Med Surg Pt. 2 Flashcards
To prevent deep vein thrombosis from developing with a patient with a cerebrovascular accident (CVA), what preventative measures should be included?
The used of sequential compression stockings, frequent position changes, and mobilization.
What intervention should you implement to a stroke patient regarding a decreased endurance and impaired balance due to paralysis on one side of the body?
Frequent rest periods from sitting in the wheelchair should be provided by returning the client to bed after therapies and meals.
What is shoulder subluxation?
Should subluxation can occur if the affect arm of a stroke patient is not supported. The weight of the arm is such that is can actually cause a painful dislocation from its socket.
Interventions for should subluxation?
When sitting the client in bed, the wheelchair, or during ambulation should be accomplished with an arm sling or strategically placed pillows.
Which side do you tell the client to hold the quad-cane with?
Have the patient keep the cane on the stronger side of the body.
What are the steps to proper cane use?
- Keep the cane on the stronger side.
- Place the cane forward 15-25cm (6-10in), keeping weight on both legs.
- The weaker leg is moved forward to the cane so body weight is divided between the cane and stronger leg.
- The stronger leg is then advanced past the cane so the weaker leg and the body weight are supported by the cane and the weaker leg.
- Repeat.
What is bariatric surgery?
Bariatric surgeries are done as a treatment for morbid obesity when other weight control methods have failed.
Client education regarding bariatric surgery should include what?
Client education, regarding bariatric surgery should include:
- The client should be limited to liquids or pureed foods for the first 6 weeks.
- The client’s meal size should not exceed 1 cup.
- The client should walk daily for at least 30 minutes.
Nursing action regarding postoperative meals for a patient who just had bariatric surgery.
- Provide 6 small meals a day when the client can resume intake. Observe for signs of dumping syndrome. The client’s first feeding may only consist of 30 mL of liquid.
What are signs of dumping syndrome?
Cramps, diarrhea, tachycardia, dizziness, and fatigue.
How long should a dietary restriction of liquids or pureed foods be implemented in a client who just had bariatric surgery?
The client should be limited to liquids or pureed foods for the first 6 weeks.
What is a pressure ulcer?
A pressure ulcer (formerly known as a decubitus ulcer) is a specific type of tissue injury caused by unrelieved pressure the results in ischemia and damage to the underlying tissues.
Interventions for health promotion and disease prevention of pressure ulcers include maintaining clean, dry skin and wrinkle-free linens.
- Appropriate use pressure-reducing surfaces and relieving devices.
- Inspect the skin frequently and document the client’s risk using a tool such as Braden Scale.
- Clean and dry the skin immediately following urine or stool incontinence.
- Apply moisture barrier creams to the skin of clients who are incontinent.
- Use tepid water (not hot), use minimal scrubbing, and pat the skin dry.
- Encourage clients to consume diets high in protein and vegetables.
- Encourage clients to take vitamin and supplements.
Pressure ulcers nursing interventions:
Reposition the client in bed at least every 2 hours and ever 1 hour in a chair. Document position changes. and Providing adequate hydration.
- Place pillows strategically.
- Maintain HOB at or below 30 degrees, unless contraindicated.
- Keep client from sliding down bed (this increases shearing forces that pull tissue apart).
- Lift, rather than pull, client up in bed.
- Raise client’s heels off of the bed.
- Ambulate the client ASAP.
- Implement active/passive exercises.
- Do not massage bony prominences.
In a patient with anemia how do you know if medication therapy has been effective?
Medication therapy is effective if the client’s Hgb (F12-16/M14-18) and Hct (F37-47%/M42-52%) levels return to a value within normal reference range and if the client reports less fatigue.
A client you are caring for has a Hgb level between 6 to 10 g/dL, you know this is an indication of what?
The client with a Hgb level of 6-10 g/dL has anemia.
What is the normal reference range for Hgb?
Normal Hgb Levels:
Females is 12-16 g/dL
Males is 14-18 g/dL
What is the normal reference range for Hct?
Normal Hct Levels:
Females 37-47%
Males 42-52%
What should you teach the client who is taking Folic acid supplements for anemia?
Tell them that taking Folic acid will turn the client’s urine dark yellow.
Client education regarding iron supplements - ferrous sulfate (Feosol), ferrous fumarate (Feostat), ferrous gluconate (Fergon)
- Instruct the client to have Hgb checked in 4 to 6 weeks to determine efficacy.
- Vitamin C may increase oral iron absorption.
- Instruct the client to take iron supplements between meals to increase absorption.
Do you take iron supplements with or without meals?
Instruct the client to take iron supplements between meals to increase absorption.
How is parenteral iron administered?
Parenteral iron is administered using the Z-track method.
When should a client be advised to have their Hgb levels checked if they are taking ferrous sulfate, or any other iron supplement?
Instruct them to have Hgb checked in 4 to 6 weeks to determine the efficacy.
What vitamin aids in oral iron absorption?
Vitamin C may increase oral iron absorption.
What is anginal pain described as?
Anginal pain is often described as a tight squeezing, heaving pressure, or constricting feeling in the chest. The pain can radiate to the jaw, neck, or arm.
Which type of angina is relieved by rest or nitroglycerin (Nitrostat)?
Stable angina (exertional angina) occurs with exercise or emotional stress and is relieved by rest or nitroglycerin (Nitrostat).
How do you differentiate MI from angina?
Pain that is unrelieved by rest of nitroglycerin and lasting for more than 15 minutes differentiates an MI from angina.
True or False: Vasodilators such as nitroglycerin (Nitrostat) can cause orthostatic hypotension.
True: Vasodilators such as nitroglycerin (Nitrostat) can cause orthostatic hypotension so encourage the client to sit and lie down slowly.
Nursing consideration: Why is nitroglycerin (Nitrostat) given to patients?
It is given to treat angina and help control blood pressure.
Nitroglycerin: client education regarding response to chest pain:
- Stop activity and rest.
- Place nitroglycerin tablet under the tongue to dissolve (quick absorption).
- If pain is unrelieved in 5 minutes, the client should call 911 or be driven to an emergency department.
- The client can take up to two more doses of nitroglycerin at 5-min intervals.
Nitroglycerin: what is a common side effect?
Common side effect of nitroglycerin is headache.
Because the nitroglycerin can cause orthostatic hypotension, what do you want to do? (Patient education)
Teach the patient to sit and lie down slowly when changing position.
If the client’s angina is unrelieved by one nitrostat tablet, what should you do?
Call 911 or be driven to the emergency department.
What are indications for a nontunneled percutaneous central catheter (triple lumen)?
Indications include:
- Administration of blood
- Long-term administration of chemotherapeutic agents
- Long-term administration of antibiotics
- Total parenteral nutrition.
How is TPN administered?
TPN administration is usually through a central line, such as a nontunneled triple lumen catheter or a single- or double-lumen peripherally inserted central line (PICC).
How long is a nontunneled percutaneous central catheter and how many lumen can it have?
15 to 20 cm in length with 1 to 3 lumens.
What is the standard length of use of a nontunneled percutaneous central catheter?
You can use it up to 3 months.
What is isotretinoin (Accutane) prescribed for?
Isotretinoin (Accutane) is used in patients who have acne and is prescribed only by a dermatologist.
How does Accutane work?
Accutane works against acne by effectively affecting factors involved in the development of acne.
A teen-aged patient who is pregnant wants to use isotretinoin (Accutane) to control her acne, what do you say to the patient?
isotretinoin 13-cis-retinoic acid is teratogenic. therefore, it is
contraindicated in women of childbearing age who are not taking oral contraceptives.
What is a big side effect of isotretinoin (Accutane) that must be monitored closely?
Depression, suicidal ideation, and/or violent behaviors are side effects of Accutane that must be monitored closely.
What is the purpose of TPN?
The purpose of TPN administration is to prevent or correct nutritional deficiencies and minimize the adverse effect of malnourishment.
How does TPN provide complete calories?
TPN contains complete nutrition, calories included through a high concentration of (20-50%) dextrose.
What is PPN
PPN is partial parenteral nutrition or peripheral parenteral nutrition is less hypertonic and is intended for short-term use in large peripheral veins. Usually dextrose concentration of 10% or less.
Is TPN a hypertonic solution?
Yes, TPN is a hypertonic solution.
If the TPN solution is unexpectedly ruined or the next bag is not available, what do you want to keep at the bedside?
Keep dextrose 10% in water at the bedside. This will minimize the risk of hypoglycemia with abrupt changes in dextrose concentrations.
Regarding, TPN, how often should to check capillary glucose?
Check capillary glucose every 4 to 6 hours for at least the first 24 hours.
What type of insulin will be needed in clients receiving TPN?
Clients receiving TPN frequently need supplemental Regular insulin until the pancreas can increase its endogenous production of insulin.
A newly licensed nurse states “never abruptly stop TPN” because she knows that…?
Never abruptly stop TPN. Speeding up/slowing down the rate is contraindicated. An abrupt rate change can alter glucose levels significantly.
A client is experiencing malabsorption/malnutrition, a complication of bariatric surgery, what should you teach the client in regards to how much servings of proteins to eat?
Tell the client to eat 2 servings of protein a day.
A client is experiencing malabsorption/malnutrition, a complication of bariatric surgery, what should you teach the client in regards to what kinds of foods to eat?
Tell the client to eat only nutrition-dense foods, Avoid empty calories, such as colas and fruity juice drinks.
