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3346 NURS > Exam 4 > Flashcards

Exam 4 Flashcards

1
Q

Identify risk factors that affect a client’s response to surgery

A

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

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2
Q

• Explain the role and responsibilities of the RN in the preoperative surgical phase

A

o Full assessment: ID risk factors, allergies, etc.
o Provide information on what to expect
o Plan care

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3
Q

 Describe priority pre-operative assessments

A 
	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
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4
Q

Explain risks associated with aspirin or anticoagulant therapy

A

o Increase risk of hemorrhaging

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5
Q

Identify herbal supplements that may increase risks associated with surgery

A

o 4 G’s garlic, gingko, ginger, ginseng

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6
Q

o Client education

A 
	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
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7
Q

Informed Consent

A 
	Adequate disclosure
	Sufficient comprehension
	Voluntary consent
	If pt is not able; family member, next of kin, or durable power of attorney
	Documented medical necessity
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8
Q

• Differentiate between diagnostic, palliative, ablative, constructive, cosmetic, and reconstructive surgeries

A

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

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9
Q

• Explain the role and responsibilities of the RN in the intraoperative surgical phase

A

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

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10
Q

o Identify interventions to prevent injury to the client

A

 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

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11
Q

 Describe basic principles of surgical aseptic technique

A

 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.

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12
Q

• Explain the role and responsibilities of the RN in the postoperative surgical phase
o Explain how clear communication contributes to client safety.

A

 Gives postop team ability to anticipate possible clinical problems be sure that special equipment needed for nursing care is available.

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13
Q

o Prioritize client care after anesthesia (ABCs)

A

 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

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14
Q

 Identify potential respiratory postoperative complications

A

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

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15
Q

 Explain early signs of hypoxia and why a post-surgical client is at risk for this.

A 
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
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16
Q

 Identify respiratory breath sounds associated with atelectasis and pneumonia

A

o Atelectasis: diminished lung sounds

o Pneumonia: crackles

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17
Q

 Resp: Explain interventions to prevent complications

A 
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
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18
Q

 Identify and explain circulatory postoperative complications

A

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

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19
Q

 Identify s/s bleeding or hemorrhage

A

o Clammy skin, drop BP, increase HR and RR.

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20
Q

o Explain interventions when these s/s occur

A

 Monitor vitals, maintain fluids, O2 therapy, notify surgeon, blood counts

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21
Q

o Prioritize care for the client receiving blood products.

A

 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.

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22
Q

o Identify signs and symptoms of a hemolytic transfusion reaction

A

 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

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23
Q

 Thrombus formation: Explain the purpose for the following interventions

A

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

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24
Q

 Identify priority nursing assessments and interventions to prevent and identify fluid and electrolyte abnormalities

A 
o	Compare lab values with pt baselin.
o	I&O
o	daily wts
o	Edema and crackles in lungs
o	BP
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25
Q

 Review intravenous fluids (isotonic, hypertonic, hypotonic) and how they relate to the surgical client

A

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

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26
Q

 Explain malignant hyperthermia

A

Increase in intracellular calcium. complication of anesthesia. Causes hypercarbia, tachyonea, tachycardia, premature ventricular contractions, unstable BP, cyanosis, skin mottling, musclular rigidity

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27
Q

 Explain the significance of an elevated temperature

A

 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

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28
Q

o Identify additional assessments when a post-op client demonstrates an elevated temperature

A

o Monitor pt end tidal volume CO2, Ca+, Labs, cardiac rhythem, HR
o Labs, RR, skin(surgical site)

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29
Q

 Neurological function
 Identify priority nursing assessments

 Identify priority nursing interventions
o Reorient pt, deep breathing and coughing,

A

o Level of orientation, reflexes, muscle strength, CMS

o Reorient pt, deep breathing and coughing,

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30
Q

 Review concepts of wound assessment and care

A

 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

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31
Q

 Demonstrate interventions to prevent dehiscence and evisceration

A

 Splinting: prevent body part from moving. Bindings

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32
Q

 Identify s/s infection of an infected wound

A

 Warm, red, tender skin around incision. Fever and chills with purulent drainage.

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33
Q

 GI function and nutrition

 Identify priority assessments:

A 
	General anesthesia slow GI motility and often causes nausea
	Passing gas?
	Bowel sounds
	Last BM
	Palpate abdomen
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34
Q

 Explain paralytic ileus:

A

 nonmechanical obstruction of the bowel caused by physiological, neurogenic, or chemical imbalance associated with decreased peristalsis. Causes abdominal distension after surgury

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35
Q

 Explain diet progression after being NPO

A

 ice chips, clear liquids. Normal diet after passing gas and first postop bowel movement. Also depends on pt chart.

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36
Q

 Explain the benefit of early ambulation:

A

 stimulate return of peristalisis

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37
Q

 Identify methods for enhancing appetite and decreasing nausea and vomiting

A

 antiemetic drugs. Avoid moving suddenly and help into comfortable position during mealtime. Manage pain.

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38
Q

 Explain the effects of anesthesia on the bladder

A

 Anesthetic prevents pt from feeling bladder fullness for 6-8hrs. W/ urinary catheter continuous flow

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39
Q

 Identify priority assessments Urinary Elimination

A

 I&O
 Palpate to feel for bladder fullness. Distension
 Bladder scan
 Observe color and order of urine

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40
Q

 Review principles of pain assessment and analgesic administration

A

 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

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41
Q

 Discuss relationship of pain to function and complications of immobility

A

 If someone is in pain, surgical recovery is slowed.

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42
Q

Serum Creatinine:

A

0.6-1.3 mg/dL

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43
Q

Serum Blood Urea Nitrogen (BUN)

A

6-20 mg/dL

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44
Q

Specific Gravity

A

1.005-1.030

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45
Q

• Identify how these factors affect urinary elimination: Aging

A

 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

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46
Q

• Identify how these factors affect urinary elimination: Diet

A

 Caffeine can promt unsolicited bladder contractions
 Alcohol decreases ADH, increasing urine production
 Increase in Na+ lead to increased urination

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47
Q

• Identify how these factors affect urinary elimination: Immobility

A

 Can cause incontinence

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48
Q

• Identify how these factors affect urinary elimination: Pain

A

 Interferes with timely access to a toilet

 Can cause to suppress urge to urinate when there is pain

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49
Q

• Identify how these factors affect urinary elimination: Surgery

A

 anesthetics can decrease bladder contractility/ sensation bladder fullness causing urinary retention
 Decrease urine output
 Decreases sensation of knowing how full toilet is

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50
Q

• Identify normal hourly urinary output.

A

o Over 30ml. 1ml/kg/hr.

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51
Q

Explain sig. urine output under 30 ml

A

 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.

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52
Q

• Define oliguria, polyuria, dysuria, and hematuria

A

o Oliguria: low urine output
o Polyuria: lose too much urine
o Dysuria: burning,
o Hematuria:

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53
Q

• Describe signs/symptoms of urinary retention

A

o Inability to empty bladder all the way, feel pressure, discomfort/pain, restlessness, incontinence

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54
Q

o Explain post void residual

A

 Urine left behind in bladder after voiding. Can be measured by bladder scan.

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55
Q

o Explain the use of a bladder scanner

A

 Ultrasound. Detects approximate volume of urine in the bladder or postvoid residual
 Pt supine position. Gel. Gender. Pressure. Aim. Clean. May be delegated

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56
Q

o Urge Inct.

A

 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

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57
Q

o Transient Incontinent:

A

 caused by medical conditions and is usually reversable. Ex. UTI, mobility impairement

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58
Q

o Functional incontinence

A

 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

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59
Q

o Overflow Urinary Inct

A

 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

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60
Q

o Stress Urinary INct.

A

 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

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61
Q

o Reflex Urinary Inct.

A

 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

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62
Q

ph urine

A

4.6-8

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63
Q

Color urine

A

o Dark Red: bleeding from kidneys or ureters
o Bright Red: bleeding from bladder or urethra or rectum
o Dark Amber: Liver Dysfunction

64
Q

o Explain the significance of the presence of WBCs, RBCs, or protein

A

 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

65
Q

• Explain the procedure for a 24-hour timed urine specimen collection

A

o Collect for 24 hours. Discard the first voiding. Collect all other urine.

66
Q

• Explain the procedure for obtaining a clean-voided urine specimen

A

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

67
Q

• Explain the procedure for obtaining a urine specimen from an indwelling catheter

A

o Sterile process. Obtain from port with sterile syringe and container.

68
Q

• Describe interventions to prevent a UTI

A

o adequate hydration, peri-care, promoting complete bladder emptying, cranberry juice

69
Q

• Identify priority assessments for a client with an indwelling catheter

A

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

70
Q

o Discuss routine catheter care

A

 Routine peri care daily and after soiling using antiseptic wipes
 Obtain urine from sampling port

71
Q

o Explain interventions to prevent catheter-associated infection

A

 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

72
Q

• Explain the purpose of continuous bladder irrigation (CBI)

A

o Prevent blood clots in the bladder after surgury

73
Q

o Identify priority assessments during CBI

A

o Assess kinks/clots, Leakage of urine around catheter, blood clots, changes in color, I&O, Pain, burning

74
Q

Unexpected outcome CBI

A

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

75
Q

• Different between upper and lower urinary tract infection signs and symptoms

A

o Lower: hematuria, dysuria, urgency, frequency, bright red bleeding
o Upper: flank pain, systemic type symptoms, dark red blood

76
Q

o Review atypical signs and symptoms in the elderly client

A

 Confusion, smell

77
Q

• Explain the purpose of pelvic floor training (Kegal exercises)

A

o Help strengthen pelvic floor

78
Q

K+

A

3.5-5

79
Q

Na+

A

135-145

80
Q

Ca2+

A

8.6-10.2

81
Q

Mg2+

A

1.5-2.5

82
Q

• Identify priority assessments prior to administering diuretics

A

o BP, dizziness, lightheadedness, hyponatremia, hypokalemia, daily wts, I&O, lung sounds, level of consciousness

83
Q

• Discuss priority nursing actions when administering diuretics

A

o Administer in the morning
o Promote adherence
o Minimize adverse effects

84
Q

• Discuss the action and effects of loop diuretics (ie. Furosemide(Lasix- after surgery, etc.) and Bumatanide).

A

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.

85
Q

o Explain how loop diuretics affect potassium levels

A

 May cause hypokalemia. Lost through secretion in the distal nephron.

86
Q

• Discuss the action and effects of thiazide diuretics (hydrochlorothiazide)

A

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

87
Q

o Explain how thiazide diuretics affect potassium levels

A

 May cause hypokalemia from excessive K excretion. K should be measured periodically

88
Q

• Discuss the action and effects of potassium sparing diuretics (Spironolactone).
o Explain how potassium sparing diuretics affect potassium levels

A

 Keep K from being excreted. Blocks actions of aldosterone in the distal nephron. Leads to increased secretion Na and decreased K.

89
Q

• Discuss the action and effects of osmotic diuretics (Mannitol)

A

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

90
Q

• Explain the potential side effects of a potassium wasting diuretic for a client taking digoxin

A

o In presence of low potassium, may cause digoxin induced toxicity as side effect hypokalemia. Increase risk of dysrhythmias.

91
Q

• Define ototoxicity

A

o Damage of the BV in the ears that causes edema in the inner ear leading the an increase of pressure.

92
Q

o Identify symptoms associated with ototoxicity

A

 Hearing loss as a result of the drug. Timitus

93
Q

• Discuss priority education for client’s prescribed diuretics

A

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

94
Q

Serum Albumin

A

3.5-5g/dL

95
Q

Serum Prealbumin

A

15-36mg/dL

96
Q

• Discuss the relationship of malnourishment with a client’s risk for poor health outcomes.

A

o Greater risk of arrhythmias, sepsis, or hemorhidge, poor wound healing

97
Q

• Identify clients at risk for nutritional problems.

A 
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
98
Q

• Differentiate between various therapeutic diets

A 
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
99
Q

• Identify foods high in protein

A

 Legumes/Beans, eggs, peanut butter,

100
Q

o Dysphagia Diet

A 
	Textures of solids
	Liquid consistency
	Thin
	Nectar
	Honey
	Spoon-thick
101
Q

o NPO diet

A 
	NG Tubes
	TPN
	Ice chips, mouth rinse, hand candy: always ask docter
	IV Fluids
	Sign in or outside room
	Advancing diet?
102
Q

o Nausea Diet

A

 “White foods”
 Dry food
 Control nausea with medication

103
Q

Indications enteral nutrition

A

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

104
Q

Parenteral Indications

A

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

105
Q

• Identify benefits of enteral feedings vs parenteral nutrition

A

o Enteral: sepsis, reduces hypermetabolic response, decreases hosp. mortality, maintains intestinal structure and function
o Parenteral: gives GI rest, provide total nutrition.

106
Q

• Identify potential complications of total parenteral nutrition

A

o Infection, metabolic alterations, pneumothorax,

107
Q

• Describe methods for preventing complications of total parenteral therapy

A

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

108
Q

o Explain why it is essential to confirm placement of the catheter before starting the infusion

A

 Catheter is supposed to be placed in one of the major veins. If placed in the wrong spot can lead to infection.

109
Q

• Explain the procedure for initiating parenteral nutrition using a central catheter

A

 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

110
Q

• Discuss potential complications of enteral feeds

A 
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
111
Q

o Identify essential steps in introducing liquid feedings through an indwelling feeding tube

A

 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

112
Q

o Explain the rationale for:
 X-ray before first enteral feeding:
 Checking for gastric residual volumes
 Checking gastrointestinal aspirate pH:

A

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

113
Q

o Describe interventions to prevent aspiration

A

 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

114
Q

o Explain why enteral feedings are started at slow rates

A

in order to check for intolerance

115
Q

o Identify interventions to prevent/treat diarrhea associated with enteral feedings

A

 Slow rate continuously
 Check pancreatic insufficiency; use low fat, lactose-free formula and continuous feedings.
 Check expiration date

116
Q

ID factors that can influence bowel elimination

A

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

117
Q

• Differentiate between common elimination problems

A

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

118
Q

 Define fecal impaction

A

stool gets impacted and watery stool leaks

119
Q

 Identify factors that contribute to constipation:

A

 Stress, depression, low fiber, low mobility, low fluid intake, don’t go=reverse peristalsis, obstruction, medication,diet, inactivety
 Non-pharmacological interventions: ambulation, squatty potty,

120
Q

 Differentiate between: stimulant, bulk-forming, hyperosmotic, and emollient laxatives

A

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.

121
Q

 Explain how diarrhea can contribute to metabolic acidosis

A

 Acid from stomach moves to pancreas. If someone loses to much acid, they lose HCO3, thus leading to metabolic acidosis.

122
Q

 Review isolation precautions and determine what type is appropriate for clients suspected or confirmed to have C. difficile

A

Contact precautions

123
Q

 Explain the general action of antidiarrheal agents

A

they slow peristalsis;sis

124
Q

o Differentiate between types of enema solutions

A

 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

125
Q

o Describe the procedure for administering a rectal enema

A

Sims L. side

126
Q

Why cramping can occur.

A

Container is raised to high up

127
Q

What should be done if cramping occurs

A

lower the container

128
Q

• Identify reasons for a client to have an ostomy

A

o Crohns, tumor, trauma, perianal wounds, inflammation.

129
Q

• Differentiate between ileostomy and colostomy: require prep., clear liquid, bowel cleansing, and sedation.

A

o Ileostomy: RLQ

o Colostomy: LUQ

130
Q

• Describe ‘pouching’ an ostomy

A

o Protects skin, remains odor free, and contains fecal material. Must be secure enough to participate in any activity.

131
Q

• Identify priority assessments during ostomy care

A

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.

132
Q

• Identify nutritional considerations for clients with new ostomies

A

o Need extra glass of fluid b/ isn’t getting reabsorbed. Low fiber can cause blockage

133
Q

• Describe nursing actions during insertion, securement, and basic care of a nasogastric tube

A

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

134
Q

o What sign/symptoms may a client demonstrate if the NG tube is not functioning appropriately?

A

 N/V, SOB, abdominal distention

135
Q

o What interventions are appropriate for ensuring patency and function of an NG tube?

A

 Gastric pH
 Chest Xray
 Chest aspirate

136
Q

o Explain how nasogastric suction may contribute to metabolic alkalosis

A

 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

137
Q

o Identify interventions to facilitate nasal and throat comfort for the client with and NG tube

A

 Ice chips
 Lubricate nares
 Oral hyiegene
 Resp. assessment

138
Q

Stages Normal Sleep Cycles

A 
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
139
Q

• Discuss characteristics of common sleep disorders

A

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

140
Q

• Identify factors/behaviors that interfere with sleep

A

o Illness, unfamiliar environment, interruption from usual setting, unrelaxed, drugs, lifestyle, emotional stress, worry, exercise and fatigue, food and caloric intake

141
Q

• Discuss nursing interventions to promote normal sleep cycles for adults

A

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

142
Q

• Discuss sleep patterns of the older adult

A

o Episodes REM shorten, Stage 3 and 4 decrease. Wake more often during night. Increase in napping during day.

143
Q

• Discuss the use of hypnotics and sedatives

A

o Benzodiazepams treat sleep problems. Low dose ambien. Cause relaxation.
o Withdrawal from barbiturates can cause insomnia
o Create a soothing effect.

144
Q

o Identify the action of benzodiazepines (lorazepam)

A

 Relaxation, antianxiety, and hypnotic effects. Resp. depression, sedation, amnesia, impaired motor functioning

145
Q

o Identify safety issues with the use of sleep aides

A

 Impaired motor function, depress resp function, addictive.

146
Q

• Explain advocacy, autonomy, responsibility, accountability, and confidentiality

A

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

147
Q

• Describe beneficence, nonmaleficence, justice, and fidelity

A

o Beneficence: doing good
o Nonmaleficence: do no harm
o Justice: fair, just culture
o Fidelity: follow through, keeping promises

148
Q

• Define an ethical dilemma

A

o Deviation from set of guiding principles that all members accept. Cause distress for provider and pt.

149
Q

• Describe the elements needed to prove negligence

A

o Missing medical records, not charting fully

o If records are lost or not complete it is assumed care was negligent

150
Q

• Explain the procedure of informed consent

A

 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

151
Q

• Explain the process of writing an incident/occurrence report

A

o Provide info in the report about what happened.

o Only facts no opinion.

152
Q

• Explain who may give informed consent

A

o Patient, parent, legal guardian, power of attorney, courts

153
Q

o Explain the purpose of a living will

A

 Written documents that direct treatment in accordance with the pt wishes in the event of a terminal illness or condition.

154
Q

• Describe nursing responsibilities when taking, reading, transcribing, and carrying out physician orders

A

o Follow MD orders unless believe there is an error or violates a policy

155
Q

• Identify examples of intentional torts: assault, battery, false imprisonment

A

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

156
Q

• Explain the legal responsibilities of the nursing student

A

o Liable to their own actions if they cause harm to a pt. by exceeding the scope of practice

3346 NURS (4 decks)

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