elimination
o Aging: older adult has a decrease in peristalsis
o Diet: fiber- creates bulk which stimulates peristalsis
o Fluid intake: fluid is needed for reabsorption
o Altered mobility: lowers peristalsis
o Pain: may lead to suppressing urge to defecate leading to constipation
o Surgery: anesthesia suppresses peristalsis
o Medications: many medications have a side effect of causing constipation. Laxatives can promote defecation.
o Food intolerance/allergy: can lead to diarhea
• Differentiate between common elimination problems
o Aging: older adult has a decrease in peristalsis
o Diet: fiber- creates bulk which stimulates peristalsis
o Fluid intake: fluid is needed for reabsorption
o Altered mobility: lowers peristalsis
o Pain: may lead to suppressing urge to defecate leading to constipation
o Surgery: anesthesia suppresses peristalsis
o Medications: many medications have a side effect of causing constipation. Laxatives can promote defecation.
o Food intolerance/allergy: can lead to diarhea
Define fecal impaction
stool gets impacted and watery stool leaks
Identify factors that contribute to constipation:
Stress, depression, low fiber, low mobility, low fluid intake, don’t go=reverse peristalsis, obstruction, medication,diet, inactivety
Non-pharmacological interventions: ambulation, squatty potty,
Differentiate between: stimulant, bulk-forming, hyperosmotic, and emollient laxatives
o Stimulant: irritate inner mucosa of intestines which stimulates peristalsis and motility. Softens as well. Seena, Bisacodyl. Can cause cramping.
o Bulk-forming: strong laxative. Increase peristalsis. Closest to natural. Least irritating.
o Osmotics: pull water into the bowel. Distend bowel and help evaculate bowel. Miralax.
o Emollient: docusate sodium. Icreases secretion by intestines to soften stool.
Explain how diarrhea can contribute to metabolic acidosis
Acid from stomach moves to pancreas. If someone loses to much acid, they lose HCO3, thus leading to metabolic acidosis.
Review isolation precautions and determine what type is appropriate for clients suspected or confirmed to have C. difficile
Contact precautions
Explain the general action of antidiarrheal agents
they slow peristalsis;sis
o Differentiate between types of enema solutions
Normal Saline: safest solution
Hypertonic: exerts osmotic pressure
Tap Water: hypotonic: 500ml or less
Soapsuds: castile soap that irritates lining of the goal
Oil Retention: lubricates the stool
Medicated: kayexalate: treats hyperkalemia
High v. Low: hight of container
o Describe the procedure for administering a rectal enema
Sims L. side
Why cramping can occur.
Container is raised to high up
What should be done if cramping occurs
lower the container
• Identify reasons for a client to have an ostomy
o Crohns, tumor, trauma, perianal wounds, inflammation.
• Differentiate between ileostomy and colostomy: require prep., clear liquid, bowel cleansing, and sedation.
o Ileostomy: RLQ
o Colostomy: LUQ
• Describe ‘pouching’ an ostomy
o Protects skin, remains odor free, and contains fecal material. Must be secure enough to participate in any activity.
• Identify priority assessments during ostomy care
o Stool consistency: soft, formed. Liquid with the ileostomy. Formed with the coloscopy.
o Stoma appearance: Deep red at first. Then pink
o Peri-stomal skin: protect the skin around using skin barrier.
• Identify nutritional considerations for clients with new ostomies
o Need extra glass of fluid b/ isn’t getting reabsorbed. Low fiber can cause blockage
• Describe nursing actions during insertion, securement, and basic care of a nasogastric tube
o Insertion-not delegated
o Placement and verification- verify by pH, pH<4
o Suction: low intermittent, not suctioning continuously
o Patency: if someone is nauseous, you always want to check the patency. Make sure tube is nor kinked, suction is on. Irrigate with normal saline.
o Medication administration: need an order to liquify, have the suction off when administer
o What sign/symptoms may a client demonstrate if the NG tube is not functioning appropriately?
N/V, SOB, abdominal distention
o What interventions are appropriate for ensuring patency and function of an NG tube?
Gastric pH
Chest Xray
Chest aspirate
o Explain how nasogastric suction may contribute to metabolic alkalosis
Remove CO2
Review signs/symptoms of metabolic alkalosis
Light headedness
Numbness/tingling of the toes and fingers
Muscle cramps
Possible excitement and confusion followed by decreased level of consciousness
Dysthymias
o Identify interventions to facilitate nasal and throat comfort for the client with and NG tube
Ice chips
Lubricate nares
Oral hyiegene
Resp. assessment
Stages Normal Sleep Cycles
o Stage 1: NREM light sleepest Gradual fall vitals and metabolism Easily aroused Feel as though been daydreaming Few miun o Stage 2: NREM light sleep 10-20minutes Sound sleep Relaxation progress, body function slow, arousal easy o Stage 3: NREM light sleep: Initial stage deep sleep Muscles relaxed Vitals decline Difficult to arouse o Stage 4: NREM: 15-30 minutes Deepest stage of sleep Vitals very low Sleeping walking and enuresis Difficult to arouse o REM: dreaming, sleeping walking 20 minutes Dreaming Rapidly moving eyes, fluctuating vitals Difficult to arouse
• Discuss characteristics of common sleep disorders
o Insomnias: difficult falling asleep
o Sleep related breathing disorder: lack airflow through mouth
o Hypersomnia’s not caused by a sleep related breathing disorder
o Parasomnias (hard to wake them up):
o Parasomnia associated with REM
o Other Parasomnia
o Circadian rhythm sleep disorder
o Behaviorally induced circadian rhythm sleep disorders
o Sleep related movement disorders
o Isolated symptoms
o Other sleep disorders
• Identify factors/behaviors that interfere with sleep
o Illness, unfamiliar environment, interruption from usual setting, unrelaxed, drugs, lifestyle, emotional stress, worry, exercise and fatigue, food and caloric intake
• Discuss nursing interventions to promote normal sleep cycles for adults
o Bedtime routines: cues to relax and get ready for sleep
o Promote safety: nightlight, bed set lower
o Promote comfort: avoid minor irritants to pt
o Establish periods of rest and sleep: exercise during day and sleep at night
o Stress redection: stress can make it difficult to fall asleep
o Bedtime snacks: warm milk, cocoa
o Melatonin
o Give pt control over environment
o Sedatives
• Discuss sleep patterns of the older adult
o Episodes REM shorten, Stage 3 and 4 decrease. Wake more often during night. Increase in napping during day.
• Discuss the use of hypnotics and sedatives
o Benzodiazepams treat sleep problems. Low dose ambien. Cause relaxation.
o Withdrawal from barbiturates can cause insomnia
o Create a soothing effect.
o Identify the action of benzodiazepines (lorazepam)
Relaxation, antianxiety, and hypnotic effects. Resp. depression, sedation, amnesia, impaired motor functioning
o Identify safety issues with the use of sleep aides
Impaired motor function, depress resp function, addictive.
• Explain advocacy, autonomy, responsibility, accountability, and confidentiality
o Advocacy: support the pt is any decision that they may make
o Autonomy: pt has autonomy over their own health
o Responsibility: authority over your own actions
o Accountability: liable/ answerable for one’s own actions
o Confidentiality: don’t share pt information
• Describe beneficence, nonmaleficence, justice, and fidelity
o Beneficence: doing good
o Nonmaleficence: do no harm
o Justice: fair, just culture
o Fidelity: follow through, keeping promises
• Define an ethical dilemma
o Deviation from set of guiding principles that all members accept. Cause distress for provider and pt.
• Describe the elements needed to prove negligence
o Missing medical records, not charting fully
o If records are lost or not complete it is assumed care was negligent
• Explain the procedure of informed consent
1. Explanation treatment/proc.
2. Receives name/qualifications of those performing procedure
3. Description of risks
4. Explanation alt. therapies
5. Understand they can refuse
6. Understand they may refuse even after treatment has already begun
• Explain the process of writing an incident/occurrence report
o Provide info in the report about what happened.
o Only facts no opinion.
• Explain who may give informed consent
o Patient, parent, legal guardian, power of attorney, courts
o Explain the purpose of a living will
Written documents that direct treatment in accordance with the pt wishes in the event of a terminal illness or condition.
• Describe nursing responsibilities when taking, reading, transcribing, and carrying out physician orders
o Follow MD orders unless believe there is an error or violates a policy
• Identify examples of intentional torts: assault, battery, false imprisonment
o Assault: intentional threat towards another person that places them in reasonable fear. No actual contact needed.
o Battery: intentional offensive touching w/out consent or lawful jurisdiction
o False Imprisonment: unjustified restraint of a person w/out a legal reason
• Explain the legal responsibilities of the nursing student
o Liable to their own actions if they cause harm to a pt. by exceeding the scope of practice
