Final Exam Flashcards
Sepsis Order
SIRS, Sepsis, Spetic Shock, MODS
SIRS Criteria
Must have two of the four
-body temp >100.5 or <96.8
-heart rate >90
-RR >20 or PaC02 <32mmHg
-leukocyte count >12,000 or <4,000
Sepsis
SIRS + Confirmed infection
-causes blood vessels to leak
What does Sepsis cause
hypotension
-because fluid is leaking
(decreased urine, increased HR+RR)
DIC (Disseminated Intravascular Coagulation)
clots using all bleeding factors and leads to the formation of small clots
-increased lactic acid and blood glucose
-confusion
-all tissue becomes hypoxic
Septic Shock
Sepsis + Hypotension
-oxygen exchange is not meeting cellular function
- serum lactate >2mm
-require vasopressor
Warm Shock (Comp)
(phase 1) EARLY
they can look better, but arent
warm extremities
increased HR, RR
decreased urine
Cold Shock (uncomp)
(Phase 2) LATE
pulling blood from vital organs
cold extremities
low cardiac output
organ dysfunction and failure (irreversible)
MODS
Organ Failure
two or more organs w/ dysfunction
hypotensive despite treatment
uncontrolled bleeding
cold and pale skin, cyanosis
Sepsis Risk Factors
immunocompromised, central lines, open wounds, malnutrition, DM, transplants, alcoholism, > 80 yo
qSOFA (quick sequential organ failure assessment)
alerts you pt needs more surveillance
1- Hypotension systolic <100mmHg
2- Altered Mental Status
3- Tachypnea RR>22
Score >/= 2 - risk of poor outcome
Sepsis Labs
WBC increased
Platelets decrease
serum lactate increased
procalcitonin increased
Sepsis 1 Hour Treatment Bundle
1- measure lactate
2- obtain blood cultures
3- Admin broad spectrum antibiotic
4- begin rapid 30mL crystalloid
5- apply vasopressors (hypotensive)
P Wave
Atrial Depolarization (contraction)
QRS Complex
Ventricular Depolarization (Contraction)
T Wave
Ventricular Repolarization (relaxation of ventricles)
PR interval
0.12- 0.20
QRS Interval
<0.10
QT Interval
<0.44
ECG box measurements
single block .04
5 blocks 0.2
QRS Measure
must be 6 boxes for measuremnts
multiply by 10
Heart Conduction
SA Node>AV Node>bundle>fibers
Heparin monitor
aPTT
daily and 6hr after admin
Warfarin monitor
aPTT w/ INR
Heparin Antidote
protamine sulfate
Warfarin Antidote
Vitamin K
DVT
sudden onset pain
Sepsis Glucose Level
140-180
Normal Sinus
60-100
Sinus Bradycardia
> 60
assess 4 hemodynamic compromise
treat underlying cause
medications
pacing
Sinus Tachycardia
> 100
assess s/s low cardiac output
treat underlying cause
medications
Beta Blockers on Heart
blocks the release of adrenaline and noradrenaline
reduces the force of blood pumping
lowers blood pressure
DVT/PE Risk Factors
-Age
-immobility
-injury/surgery
-smoking
-cancer
DVT/PE Diagnostics
Venous Duplex Ultrasound
doppler
venogram
MRI
Non-surgical interventions for DVT/PE
-early ambulation
-exercise
-compression stocking
-well hydration
DVT Therapeutic INR
1.5-2
Warfarin pt education
no vitamin k (leafy greens)
cholesterol within range
ABG Interpretion
Vomiting (Alkalosis)
Diarrhea (Acidosis)
Chest Xray
No metal
No pregnancy
tell them to hold breath
thoracentesis
-obtain consent
-will be sitting upright
-nurse at bedside w/ ultrasound
-don’t remove too much (1000ml)
Bronchoscopy
consent, anticoagulant use
NPO 4-8 hrs prior
montior gag reflex post
methemoglobinemia
become unresponsive to oxygen therapy which leads to hypoxia
most likely from benzocaine
rigid bronchoscopy
General anesthesia
can use benzocaine or lidocaine
Pulmonary Function Test
determine lung function + breathing
dont smoke 6-8 hrs prior
no bronchodilators 4-6 hrs prior
performed during exercise
nose clip to prevent air escape
Pneumothorax
air in pleural space
chest pain, SOB, deviation of midline, subcutaneous emphysema
tension pneumothorax
medical emergency
air trapped and completely collapses lungs
respiratory distress, cyanosis, distended neck veins
hemothorax
blood in the pleural space
simple <1000mL Massive >1000mL
can have both pleural and hemothorax
pleural effusion
fluid in pleural space
chest xray, CT
thoracentesis is treatment
Flail Chest
3+ rib fractures in 2 or more places
paradoxical chest movement
impaired gas exchange
monitor I+O, high fowlers
Pulmonary Contusion (bruising)
asymptomatic at first
bruise to the lung tissue caused by trauma
impaired gas exchange
Chest Trauma Prioritization
ABC’s
ensure oxygen
monitor for shock
chest tube malfunction
Atelectasis
Collapsed Lung
-IS, Breathing exercises, ventilators, lung expansion therapy, bronchodilators
NIPPV (noninvasive positive pressure ventilation)
noninvasive support w/o intubation
positive pressure keeps alveoli open
ONLY for alert pt
watch for skin breakdown
CPAP (continuous positive airway pressure)
increases intrathoracic pressure
1 continuous pressure
pressure in alveoli can help push fluid out
BiPAP (bilevel positive airway pressure)
different level on inspiration and expiration
prevent intubation
PEEP (positive end exploratory pressure)
keeps alveoli open, doesnt allow them to close
Chest Tube
consent
removes air, fluid, blood
restores intrapleural pressure ( lung expansion)
sterile water for troubleshooting
chest tube for pneumothorax
2nd intercostal space
chest tube for hemothorax
5th intercostal space
Drainage Collection Chamber
water seal, drainage collection, suction control
notify if >70 mL
wet suction
controlled suction based on amount of fluid
dry suction
controlled by dial
Water Seal Chamber
stops air from returning to lungs
gentle bubbling expected
(excessive=air leak)
(none=troubleshooting)
tidal movement
expected movement of water in water seal chamber
Suction Chamber
monitor level 24cm
refill every shift
check hourly
sterile water at bedside
Chest Tube Complications
Air leak (continous bubbling)
disconnected
pulled out (cover w dry gauze and notify provider)
monitor for tension pneumothorax
chest tube nursing management
premed 30 mins prior
suture removal kit
deep breaths and bear down
chest x ray post
monitor drainage and wound for infection
hypothalamus
control center
makes ADH+Oxytocin
pituitary gland
master gland
thyroid gland
wraps around trachea
regulates bodys metabolism (t3+t4)
parathyroid
regulates body calcium level
adrenal glands
located above kidneys
cortex(outside) steriods
medulla (inside) catecholamines (fight/flight)
Gonads
ovaries/testies
DM Risk Factors
Family history
African Americans
High birth weight babies
PCOS
BMI >25
Type 1 DM
Beta Cell destruction
autoimmune
insulin dependent
onset <30 yo
thirst,hunger, increased urine, weight loss
Type 2 DM
Beta Cell dysfunction
insulin required for 20-30%
onset any age
frequently no s/s: thirst, fatigue, blurred vision
metabolic syndrome 60-80%
Metabolic Syndrome
increases risk of type 2 DM
Must Have 3 for Diagnosis
1- abdominal obesity >40 male >35 female
2- hyperglycemia
3- hypertension
4- hyperlipidemia
Normal Blood Labs
A1C 4-5.7%
fasting glucose 74-100
glucose tolerance <140
Prediabetes Blood Labs
A1C 5.7-6.4%
fasting glucose 100-125 mg
glucose tolerance 140-199
Diabetes Blood Labs
A1C >/= 6.5%
fasting glucose >/= 126
glucose tolerance >/= 200
Metformin
reduces production of glucose in liver
slows carb absorption
increases sensitivity to insulin
contraindicated in gastroparesis
take vitamin b12 and folic acid
no alcohol (lactic acidosis)
Rapid Acting Insulin
Humalog, premeal
onset: 10-30 min
peak: 1-3 hrs
Short Acting Insulin
Regular Insulin, premeal
onset: 30 min
peak: 1-5hr
U100
only admin IV
U500 never admin IV
Intermediate Acting
NPH
onset: 60-120 mins
peak: 6-14hr
Long Acting
insulin glargine
usually 1-2 every 24hr
no peak/trough
onset: 60-120 min
insulin preferred injection site
abdomen
45-90 degrees (90 for obese)
Hospitalized/Sick Pt DM
keep glucose between 140-180
monitor BG every 2-4 hours
test urine for ketones
increase fluid intake
15g CHO
glucose tablets
120 mL fruit juice/ soda
5 hard candies
4 cubes/tsp of sugar
1tbs honey/syrup
hypoglycemia treatment
15-15 Rule
BG <70=15g CHO
BG <50=30g CHO
HHS (Hyperosmolar Hyperglycemic State)
most common in type 2 DM (undiagnosed)
slow onset
hyperglycemia, altered mental status
produce just enough to avoid DKA
Glucose >600
urine ketones negative
pH >7.4, HCO3 >20
DKA
sudden onset
causes by stress,infection, or no insulin
s/s: kussmaul resp, fruity breath, nausea, abd pain, dehyrdation
glucose >300
postive urine ketones
pH <7.35, HCO3 <15
Hypoglycemia
cool,clammy,sweaty skin
no dehydration
nervous,irritable, confusion, decrease LOC
weak,blurred vision, tachycardia, palpitations
glucose <70
negative ketones
hyperglycemia
warm, dry skin
dehydration
kussmaul- fruity breath
stuporous, obtunded, coma
varies with DKA and HHS
> 180mg/dL
Positive ketones with DKA
Diabetic Retinopathy
Changes of vessels in eye
vision loss
diabetic neuropathy
loss of feeling in feet
diabetic nephropathy
kidney dysfunction
-control blood glucose+BP
ACE/ARB’s ( decrease BP)
Albuminuria
footcare education
wear shoes, lotion not between toes
do not cut toenails
wash in warm water
Negative feedback loops
when a body receives signal, it either tells body to secrete more or less hormone
decreased ACTH (adrenocortopic hormone)
anorexia, decreased serum cortisol levels, hypoglycemia, hypoatremia, lethargy
Hypopituitarism
selective: one hormone is deficient
panhypopituitarism: two or more
deficiencies of ACTH and TSH are most life threatening
treatment: lifelong hormone replacement therapy
risk factors: TUMORS
Primary: direct problem w pituitary gland
Secondary: orginaties in hypothalamus
decreased cortisol
decreased BP and BG
decreased thyroid stimulating hormone (TSH)
alopecia, cold intolerance, lethargy, menstrual abnormalities, weight gain, slow cognition
decreased growth hormone
child: shorter height/dwarfism
adults: decreased bone density, decreased muscle strength, increased serum cholesterol levels
decreased gonadotropins (LH+FSH)
male: decreased facial hair, decreased bone density, reduced muscle mass
female: amenorrhea, anovulation, breast atrophy, decreased bone density, decreased estrogen
decreased antidiuretic hormone (ADH)
(increases reabsorption of water in kidneys)
dehydration, increased urine, hypotension, increased thirst, increased sodium, urine output doesnt decrease when fluid decreases
hyperpituitarism
most common: GH and ACTH
caused by anterior pituitary tumor
s/s: vision changes, HA, Increased intracranial pressure
acromegaly
overproduction of growth hormone and increased serum somatotropin
**oral glucose test
s/s: enlarged pituitary gland, visual disturbances, slanting forehead, coarse facial features, increased BP, CHF, and enlargement of bones in hands and feet
Cushings Disease
excess ACTH and elevated cortisol levels
s/s: weight gain, trunkel obesity, moon face, loss of bone density, extremity muscle wasting, HTN, hyperglycemia
hyperthyroidism
primary: issue w thyroid gland itself
secondary: excess in thyroid hormone
cardiovascular symptoms and weight loss
graves disease
whats the common symptom?
most common cause of hyperthyroidism
*pretibial myxedema (dry waxy swelling), exophthalmos (eyes buldging)
Thyroid Storm
high fever and severe HTN
increased temp = worse
do not palpate a goiter or thyroid tissue in pt with hyperthyroidism ( can stimulate release of hormone)
hyperthyroidism labs
t3 + t4 elevated
tsh: graves disease= low
radioactive iodine
sit down when urinating to avoid splashing
close lid when you flush and flush 2-3 times
males use condom catheter instead of brief
avoid contact w pregnant or young children for a week
avoid sleeping in bed with someone
dont share drinks, tooth brush
do not prepare food
hypothyroidism
hashimoto is most common cause
iodine deficiency (needed for thyroid hormones)
*goiter (neck swelling)
s/s: everything decreased but weight
myxedema coma (hypothyroid crisis)
serious complication of untreated hypothyroidism
medical emergency
assess every 8hr (mental status)
hypothyroidism labs
increased TSH
decreased t3 + t4
Thyroiditis
inflammation of thyroid gland
chronic thyroiditis (hashimoto) most common
risk: bacterial/viral infection, women
s/s: dysphagia, painless enlargement, chills, fever, muscle/joint pain
thyroid cancers
papillary carcinoma: most common, younger women
follicular carcinoma: older adults
medullary carcinoma: >50 yo
anaplastic carcinoma: rapid growing, aggressive
thyroid cancer labs
elevated Tg level
(men .5-53) (women 0.5-43)
hyperparathyroidism
excess production of PTH
increased parathyroid hormone
increased calcium
increased magnesium
decreased phosphorus
s/s: kidney stones, osteoporosis, GI issues, weight loss
hypoparathyroidism
hypocalcimia
(mild tingling, severe seizures)
decreased parathyroid hormone
decreased calcium
decreased magnesium
increased phosphorus
hypophysectomy
nasal packing post surgery (2-3 days) (mustache dressing)
don’t brush teeth,cough, blow nose, bend forward ( increased ICP)
monitor neuro for 24 hrs
deep breathing
thyroidectomy
TX: graves or hyperthyroidism and goiter causing problems
iodine prep to decrease thyroid size and reduce thyroid storm or hemorrhage
deep breaths every 30-60 mins
monitor VS q15 min until stable then q30. min
quiet and limit visitors
parathyroidectomy
minimally invasive
hypocalcemic crisis: assess calcium levels post
laryngeal nerve damage: assess voice post surgery
BUN range
10-20
Creatine Range
m- .6-1.2
f- .5-1.1
Glucose in urine
if passed 180 threshold check blood glucose
Urinalysis
purpose: evaluate waste product from kidney
measures: color, clarity, –concentration, specific gravity, pH, wbc, nitrate, bacteria, rbc, ketones, glucose
-collected early in morning
24 hour urine collection
purpose: measure creatinine clearance, urea nitrogen, sodium, chloride, calcium, and proteins
-discard the first void, then collect for next 24 hours
-collection restarted if any sample is discarded
-samples are refrigerated or on ice
renal CT/MRI
purpose: 3 dimensional imaging of organ system, can assess kidney size, cyst, or mass
prep:assess for iodine or shellfish allergy
post: assess kidney function
Voiding Cystourethrogram
purpose: detects urethral or bladder injury after instillation of contrast to provide imaging of bladder and ureters.
pre: informed consent, may require anesthesia
procedure: insert catheter, instill contrast, obtain x ray, remove catheter
post: monitor for UTI first 72 hours, increase fluids, monitor output
Kidney biopsy
Purpose: removal of a sample of tissue by excision or needle aspiration for
histological examination.
* Pre-procedure: informed consent, coagulation studies, NPO for at least 4
hours, typically local anesthesia, pt must lay prone (procedure is
contraindicated if they cannot lay in this position for extended periods)
* Post-procedure: monitor for bleeding–> high risk b/c kidney is highly
vascularized–> hematuria, H&H, bruising at puncture site
Cystoscopy/cystourethroscopy
Purpose: used to discover bladder wall abnormalities or occlusions of ureter or urethra
* Pre-procedure: NPO, informed consent, laxative or enema for bowel prep night before. May require anesthesia (not always)
* Intra-procedure: Lithotomy position, vitals monitoring
* Post-procedure: monitor urine output and characteristics (may be pink
tinged), irrigation may be necessary if blood clots are present, encourage
increased fluid intake
Lithotripsy
Purpose: to break a stone into smaller fragments
* Pre-procedure: pt must be able to lie flat, assess for dysrhythmia (as this
procedure can cause or worsen existing)
* Intra-procedure: monitor ECG
* Post-procedure: strain urine for stone passage, bruising may occur at site
(expected finding), assist with pain management r/t stone passage
Ureterolithotomy & nephrolithotomy
Percutaneous:
* Purpose: removal of stone through the skin.
* Pre-procedure: NPO, Informed consent, pt must lie prone
(contraindicated if they cannot do so for extended periods)
* Post-Procedure: monitor nephrostomy for drainage and presence of
blood
Open:
* Purpose: for large or impacted stones
* Pre-procedure: NPO, Bowel prep, Informed consent
* Post-procedure: monitor for excess bleeding, maintain fluid intake,
strain urine for passage of additional fragments, teach prevention
measures
Care and nursing interventions for a nephrostomy tube
Monitory amount of drainage and type hourly within the 1st 24 hours
* A decrease in drainage amount and back pain can indicate tube obstruction
or dislodgement
Monitor for nephrostomy leaking
Sterile dressing changes
Tube flushing–> to check patency and dislodge clots
Urinary tract infections
S/S: pain, fatigue, fever, confusion, frequency, urgency, dysuria, nocturia,
hematuria, retention, feeling of incomplete bladder emptying
* Diagnosis: history, physical exam, urinalysis, CBC, cystoscopy if
recurrent
* Tx: antibiotic therapy, phenazopyridine (urinary analgesic), antipyretic,
increased fluid intake, warm sitz bath 2-3 times a week can relieve pain
* Education: full abx course, drink 2-3 L/day, wipe front to back, do not
hold urine, phenazopyridine (urinary analgesic) will turn urine orange
* Labs: urinalysis–>expect positive WBCs, Nitrite, bacteria, leukocyte esterase, casts; Urine culture and sensitivity; CBC-> elevated WBCs
Renal calculi
S/S: flank pain, fluctuating pain (depending on location of stone), oliguria,
anuria, dysuria, hematuria, bladder distention.
* Diagnosis: x-ray KUB, CT KUB, Ultrasound KUB
* Tx: NSAIDs, Antiemetics, Antibiotics, increase fluid intake (to aid in
passing stone and prevent further stone formation), watchful waiting (for
stones to pass), straining of urine
* Education: once stone type has been determined, patient may need to alter
intake of certain foods.
* Calcium: avoid milk and other dairy products
* Oxalate: avoid spinach, black tea, and rhubarb
* Uric Acid: decrease purine intake–> poultry, fish, gravies, red
wines, sardines
* Struvite: typically results after a bacterial infection. Avoid high
phosphate foods (dairy, red or organ meats, whole grains)
* Labs: urinalysis–> rule out infections, may be positive for RBCs,
Hyperkalemia, Hyperphosphatemia
Polycystic Kidney Disease
S/S: weight gain (due to cyst formation and increased kidney size), flank pain, headache (stroke risk r/t hypertension), hematuria, hypertension (r/t decreased kidney perfusion and initiation of the RAAS system), dysuria, nocturia, constipation (enlarged kidney compresses bowels), enlarged abdominal girth (r/t enlargement of kidneys), kidney stones
* Diagnosis: ultrasound, family history/genetic testing
* Tx: blood pressure control (typically with ACEs or ARBs because they
work directly on the RAAS system), pain management (typically acetaminophen and nonpharmacologic interventions), interventions to slow progression of kidney damage (surgical cyst drainage, dialysis, smoking cessation), infection prevention, Pt will inevitably need a kidney transplant (if they live that long)
* Education: importance of diet (decrease sodium intake), importance of smoking cessation (hypertension risk),
* Labs: urinalysis: + proteinuria, + hematuria; decreased GFR; elevated BUN and creatinine levels, fluctuation in sodium level (can be wasted or retained)
Hydronephrosis/Hydroureter
S/S: flank pain, anuria, abdominal asymmetry (may indicate kidney mass),
abdominal tenderness
* Diagnosis: renal ultrasonography (1st choice), UA, CBC, CT or X-Ray
KUB
* Tx: removal or treatment of obstruction–>
nephrolithotomy/ureterolithotomy, cystoscopy, stent placement;
Nephrostomy placement
* Labs: depend on severity and related kidney damage–> if left untreated
kidney damage will result in low GFR, elevated BUN, elevated Creatinine
Pyelonephritis
S/S: UTI symptoms, N/V, recent cystitis or other UTI
* Diagnosis: urinalysis, culture and sensitivity, Imaging (X-ray KUB, CT)
* Tx: antibiotics, increase fluid intake, pain interventions, antipyretic,
* Education: do not hold urine, drink plenty of fluids, wipe front to back,
take full course of abx,
* Labs: BUN may be elevated (but creatinine will not), urinalysis- + WBC,
+ nitrite, + bacteria, cloudy, foul odor
Glomerulonephritis- acute and chronic
Acute: results from excess immune response within the kidney tissues –> onset about 10 days after time of infection
Chronic: do not know cause
S/S: Proteinuria, hematuria, hypertension, edema (especially in the face and hands), Pulmonary edema (dyspnea, shortness of breath, crackles), neck vein distension, weight gain
Diagnosis: can only be officially diagnosed by kidney biopsy
Tx: r/t fluid overload–> diuretics, sodium restriction, water restriction; Antihypertensives, Dialysis, antibiotic therapy
Education: educate on medication, if dialysis is required–> educate on vascular access care and dialysis schedule/routine
Labs: Elevated BUN and creatinine, electrolyte imbalances r/t ineffective filtration, urinalysis: + RBC and protein, decreased GFR (normal: greater than 125 mL/min)
Stages of bone healing
Hematoma formation within 24-72 hours of fracture
Granulation tissue invades hematoma to form fibrocartilage within 3 days-
2 weeks
Fracture site is surrounded by new vascular tissue known as a callus
within 3-6 weeks
Callus is gradually resorbed and transformed into bone within 3-8 weeks
Consolidation and remodeling of bone can continue for up to 1 year after
Open fracture
breaks through skin
closed fracture
break remains in skin
greenstick fracture
bends enough to snap but only cracks on one side
more common in children
spiral fracture
created from twisting motion; fracture line goes around
transverse fracture
complete fracture that runs horizontally across bone
oblique fracture
diagnoally complete break that runs horizontally across bone
compression fracture
from loading force (even gravity can cause these)
ex) trauma, osteoporsis, tumors
comminuted fracture
broken bone that is in multiple pieces
-usually three or more
simple fracture
single line fracture with no other damage
pathologic/spontaneous fracture
occurs when bone structure is weakened by disease
fatigue fracture
fracture caused by repeated stress over time
most common in athletes
impacted fracture
type of fracture that occurs when pressure is at boths sides of the bones causing it to split and broken ends jam together
traction
used to maintain alignment of the bone fragments/pieces.
Used to decrease muscle spasm
skin traction/ buck’s traction
a short-term treatment that uses weights and a pulley system to help realign broken bones in the lower limb
skeletal traction
pins placed into bone
nursing intervention traction/external fixator
Weights are not touching anything (I.e. bed or floor) Ropes are intact (not fraying or thinning)
Pulley systems are intact
Cleanliness of pins: sterile cotton swab with approved antiseptic–> clean from pin base up the pin, use different swab for each pin–> pin care should be completed at least once a shift
Foot pedal is not touching the bed
Surgical bone procedures:
ORIF (open reduction internal fixation): Hardware is inside bone
External Fixation: Hardware is outside–> assess pin sites every 8-
12 hours for s/s of infection
Amputations
May be Elective or traumatic
Elective: surgical removal r/t chronic disease –> more commonly the lower extremities
Traumatic: result of an injury/trauma –> more commonly the upper extremities
Nursing Care:
Physical assessment: Neurovascular assessment
Psychosocial assessment: altered body image, depressed mood,
financial concerns (connect with proper resources including social worker), denial, self-esteem issues
“Assessing ability to cope, identify and acknowledge feelings, help connect with resources”
Medication: pain management, IV CALICTONIN Post-amputation Tx:
Pain management: especially for phantom limb pain
Phantom limb pain: REAL PAIN!!!! More likely to occur if
they had chronic pain in that limb prior to amputation (ex:
diabetic neuropathy)
Proper stretching of area (flexion contracture prevention)
Neuroma removal (tumor of damaged nerve cells typically at the
end of a limb) can reoccur after removal
Carpal tunnel syndrome
Compression of the median nerve from inflammation (can occur in both hands, but more likely in the dominant hand)
Inflammation=swelling –> increased fluid in space–> fluid compresses nerve
S/S: dull ache/discomfort, paresthesia that may extend up the arm, muscle weakness (may have difficulty holding small objects, turning knobs/keys, and doing other fine motor tasks)
Risk factors: repetitive stress (typing, crocheting, tennis, etc.), obesity, pregnancy, joint inflammation
Dx: Phalen’s maneuver: wrist flexion for 1 minute (numbness in hands indicates positive test), Tinel’s sign: repetitive tapping of the transverse ligament (results in paresthesia indicates positive test)
Tx: wrist immobilization and NSAIDs, behavior modification (ergonomic typing: hands parallel to each other at table, wrist support), physical therapy, corticosteroid injection, median nerve decompression surgery
Median nerve decompression surgery: post-op wrist immobilizer for 4-6 weeks, no heavy lifting
Sprains
tear or stress on ligament (bone to bone)
Strains
tear or stress to tendon ( muscle to bone)
RICE
REST
ICE
COMPRESS
ELEVATE
Compartment syndrome
Rapid increase in pressure within a muscle compartment (compresses muscle, blood vessels, and nerves)
S/S: 6 P’s–> Pain (out of proportion to injury), Paresthesia, Pallor, Pulselessness, Poikilothermic (decreased temperature in one area–> r/t decreased circulation and swelling), Paralysis
Intervention: immediately notify provider, if cause is known remove it (ex: cast), emergency fasciotomy
Fat embolism
S/S: similar to DVT/PE, if in lung, a petechial rash may appear on the chest (usually the last sign to develop)
Intervention: ABC Maintenace while waiting for fat to be reabsorbed by the body. (Intubation may be required), hydration, fracture immobilization, bedrest
Infection of bone (osteomyelitis)
S/S: Fever (typically greater than 101 Fahrenheit), chills, sweats, elevated
WBC, Bone pain (constant, localized, pulsating, worse with movement), swelling and tenderness
Intervention: intense antimicrobial therapy via IV (for up to 3 months or until infection is eliminated), oral drug therapy may be required after IV, pain management
Complication: loss of function, persistent pain, amputation, death r/t sepsis
Synthetic Fiberglass Cast
More lightweight, strong, dries quickly (within 30 minutes),
can be made water-resistant
Plaster of Paris
Heavy, can take up to 3 days to fully dry, cannot get wet
5 P’s musculoskeletal
Pain, Pulse, Pallor, Paresthesia, Paralysis
Nursing interventions for prevention of musculoskeletal problems associated with aging.
Weight bearing exercises for bone strengthening–> slows bone loss
Maintenance of adequate calcium and vitamin D intake (diet or supplementation)
Smoking cessation–> nicotine has been shown to negatively impact
musculoskeletal and immune systems
Maintain regular exercise–> muscle fibers decrease in size and number with age
and can atrophy if unused
Osteopenia (decreased bone density) –> safety through fall prevention is top
priority
Kyphosis (hump-back) –> teach proper body mechanics
Calcium r/t bones
bone strength and muscles–>maintain adequate intake–> (9.0-10.5)
Phosphorous r/t bones
calcium balance and bone strength–> maintain intake–> inverse
relationship with Ca (Ca increases; P decreases) –> (3.0-4.5)
Vitamin D r/t bones
r/t calcium and phosphorous absorption–> maintain intake–>
deficiency can result in calcium deficiency
Creatinine Kinase:
can indicate muscle trauma–> recall rhabdomyolysis
Estrogen r/t bones
stimulates osteoblastic activity–> deficient estrogen=weakened bones
LDH and AST r/t bones
can indicate skeletal muscle trauma
what does a 24 hour urine collection measure
creatinine clearance, urea nitrogen, sodium, chloride, calcium, and proteins
Lithotripsy
breaks stone into smaller pieces
Percutaneous nephrolithotomy
a surgical procedure to remove kidney stones that are too large to pass on their own or don’t respond to other treatments
go in through the skin
Open ureterolithotomy
Removes a stone from the ureter
Open nephrolithotomy
Removes a stone from within the kidney
nephrostomy tube
a thin, flexible tube that drains urine directly from the kidney into a bag outside the body.
UTI Labs
urinalysis–>expect positive WBCs, Nitrite, bacteria, leukocyte esterase, casts; Urine culture and sensitivity; CBC-> elevated WBCs
Renal calculi s/s
flank pain, fluctuating pain (depending on location of stone), oliguria,
anuria, dysuria, hematuria, bladder distention.
Renal Calculi- Calcium
avoid milk and other dairy products
Renal Calculi- Oxalate
avoid spinach, black tea, and rhubarb
Renal Calculi- Uric Acid
decrease purine intake–> poultry, fish, gravies, red
wines, sardines
Renal Calculi- Struvite
results after a bacterial infection.
Avoid high
phosphate foods (dairy, red or organ meats, whole grains)
Renal Calculi Labs
urinalysis–> rule out infections, may be positive for RBCs,
Hyperkalemia, Hyperphosphatemia
Polycystic Kidney Disease treatment
blood pressure control (typically with ACEs or ARBs because they
work directly on the RAAS system), pain management (typically acetaminophen and nonpharmacologic interventions), interventions to slow progression of kidney damage (surgical cyst drainage, dialysis, smoking cessation), infection prevention, Pt will inevitably need a kidney transplant (if they live that long)
Polycystic Kidney Disease pt education
importance of diet (decrease sodium intake), importance of smoking cessation (hypertension risk),
Polycystic Kidney Disease labs
urinalysis: + proteinuria, + hematuria; decreased GFR; elevated BUN and creatinine levels, fluctuation in sodium level (can be wasted or retained)
Hydronephrosis
The dilation of the renal pelvis and calyces, which can affect one or both kidneys.
Hydroureter
The dilation of the ureter
Pyelonephritis
kidney infection
Voiding Cystourethrogram
an X-ray exam that uses a contrast material to image the bladder, urethra, and kidneys while the bladder is filling and emptying
Glomerulonephritis
a term for a group of kidney diseases that damage the glomeruli, the tiny filters in the kidneys
acute: strep infection after 10 days
chronic: occurs 20-30 year
s/s Glomerulonephritis
Proteinuria, hematuria, hypertension, edema (especially in the face and hands), Pulmonary edema (dyspnea, shortness of breath, crackles), neck vein distension, weight gain
elective amputation
surgical removal r/t chronic disease –> more commonly the lower extremities
traumatic amputation
result of an injury/trauma –> more commonly the upper extremities
Phalen’s maneuver
wrist flexion for 1 minute (numbness in hands indicates positive test),
Tinel’s sign
repetitive tapping of the transverse ligament (results in paresthesia indicates positive test)
Age-Related GI Changes and Diagnostic Interventions
Peristalsis slows with age–> maintain physical activity which promotes peristalsis
Abdominal muscle weakens with age–> increased hernia risk and increased straining with defecation (fiber and fluid intake can assist with straining)
upper GI series (pre/post care)
pt drinks barium–> X-ray while drinking and post drinking–> allows for visualization of anatomical structures and the flow of contents
Pre: NPO @ midnight, avoid smoking and chewing gum
Post procedure: ensure barium leaves the system by encouraging fluid intake. –> stool will be chalky white–> if no bowel movement within 24 hours a laxative may be administered to promote defecation
endoscopic ultrasound
provides ultrasound image from within the body–> can be used to measure size of esophageal tumor
EGD (pre/post care)
Pre: NPO, informed consent, remove dentures and other oral inserts, assess for anticoagulant therapy, moderate sedation
Intra: pt positioned left side lying with HOB elevated, biopsy and ultrasound can be performed during the procedure using the EGD scope
Post: verify gag reflex (withhold fluids until verified), monitor for s/s of perforation (fever, pain, dyspnea, bleeding), use throat lozenges if sore throat or hoarseness persists
ERCP (pre/post care)
(Endoscopic retrograde cholangiopancreatography)
-visualizes biliary tree
Pre: NPO, anticoagulant cessation, removal of dentures and other oral inserts
Intra: pt will be semi-prone initially and will reposition during procedure
Post: monitor ABCs, verify gag reflex, monitor for infection, throat lozenge for sore throat and hoarseness
pH monitoring (pre/post care)
Probe inserted from nose to end of esophagus to measure pH and changes of a certain period (typically 48h)
Keep food diary for time while monitor is in place, keep a record of symptoms, when they occur, and how they were positioned
GERD s/s and complication
S/S: pyrosis, dyspepsia, regurgitation, chest pain, water brash (hypersalivation to compensate for the increased acidity in the lower esophagus), Globus (feeling of something stuck in the throat), coughing at night
complications- ´ esophageal erosion, Barret’s esophagus (premalignant)–> increased risk for esophageal adenoma
GERD education/treatment
Education: Avoid acidic and spicy foods, avoid chocolate/caffeine/carbonated drinks, do not lay down after eating, do not wear tight clothing or lift heavy weights (increase abdominal pressure), eat multiple small meals per day, sleep with HOB elevated
Tx: Lifestyle changes–> diet, medication therapy–> PPI (Pantoprazole, omeprazole)
Hiatal hernia s/s and complications
S/S: Type I/sliding type: GERD Symptoms;
Type II/rolling type (herniation of the upper portion of the stomach but the gastroesophageal junction remains in normal position): fullness after eating, sense of suffocation, worsening of symptoms when reclined
complications: perforation, ischemia/necrosis
Hiatal hernia Dx, Ed, Tx
Dx: EGD (visualize esophagus and gastric lining), Barium Swallow
Education: GERD teaching
Tx: lifestyle changes–> diet, surgery if severe
esophageal tumors s/s and complications
S/S: Dysphagia (most common symptoms), odynophagia, regurgitation, globulus (feeling of something stuck in the throat), halitosis, change in bowel habits, chronic hiccups (r/t diaphragmatic irritation), voice changes
Complications: metastasis, airway obstruction, surgical complications (discussed in esophageal tumor surgery section)
esophageal tumors dx
(EGD) esophagogastroduodenoscopy
esophageal tumors treatment
endoscopic resection–> high risk of cardiac and respiratory complications (fluid overload and post-op A fib.), esophagectomy with lymphadenectomy, combo chemo and radiation, consult with registered dietician (nutrition) and speech language pathology (swallowing study and techniques)
Gastritis (acute vs chronic) s/s and complications
S/S: dyspepsia, gastric pain, N/V, bloating, weight loss, hiccupping, evidence of GI bleed
Complications: GI bleed, Ulcer formation
Gastritis (acute vs chronic) dx
endoscopy with biopsy, H pylori (blood and stool test or urea breath test)
Gastritis (acute vs chronic) education and treatment
Education: eat small frequent meals, smoking and alcohol cessation, medication education (PPI, Sucralfate, Antacids)
Tx: identify and avoid cause of gastric irritation, H pylori–> triple therapy with clarithromycin, amoxicillin, and PPI
PUD (peptic ulcer disease) s/s and complications
S/S: Abdominal pain, hematemesis, increased pain with eating (gastric ulcer), bloating, belching, decreased pain while eating (duodenal ulcer)
Complications: Bleeding (most common), Pyloric obstruction (long standing ulcers cause edema and swelling), perforation, peritonitis
PUD dx and tx
Dx: EGD and H. pylori test
Tx: PPI, H-2 blockers, sucralfate or misoprostol, surgery depending on severity (Gastrectomy, pyloroplasty, vagotomy)
gastric cancer s/s and complications
S/S: Early–> dyspepsia, abdominal discomfort, abdominal fullness. Late–> N/V, palpable mass, weight loss, enlarged lymph nodes, weakness
Complications: dumping syndrome, malabsorption
gastric cancer dx and tx
Dx: EGD with biopsy
Tx: chemotherapy and radiation combo therapy, surgical–> total or subtotal gastrectomy
Dumping syndrome s/s and complications
S/S: full sensation, diaphoresis, palpitations, dizziness, diarrhea, pallor, H/A, drowsiness
Complications: fluid and electrolyte imbalance r/t rapid gastric emptying, hypoglycemia r/t rapid release of insulin from the pancreas as food quickly enters the small intestine
Dumping syndrome education
do not drink with meals but between meals, small/freq meals, low-fiber and low-carb foods, high-protein, lie down after eating to slow gastric movement
IBS s/s
constipation/diarrhea depending on IBS type, Abdominal bloating and cramping, passage of mucous, distension, nausea with meals or passing stool, belching, sensation of incomplete defecation
IBS dx and tx
dx hydrogen breath test–> can indicate s/s being r/t bacterial overgrowth in gut, malabsorption, or impaired digestion
tx diet changes, stress reduction, avoiding triggers
IBS Education
Diet- avoid irritating foods (caffeine, lactose, gluten), increase physical activity, stress reduction techniques
most common herniation
inguinal
herniation s/s and complications
S/S: visible lump or a lump that emerges with increased intrabdominal pressure (ex: coughing), heavy discomfort around gut, pain with palpation, constipation
´ Complications: strangulation of bowel–> surgical emergency
herniation education
turn/deep breath post-surgery (do not cough), avoid increasing intra-abdominal pressure (coughing, straining, heavy lifting), constipation prevention
herniation tx
may require surgery (especially if irreducible) –> herniorrhaphy/ hernioplasty–> men may require catheterization post-op due to swelling
´ Reducible–> can be manipulated back into the abdominal wall–> application of a truss post-reduction to keep in place and provide support
Colorectal Cancer s/s and complications
S/S: melena/visible clots/rectal bleeding, weight loss, fatigue, palpable mass, increased bowel frequency, abdominal pain, passage of mucous, hematochezia
Complications: obstruction from polyp or tumor, metastasis
Colorectal Cancer dx
colonoscopy (used for screening every 10 years starting at age 45 unless at increased risk due to presence of polyps or an inflammatory bowel disease), fecal occult blood test/guaiac (done yearly), sigmoidoscopy (not recommended as it only visualizes one section of the colon) Carcinoembryonic antigen is released in colon cancer
colorectal cancer tx and education
Education: Increase fiber intake, decrease smoking and alcohol use, increased exercise, decrease processed food intake, need for screening, avoid NSAIDS/red meat 1 week prior to FOBT
Tx: Combination of chemotherapy and radiation, surgical intervention–> partial or total colectomy and lymphadenectomy then anastomosis(may require temporary or permanent ostomy)
mechanical intestinal obstruction
Physical blockage
Adhesion, tumor, intussusception (telescoping aka going inside itself), hernia, volvulus (180 twisted), stool
Pseudoobstruction/Paralytic Ileus intestinal obstruction
- “Functional obstruction”
- Myopathy or neuropathy
-Most common in post-op abdominal surgery pt’s
small intestine obstruction
- Vomiting is more likely and begins earlier (more likely to be undigested contents)
- if high in small intestine Metabolic alkalosis risk, lower in small intestine duodenum or lower metabolic acidosis*
- Pain is more centrally located in the abdomen and a cramping sensation
Visible peristaltic waves
large intestine obstruction
- Vomiting is less likely to occur until later stages of obstruction
- Typically, fewer fluid and electrolyte issues–> Metabolic acidosis risk
- Pain/spasm in lower quadrants
- Diarrhea or ribbon-like stools
Intestinal Obstructions s/s and complications
S/S: Obstipation (inability to pass flatus or stool), fever, tachycardia, N/V, abdomen tender to palpation, hyperactive bowel sounds above obstruction site, hypoactive or absent bowel sounds below obstruction
complications: Perforation of bowel, peritonitis, dysrhythmia (r/t fluid and electrolytes), bowel ischemia, sepsis, acid-base imbalances, hypovolemia/shock, increased peristalsis
Intestinal Obstructions dx
Imaging–> CT abdomen and pelvis with contrast, Abd X-ray, endoscopy - Labs–> CBC (elevated H&H r/t fluid and electrolyte changes and fluid shift), Urinalysis (BUN elevates r/t dehydration, creatinine elevates in later stages r/t decreased renal perfusion), CMP for electrolyte monitoring, Lactate level r/t sepsis risk
Intestinal Obstructions tx
Non-surgical: digital disimpaction (perforation risk), enema (perforation risk), laxatives (increased fluid imbalance risk), NPO (especially for paralytic ileus), NG tube decompression, cardiac monitoring/ I&O (r/t fluid and electrolyte imbalances), alvimopan (stimulates peristalsis in post-op paralytic ileus)
Surgical: type of surgery is dependent upon cause–> Exploratory laparotomy may be indicated when cause is unknown–> more invasive than other surgeries–> extended recovery time and increased risk for complications
hemorrhoids s/s
pain with defecation, small amounts of frank blood in stool, mucus discharge, sudden perianal pain, perianal mass (s/s depend on if the hemorrhoids are internal or external (prolapsed or not)
hemorrhoids tx
high fiber diet, sitz bath (comfort) steroid cream (can be bought OTC), rubber band ligation/hemorrhoidectomy (if conservative measures are unsuccessful
Nissen fundoplication
esophageal hug surgery” –> for hiatal hernia
Pre: NPO, informed consent, general anesthesia,
Intra: laparoscopic or open
Post: nasogastric decompression–> do not touch unless ordered
Esophageal tumor surgery
Pre: NPO, general anesthesia, informed consent, oral care–> very important b/c poor oral care increases post-op infection risk
Post: monitor EKG as post-op A fib is more likely with this procedure, monitor ABCs–> increased risk for respiratory complications especially r/t fluid overload, assess for anastomosis leak–> infection S/S (presence of anastomosis depends on type of surgery), pt will remain intubated for extended period–> freq oral care, turning, suctioning
Gastrectomy
Pre: NG tube will typically be placed prior and left in place post-surgery, educate on possible complications–> especially dumping syndrome–> other complications include malabsorption (may require nutrient supplementation
Post: keep HOB elevated, monitor for manifestations of dumping syndrome and hypoglycemia related to dumping syndrome (pancreas “slams” body with insulin as food rapidly enters the small intestine)
hernia repair
Pre: informed consent, men may require catheterization post-op due to swelling
Post: can be outpatient surgery–> quicker recovery time, use of truss pad post hernia reduction (truss can be removed at night)
colorectal cancer surgery
colon resection (removal of a portion of the colon) or colectomy and lymphadenectomy (removal of all the colon)
exploratory laparotomy
Pre: general anesthesia, NPO, informed consent, education on increased risk of complication and prolonged recovery time
Post: surgical management similar for other abdominal surgeries
what acid-base imbalances can occur because of GI problems?
metabolic alkalosis with obstruction/emesis, and overuse of calcium carbonate
lower GI diagnostics (pre/post care
barium enema
Pre: NPO, avoid smoking or chewing gum (increases peristalsis), assess for contraindication for bowel prep (increased perforation or obstruction risk, inflammatory disease)
Post: Post procedure: ensure barium leaves the system b
colonoscopy
Pre: moderate sedation, NPO, avoid red liquids as they can indicate false bleeding to the physician, bowel prep day before (risk for fluid and electrolyte imbalance especially with older adults)
Intra: pt positioned left side with knees to chest
Post: monitor for rectal bleeding, monitor for s/s of perforation, encourage fluid intake, may experience increased flatulence post-procedure
Appendicitis s/s and complication
S/S: RLQ pain/ McBurney’s point (typically first sign/ #1 cause of acute RLQ pain), N/V, fever, tachycardia, rebound tenderness
Complications: Appendix rupture–> peritonitis–> sepsis
Appendicitis dx and tx
Dx: abdominal ultrasound–> then CT for confirmation, CBC may show elevated WBCs
Tx: Appendectomy (laparoscopic or open) pre and post op similar to other abdominal surgery with general anesthesia–> may start as laparoscopic but can quickly turn into open
´ Non-surgical: abx and pain management (no heat–> causes vasodilation–> increases swelling–> increases risk of rupture), NPO, IV fluids, semi-fowlers position (pools fluid in lower abdomen)
peritonitis s/s
rigid/board-like abdomen (classic sign), fever, tachycardia, hypotension, increased RR, hypoactive bowel sounds (peristalsis slows/stops), hypovolemia (dehydration and decreased urine output), dyspnea (r/t increased intrabdominal pressure/fluid shift), hiccups (pressure on diaphragm causes diaphragmatic spasm)
peritonitis dx
Increased H&H r/t hypovolemia, elevated BUN and creatinine, elevate WBCs, blood cultures + for gut bacteria, X-ray can be done to visualize air and fluid
peritonitis tx
Non-surgical: O2 therapy, sepsis monitoring (vitals, urine output, neuro status), broad-spectrum Abx, fluid replacement, semi-fowlers (decreases diaphragmatic pressure and pulls fluid to lower abdomen)
Surgical: dependent upon cause–> exploratory laparotomy if cause unknown
gastroenteritis s/s and complications
S/S: N/V (typically first), abdominal pain, diarrhea, fever, tachycardia, electrolyte imbalance
Complications: fluid and electrolyte imbalance–> especially in children and older adults
gastroenteritis dx
S/S, elevated inflammatory markers–> ESR and CRP, elevated WBCs, Hx (where they’ve eaten, what they’ve eaten, have they traveled recently), stool sample can be done to determine pathogen, CBC to assess for dehydration
gastroenteritis ed and tx
ed- FLUIDS
tx-´ oral rehydration therapy, IV fluids, potentially abx depending on the cause (not typically used because it can also destroy good bacteria), practice good hygiene, skin care (avoid using toilet paper–> use absorbent wipes or soap and water)
ulcerative colitis s/s and complications
s/s only in the large intestine (key difference from Crohn’s), LLQ pain, bloating, cramping, more severe and frequent diarrhea, tenesmus, weight loss, blood in stool (depending on severity and presence of ulceration), periods of remission and exacerbation
Complication: colorectal cancer, bowel obstruction, perforation
ulcerative colitis dx
Stool consistency/color/frequency/presence of blood, family history, medication use (PPI, antacids, H2 blockers), colonoscopy, decreased albumin (r/t diarrhea), elevated inflammatory markers (WBCs, ESR, CRP), colonoscopy, barium enema
ulcerative colitis education
diet–> avoid caffeine, spicy foods, fiber as they worsen s/s, record color/volume/freq/consistency of stool, record weight 1-2 times per week
ulcerative colitis tx
Non-surgical; anti-inflammatory (aminosalycilates), corticosteroids, antidiarrheals, immunosuppressors
Surgical: total colectomy–> generally curative–> may require permanent ostomy
chron’s disease s/s
Cobblestone appearance to GI tract (areas of raised tissue (strictures) and areas of indentation (fissures)–> fissures increase risk for fistulas), can be located anywhere along the GI tract, periods of exacerbation and remission, multiple stools a day, may have diarrhea, RLQ pain or other abdominal pain (most often Crohn’s occurs in the ileum), steatorrhea (fatty stools r/t decreased fat absorption in the small intestine), nutrient deficiencies (if it’s affecting the small intestine)
Chron’s disease complications
fistula formation–> perforation risk or fistula formation btwn organs or skin, bowel obstruction, colorectal cancer, osteoporosis (poor calcium and vitamin D absorption)
Chron’s disease dx
M2A/pill camera, H&H remains WNL (bleeding is less likely with Crohn’s), decreased albumin (r/t diarrhea), decreased folic acid and vitamin B12 (decreased intestinal absorption), WBC/ESR/CRP elevated, MRE (magnetic resonance enterography)
Chron’s disease tx
Non-surgical: Same medication regimen as UC
Surgical: Fistula repair–> can heal without intervention if small or Tissue removal–> not curative–> unlikely unless very severe
diverticular disease s/s and complications
S/S: may be asymptomatic–> unless diverticulitis occurs (LLQ pain–> diverticula are more common in the sigmoid colon, bleeding, N/V, Fever, chills, diarrhea)
Complications: perforation or diverticula, peritonitis, bowel obstruction, fluid and electrolyte imbalance
diverticular disease dx
colonoscopy, elevated WBC–> in diverticulitis, CT, Barium enema-> less likely because it increases perforation risk of diverticula
diverticular disease ed and tx
Education: avoid nuts, seeds, corn, and other indigestible foods, increase fiber and fluids
Tx: Non-surgical: Diet changes, IV abx/ antiemetics/bowel rest–> for diverticulitis
´ Surgical: resection–> used when they have many episodes of diverticulitis
paralytic ileus s/s
S/S: absent or decreased bowel sounds r/t diminished peristalsis, diffuse constant pain, abdominal distension, frequent vomiting, obstipation
paralytic ileus tx
Tx: intestinal obstruction tx–> alvimopan can stimulate return of peristalsis post-surgery
appendectomy
Pre: education will likely be limited due to pain, general anesthesia
Post: Same as other abdominal surgery
Colectomy
Pre: WOCN consult for ostomy education, general anesthesia
Intra: may perform an ileostomy/ileoanal pull through–> 2-part surgery that does not result in a permanent ostomy, or an abdominoperineal resection–> removal of entire colon and rectum–> permanent colostomy
Post: Stoma monitoring, reinforcing of teaching for ostomy care, do not sit on bottom or use donut pillow (reduces blood flow and delays healing)
colon resection
Pre: may require ostomy–> education and WOCN consult may be required
Post: monitoring for complications–> anastomosis leakage, infection, bleeding, general post-op abdominal care
Care of colostomies
Consult with wound ostomy care nurse for placement marking and client education
Empty when 1/3 to 1/2 full
Stoma should be pink and moist
Assess surrounding skin for maceration
Change the pouch system every 2 weeks
Monitor stoma output for consistency and pH–> more liquid and more acidic the higher up it is
Crohns pain
RLQ
Appendicitis pain
RLQ, McBurneys point
UC location
LLQ
Diverticulitis location
LLQ
