Med Surge Flashcards
What lab finding do you expect in the initial 24 hours of a burn client?
- HCT & HGB elevated due to loss of fluid volume
- Na decreased due to third spacing
- K increased due to cell destruction
- Blood glucose increased due to stress
- WBC increase
- ABG metabolic acidosis
What lab findings do you expect within 48-72 hrs of a burn client?
- Hgb & Hct decreased due to fluid shift
- Na decreased due to renal loss
- K decreased due to renal loss movement back to into cells
- WBC decreased
Pt exhibit ventricular fibrillation what is the priority nursing intervention?
Defibrillation followed by CPR
Why is an arterial line insertion used?
Needed for continuous blood pressure monitoring and access to withdraw ABG sample and CBC.
What is a pulmonary artery catheter insertion is used for?
Inserted to measure cerebrovascular pressure, pulmonary artery pressure and CO. Used for the management of fluids and inotropic medications
What is the diagnostic procedure best to asses for ECG changes associated with MI and dysrhythmias?
ECG
What is the diagnostic procedure best used for cardiomegaly, cardiomyopathy, evaluation of cardiac contractility and function, PE, and pleural effusion?
Echocardiogram
What is the diagnostic procedure to diagnose cardiomegaly, pneumothorax, and evaluation of the lungs?
CT scan
Injection of photosensitizing agent that is absorbed by all the cells in the body, one to three days later when the agent remains in only the cancer cells, tumor is exposed to a specific wavelength of the light via an endoscope.
Photodynamic Therapy (PDT)
Patient using PDT, client educaiton
- Instruct client to avoid sun exposure for 6 weeks
- Instruct the client to consume a liquid diet for several days until pain subside
Delivery of synchronized, direct countershock to heart; elective treatment for atrial dysrhythmias supraventricular tachycardia, ventricular tachycardia with pulse
Cardioversion
Delivery of unsynchronized, direct countershock to the heart. stops all electrical activity in the heart allowing the SA node to take over and re-establish a perfusing rhythm; tx for ventricular fibrilation or pulseless ventricular tachycardia
Defibrillation
Pre procedure for client prior to cardioversion
Anticoagulation therapy to prevent dislodgment of thrombi in blood stream
What is the priority nursing intervention for client receiving cardioversion
Obtain consent
What should the nurse do before cardioversion takes place?
Administer sedation as prescribed before cardioversion
Nursing procedure for cardioversion
- Administer sedation
- Administer prescribed antidysrhythmic -medication
- Monitor the client in a lead that provides upright QRS wavelength
- Perform CPR for cardiac asystole or pulsless rhythm
- Monitor client for PE pr systemic emboli following cardioverison
Client education after cardioversion
Teach client and family how to assess pulse
Advise client to report palpitations or irregular heart beat
Client diagnosed with osteoporosis, client teaching on estrogen (Premarin).
Caution to clients with DVT, and encourage self breast exams
Client teaching on Raloxifene hydrochloride (Evista)
Monitor liver function tests
Client teaching on Calcium carbonate supplement
Give with food.
Monitor kidney stones
Client teaching on Alenodrate sodium (Fosamax), Ibandronate sodium (Boniva), Risedronate (Actonel)
Take with 6-8 oz of water early in am before eating
Remain upright for 30 min
Client teaching Vit D supplements
Watch for S&S of toxicity: nausea, constipation, kidney stone
Client education on Calcitonin
Can be taken IM/SC or nasally
Pt teaching with osteoporosis
- Exposure to vit D (sunlight, fortified milk)
- Encourage weight bearing exercise to improve strength
- Reinforce use of safety measures and assistant device
- Adequate amounts of protein, Mg, K and trace minerals
What are the clinical manifestations of a client with L-sided heart failure?
Dyspnea, othopnea, fatigue, S3 gallop, hypertrophy, pulmonary congestion,( dypnea, cough, bibsalar crackles), frothy sputum(blood tinged), altered mental status, oliguria
Client teaching about topical coritcoidsteroids to a client with contact dermatitis?
Topical corticosteroids triamcinolone acetonide apply but avoid face, folds, and take periodic medication vacations.
Pt teaching on coal tar
- May stain skin and hair
- May stimulate growth of skin cancer
- Apply at night with gloves
What is medication for a client with contact dermatitis is contraindicated for pregnant client?
Tazarotene (Tazorac) caused birth defects
Methotrexate (Mexate)
What to monitor for client taking Methotrexate (Mexate)?
Monitor for fever, sore throat, bleeding, bruising, and fatigue.
Pt exhibits, vomiting, diarrhea, and is having a tap water enema is at risk for.
Hyponatremia
What are the clinical manifestations for a client with hyponatremia?
Hypothermia, tachycardia, rapid thready pulse, hypotension, head ache, confusion, lethargy, muscle weakness and fatigue
Pt with increased gastric motility. hyperactive bowel sounds, and abdominal cramping is at risk for.
Hyponatremia
Client with mOsm of less than 270 mOsm/L
Hyponatremia
Client with CHF and is hyponatremic what would you administer?
Loop diuretics
Ace inhibitors
A pt that has acute hyponatremia, what would the nurse administer?
- Administer hypertonic oral and IV fluids
- Administer 3% NaCl slowly and monitor Na
What would you recommend a pt with hyponatremia in their diet?
Cheese, milk, and condiments
How do you restore normal ECF fluid volume?
- Administer isotonic IV (0.9% NaCl)
- Administer lactated Ringers
What should you tell patient to report to provider who is hyponatremic?
Encourage client to report weight gain of 1-2 lbs in 24 hrs
What to monitor for pt who is hyponatremic
Monitor I&O and weight daily
What are the expected findings for a pt with an eye disorder?
Frequent headaches, eye strain, Blurred vision, poor judgement of depth, diplopia
The tendency to close or favor one eye and poor hand eye coordination may be objective findings for what type of patient?
A patient with an eye disorder
What is the nursing intervention for a client with an eye disorder?
Increase amount of light in the room
What do you provide for a client with an eye disorder?
Magnifying lens and large print books and newspapers
Client education for a patient with eye disorder?
Wear protective sunglasses to protect the eyes
Client education for a patient with eye disorder?
Wash hands before and after eye medication
What foods do you want patient with eye disorder to incorporate in their diet?
Foods rich in antioxidants , such as green leafy vegetables
Client teaching to older clients to prevent eye disorders
Clients 40 years or older should have annual eye checks ups and measurements of IOP
To prevent injury for a client with eye disorder
Arrange the home to remove hazard, such as throw rugs
A pressure monitoring system comprised of catheter with infusion system, a transducer, and a monitor is used to display hemodynamic information.
Arterial Line
What are the components of a hemodynamic monitoring system?
- Pressure transducer
- Pressure tubing
- Monitor
- Pressure bag and flush device
Arterial lines are not used for
intravenous fluid infusion
Where are arterial lines placed?
Radial (most common), brachial, femoral artery
What should be assessed to verify the integrity of arterial waveform?
Blood Pressure readings
How do you monitor the circulation of limbs with arterial line?
Capillary refills, temperature, and color of the limbs
Permit of withdrawal of blood samples can be done through what?
Arterial line
Client presents with tachycardia, bounding pulse, hypertension, tachypnea, increased CVP is in what state?
Client is hypervolemic
Clinical manifestations of hypervolemia
Dyspnea, orthopnea, crackles, diminished breath sounds, edematus, and distended neck veins
Critical lab finding for pt with Hypervolemia
- Hct decreased
- Osmolarity decreased
- Na WNL
A client who is respiratory alkalosis and chest xray reveals possible pulmonary congestion
Pt is at risk for hypervolemia
Causes of hypervolemia
- Chronic stimulus to the kidney to conserver sodium and water
- CHF, cirrhosis, increased glucocorticoids
Nursing implementations for a client who is hypervolemic?
Check ABGs, SaO2, and chest x ray
What position should a pt with hypervolemia be placed in
semi Fowler’s position
What do you want to monitor for a patient with hypervolemia?
Daily weight
I&O
What would you administer for a client with hypervolemia?
-Administer diuretics (osmotic, loop) as prescribed.
A client with hypervolemia should limit
fluid and sodium
What lung sounds would you expect for a client with hypervolemia?
crackles
What do you monitor and document for a pt with hypervolemia?
Presence of edema (pretibial, sacral, periorbital)
Client education for a patient with hypervolemia
-Encourage client to weigh themselves daily,and notify PC if 1 to 2 lb gain in 24 hrs
What diet should a patient with hypervolemia have?
-consume a low sodium diet, read food labels to check for sodium contents
What are the client outcomes for a patient with hypervolemia?
- Client will maintain adequate oxygen level
- Client will be free for anxiety
- Client will be compliant with fluid restriction intake
- Client will consume a low sodium diet
What are the causes for hypovolemia?
-Abnormal GI losses (vomiting, nasogastric sunctioning, diarrhea,) diaphoresis, diuretic therapy, DI, renal disease, adrenal insufficiency
Pt is hyperthermic, tachycardia, thready pulse, hypotension, orthostatic hypotension, decreased CVP is in what state?
Hypovolemic
Pt is dizzy, syncope, confused, and weak, and fatigued, what is the priority nursing intervention?
Administer supplemental oxygen
Pt exhibits increased osm greater than 300 mOsm/L, increased protein, BUN, electrolytes, and glucose. This patient is in what state?
Hypovolemic shock
What fluid replacements would you administer for a patient with hypovelmia?
- Colloids (whole blood, packed RBCs, plasma, synthetic plasma expanders)
- Crystalloids (Ringer’s lactate, normal saline)
What vasconstrictors would you administer to a pt with hypovolemia?
dopamine (Intropin)
norepinephrine (Levophed)
A patient with respiratory acidosis nursing priority intervention.
Oxygen therapy
A patient with respiratory alkalosis nursing priority intervention.
Oxygen therapy
A patient with metabolic acidosis and has DKA nursing priority intervention.
Administer insulin
A patient with metabolic acidosis and has GI disruption what is nursing priority intervention?
Administer antidiarrheal and provide rehydration
A patient with metabolic alkalosis and has GI loses what is nursing priority intervention?
Administer antiemetics and electrolyte replacements
Respiratory acidosis nursing care:
- Oxygen therapy
- Maintain patent airway
- Positioning (enhance gas exchange)
- Breathing techniques
- Ventilatory support
- Bronchodilators
- Mucolytics
Respiratory alkalosis nursing care:
- Oxygen therapy
- anxiety reduction
- rebreathing techniques
Pt exhibits tachycardia, tachypnea, shallow, rapid breathing, pale and is cyanotic is experiencing what acid base imbalance?
Respiratory Acidosis
Pt exhibits tachypnea, anxiety, tetany, tingling, and numbness has rapid deep respirations is experiencing what acid base imbalance?
Respiratory Alkalosis
What clinical manifestations does a client with metabolic acidosis exhibit?
Bradycardia, weak peripheral pulses, hypotension, tachypnea, muscle weakness, flaccid paralysis, fatigue, confusion, Kussmaul respirations.
A client with depressed skeletal muscles resulting in ineffective breathing is in what acid base imbalance state?
Metabolic alkalosis
pH 7.30 PaCO2 50 HCO3 24
Respiratory acidosis
pH 7.47 PaCO2 37 HCO3 21
Metabolic alkalosis
A patient with acid base imbalance is at risk for convulsion, coma, respiratory arrest. What is the priority nursing intervention?
Implement seizure precautions and perform management interventions in necessary .
Clinical manifestations for a client with hyponatremia
headache, tachycardia, confusion, muscle weakness, fatigue, decreased deep tendon reflexes, seizures
What should the nurse administer for a patient with hypernateremia?
hypotonic IV fluids (0.45 NaCl) isotonic IV (0.9% NaCl)
Client education for a client with hypernatremia?
Encourage water intake and discourage sodium intake
Monitor the client’s level of consciousness and ensure safety.
Seizure Precautions
What nursing intervention can decrease thirst?
Provide oral hygiene
What to report to PCP for a client with hypernatremia?
Inadequate renal output less than 30 ml/hr
For a client with acute hypernatremia complications include seizures, convulsions if not treated immediately. What is the priority nursing intervention?
Maintain open airway and monitor clients vital signs
What does the volume (low pressure) alarm indicate in a ventilator?
Low exhale volume due to disconnection, cuff leak, and or tube displacement.
What does pressure (High pressure) alarms indicate in a ventilator?
Excess secretion, client biting the tubing, kinks in the tubing, client coughing, pulmonary edema, bronchospasms, and pneumothorax
What does apnea alarms indicated in a ventilator?
Ventilator does not detect spontaneous respiration in preset time.
What pressure should the cuff pressure be kept to reduce the risk of tracheal necrosis?
20 mm Hg
A client speaking, air hissing, or decreasing Sa O2 may indicate what?
Air leak around the cuff. Inadequate cuff pressure can result in inadequate oxygenation and or accidental extubation.
Clients receiving mechanical ventilation may require sedation or paralytic agents to prevent competition between extrinsic and intrinsic breathing. What are types of sedatives to use?
propofol( Diprivan), diazepam (Valium), lorazepam (Ativan), midazolam (versed_ and haloperidol (Haldol)
How often do you reposition the oral endotracheal tube?
Q24H
How do you assess for adequate nutrition for mechanically ventilated patients?
- Bowel movement q8h
- Monitor bowel habits
- Administer enteral or parental feedings as RX
A client with RR greater than 30, BP changes more than 20% baseline, and SaO2 less than 90%, elevated ST segments, shows signs of what?
Weaning intolerance
Following extubation what should you monitor the client for?
Respiratory distress, airway obstruction such as ineffective cough. dyspnea, and stridor
Older clients have decreased respiratory muscle strength and chest wall compliance which make them susceptible to what.
Aspiration, atelectasis, and pulmonary infection
A client who is on a mechanical ventilator has a risk of increased thoracic pressure which results in what?
Increased Positive Pressure
Monitor for tachycardia, hypotension, urine output less than or equal to 30 ml/hr, cool clammy extremities, decreased peripheral pulses and decreased LOC illustrates:
Hemodynamic compromise
How do you decrease risk of aspiration?
Elevated HOB 30-45 degrees
What are medications used to prevent ulcers in mechanically ventilated patients?
sucrafalate
Histamine 2 blockers
What is the flow rates of T-pieces?
10L/min
What device can be used for clients who have tracheostomies, laryngectomies, or ET?
T-piece
What is the disadvantages of T-pieces?
High humidifications require frequent monitoring
What is the priority nursing interventions for a T-piece?
- Ensure that exhalation port is open and uncovered
- Make sure that the T piece does not pull on the tracheostomy or ET tube
- Ensure that the mist is evident during inspiration and expiration.
What are the signs and symptoms of hypoxemia?
SOB, anxiety, tachypnea, tachycardia, restlessness, pallor, cyanosis of the skin, or mucous membranes, adventitious breathe sounds, confusion
Client exhibits tachypnea, tachycardia, restlessness, pale skin, elevated BP, adventious lung sounds which is representative of early or late findings of hypoxemia?
Early findings
What are late findings of hypoxemia in a client?
Confusion and stupor, cyanotic skin and mucous membranes, bradypnea, bradycardia, hypotension, and cardiac dysrhythmias
What position should the client be to facilitate breathing and promotion of chest expansion?
semi-fowler’s position or fowler’s position
What are the S&S of hypercarbia?
Restlessness, hypertension, and headache
Which symptoms of respiratory depression should be notified to the PCP?
Decreased RR and Decreased LOC
What are the clinical manifestations for a pt experiencing oxygen toxicity?
Nonproductive cough, substernal pain, nasal stuffiness, nausea, vomiting, fatigue, headache, sore throat, and hypoventilation
What is the nursing priority with a pt exhibiting oxygen toxicity.
Use the lowest level of oxygen necessary to maintain and adequate SaO2.
What are the signs and symptoms of hypoxemia?
SOB, anxiety, tachypnea, tachycardia, restlessness, pallor, cyanosis of the skin, or mucous membranes, adventitious breathe sounds, confusion
Client exhibits tachypnea, tachycardia, restlessness, pale skin, elevated BP, adventious lung sounds which is representative of early or late findings of hypoxemia?
Early findings
Nursing actions for a client using oxygen therapy
- Signs to alert others of a fire hazard
- Know where the closest fire extinguisher is located
- Educate clients/family about smoking due to O2 use
- Have the client wear cotton gown, bc synthetic or wool fabrics can generate static electricity
- Ensure that all electric devices (razors, hearing aids, radios) are working
- Ensures electric machinery (monitors, suction machines) well grounded
- Do not use volatile, flammable materials (etOH) near clients receiving O2)
What are the advantages of Positive-pressure ventilators?
- Forced/enhanced lung expansion
- Improved gas exchange (oxygenation)
- Decreased work of breathing
How do you establish method of communication with a patient who is on a mechanical ventilation?
- Asking yes/no questions
- Providing writing materials
- Using dry erase boards
- Picture communication board, or lip reading
Which symptoms of respiratory depression should be notified to the PCP?
Decreased RR and Decreased LOC
What are the clinical manifestations for a pt experiencing oxygen toxicity?
Nonproductive cough, substernal pain, nasal stuffiness, nausea, vomiting, fatigue, headache, sore throat, and hypoventilation
What do you monitor and document in ventilators settings hourly?
- Rate, FiO2, and tidal volume
- Mode of ventilation
- Use of adjuncts (PEEP, CPAP)
- Plateau or peak inspiratory pressure
- Alarm settings
What do you monitor for a client with oxygen induced hypoventilation?
Monitor client’s RR and pattern, LOC, and SaO2
What type of mask should the nurse use for delivery of precise oxygen levels?
Venturi masks
Nursing actions for a client using oxygen therapy
Signs to alert others of a fire hazard
Know where the closest fire extinguisher is located
Educate clients/family about smoking due to O2 use
Have the client wear cotton gown, bc synthetic or wool fabrics can generate static electricity
Ensure that all electric devices (razors, hearing aids, radios) are working
Ensures electric machinery (monitors, suction machines) well grounded
Do not use volatile, flammable materials (etOH) near clients receiving O2)
How do you establish method of communication with a patient who is on a mechanical ventilation?
Asking yes/no questions
Providing writing materials
Using dry erase boards
Picture communication board, or lip reading
What is the priority nursing intervention in a patient on a mechanical ventilator?
Maintain a patent airway
What diet restrictions should a client with Crohn’s disease have?
- Educate client to eat foods high in protein and calories, and low in fiber
- Instruct client to avoid caffeine and alcohol, and take multivitamin that contains iron
A client with a mild case of diverticulitis should be prescribed what by the health care provider?
- Antibiotics
- Analgesics
- Antispasmodics
- Rest
What delivers an FiO2 of 24%-55% at flow rates of 2-10 L/ min via different sized adaptors?
Venturi Mask
A client taking Sulfasalazine (Azulfidine) should be advised to
- Take with food
- Avoid sun exposure
- Increase fluid intake
- Urine and skin may appear yellow or brown
What delivers an FiO2 of 80%-95% at flow rate of 10-15 L/min to keep the reservoir bag 2/3 full during inspiration and expiration?
Nonrebreather mask
What adverse side effects should a client inform the PCP when taking Mesalamine (Asacol, Pentasa, Rowasa)?
Headache or GI problems, such as abdominal discomfort or diarrhea
Clients taking Prednisone (Deta son) for Ulcerative colitis should report what to PCP?
Unexpected weight gain or other signs of fluid retention
What diet restrictions should a client with Crohn’s disease have?
Educate client to eat foods high in protein and calories, and low in fiber
Instruct client to avoid caffeine and alcohol, and take multivitamin that contains iron
A client with a mild case of diverticulitis should be prescribed what by the health care provider?
Antibiotics
Analgesics
Antispasmodics
Rest
What type of diet is appropriate for a client with diverticulitis?
Limited to clear liquids initially but may progress to a high fiber, low fat diet.
A client taking Sulfasalazine (Azulfidine) should be advised to
Take with food
Avoid sun exposure
Increase fluid intake
Urine and skin may appear yellow or brown
A client taking Olsalzine (Dipentum) is intolerant to sulfaszlazine and should report what to the PCP?
Sore throat, rash, bruising, and or fever
Clients taking Prednisone (Deta son) for Ulcerative colitis should report what to PCP?
Unexexpected weithg gain or other signs of fluid retention
Client teaching for use of Budesonide (Entocort)?
Avoid crowds and other exposures to infectious disease
A client with IBS taking Cyclosporine (Sandimmune) and methotrexate (Rheumatrex) should monitor for?
Bleeding, bruising, or infection
Client education on levothyroxine (Synthroid)
- Tx begins slowly and dosage is increased 2-3 weeks
- Serum TSH labs will be drawn at sched times to ensure appropriate dosage
- Monitor for and report signs and symptoms of hyperthyroidism ( irritability, tremors, tachycardia, and palpitations, heat intolerance)
- Inform client that tx is lifelong requiring medical assessment of thyroid function
Client with myxedema coma will exhibit:
- Significantly depressed respirations
- Decreased CO
- Worsening cerebral hypoxia
- Stupor
- Hypothermia
- Bradycardia
- Hypotension
- Hypoglycemia
- Hyponatremia
What do you observer the client for when taking Diphenoxylate hydrochloride and atropine (Lomotil)
Respiratory depression
Decreased T3, Elevated TSH with primary, Decreased T4, Elevated cholesterol, CBC showing anemia are lab findings for?
Hypothyroidism
What is the treatment of choice for a client with hypothyroidism?
Thyroid hormone replacement therapy levothyroxine (Synthroid)
levothyroxine (Synthroid) effects of warfarin
It increases effects of warfarin (Coumadin) and can increase the need for insulin and digoxin (Lanoxin)
Nursing Actions for preprocedure to a client receiving hemodialysis:
- Assess patency of access site (presence of bruit, palpable thrill, distal pulses, and circulation
- Avoid taking BP, administering injections, or venipunctures on arm with access site
- Assess VS, lab values (BUN, creatine, electrolyte, Hct) weight
Client with myxedema coma will exhibit:
Significantly depressed respirations Decreased CO Worsening cerebral hypoxia Stupor Hypothermia Bradycardia Hypotension Hypoglycemia Hyponatremia
What is the priority nursing intervention to a client with myxedema coma?
Maintenance of airway patency with ventilatory support if necessary
What is the client outcome for a client taking a Synthroid?
The client’s TSH will return to the expected reference range.
What complication is the client at risk for using hemodialysis?
Clotting and infection of access site
What is the priority nursing intervention for a client receiving hemodialysis?
Use surgical aseptic technique during cannulation
Client education after dialysis procedure?
- Avoid lifting heavy objects with access site arm
- Avoid carrying objects that compress the extremity
- Avoid sleeping on top to the extremity with access device
- Perform hand exercises that promote fistula maturation
What types of medications are witheld until after dialysis?
Medications that lower BP
Client experiencing hypotension during dialysis, what is the priority nursing intervention?
Carefully replace fluid volume with transfusion of IV fluids or colloids as Rx. and then slow dialysis exchange rate then lower head of bed
FOR SEVER Hypotension: D/C dialysis
A client with anemia who is receiving dialysis, nursing intervention:
- Administer Rx med therapy (erythropoetin)
- Monitor Hgb, and RBC levels
- Monitor of hypotension and tachycardia
After dialysis what would you expect a decrease in?
Decreases in BP, weight, and lab values
What complications should the nurse assess for after dialysis?
Hypotension, clotting of vascular access, headache, muscle cramps, bleeding
What is the preventative measure the nurse will use for a client with an bloodborne disease?
Use standard precautions
A peritoneal dialysis (PD) is used for
A client requiring dialysis and are unable to tolerate anticoagulation, or have difficulty with vascular access
Client experiencing hypotension during dialysis, what is the priority nursing intervention?
Carefully replace fluid volume with transfusion of IV fluids or colloids as Rx. and then slow dialysis exchange rate then lower head of bed
FOR SEVER Hypotension: D/C dialysis
How long is continuously ambulatory peritoneal dialysis (CAPD) done?
7 days a week for 4 to 8 hrs
What is the client teaching on a pt’s diet who is anemic and receiving hemodialysis?
Educate client to eat foods high in folate (beans, green veggies)
A client who has frequent blood transfusions and frequent blood access due to hemodialysis are at risk for?
Transmission of blood borne disease such as HIV and hep B and hep C
A peritoneal dialysis is used for
A client requiring dialysis and are unable to tolerate anticoagulation, or have difficulty with vascular access
Signs of infection and complications for a client receiving PD?
Infection: fever, blood, cloudy, or frothy dialysate return; drainage at access site
Complications: respiratory distress, abdominal pain, insufficient blood flow, discolored outflow
What is the priority nursing interventions for a client receiving PD?
Monitor client’s VS frequently during initial dialysis in a hospital setting
What lab value will you be monitoring for a client during PD?
serum glucose level
What will the nurse record while a client is receiving a PD?
Record the amount of inflow compared to outflow of dialysate
Signs of infection and complications for a client receiving PD?
Infection: fever, blood, cloudy, or frothy dialysate return; drainage at access site
Complications: respiratory distress, abdominal pain, insufficient blood flow, discolored outflow
How do you prevent reflux of a client receiving PD?
Keep the outflow bag lower than the client’s abdomen
Post procedure for a client receiving PD, nursing actions:
Monitor weight, serum electrolytes, creatine, BUN, and blood glucose
What to teach client for home care of access site (PD)?
Instruct the client and family how to perform peritoneal dialysis with home visits and support groups
A client that is receiving PD may allow microorganisms into the peritoneum and cause what?
Peritonitis
What is the nursing actions for a client at risk for peritonitis?
Maintain surgical asepsis during procedure
Monitor for infection: fever, purulent drainage, redness or swelling, and cloudy or discolored drained dialysate
What should you educate the client about to prevent peritonitis?
Educate the client to use sterile asepsis during procedure
What do you want to assess for in the access site to prevent infection?
Assess site for wetness from a leaking catheter
Purulent drainage, redness or swelling
For protein loss in a client receiving PD what lab value do you want to monitor?
serum albumin
What do you want to teach the client with protein loss during peritoneal dialysis?
Instruct client to follow recommended renal diet with an increase in dietary protein
If the tubing is obstructed or twisted causing a decrease in flow what should the nurse do?
- Reposition the client if inflow or outflow is inadequate
- Milk tubing to break fibrin clots
- Check tubing for kinks or closed clamps
- Tell the client to avoid constipation by using stool softeners and consuming a diet high fiber
What lab value will you monitor for if patient is at risk for hyperglycemia?
Glucose
What would the nurse administer when hyperglycemia is suspected?
Administer insulin for glycemic control
A client with hyperglycemia should be instructed to:
Instruct pt to check serum glucose
A client with increased AST aspartate amniotransferase (5-40 u/L) and ALT alanine aminotransferase (8-20 u/L)
Elevated AST and ALT occurs with hepatitis or cirrhosis
What is the function of dialysis?
Rids the body of excess fluids and electrolytes
Achieves acid base balance
Eliminates waste products
Restores internal homeostasis by osmosis , diffusion, and ultrafiltration
What is disequilibrium syndrome?
DS is caused by too rapid a decrease in BUN and circulating fluid volume. It may cause cerebral edema and increased ICP
What is the nursing intervention for a client experiencing disequilibrium syndrome (nausea, vomiting, change in LOC, seizures, and agitation)?
Use a slow dialysis exchange rate
Administer anticonvulsants/ barbiturates if needed
A client with increased ALP alkaline phosphatase (42-128 u/L)
Elevated ALP indicates liver damage
A client with elevated Amylase (56-90 IU/L), Lipase (0-110 u/L)
Elevated amylase and lipase indicate pancreatitis
A client presents with GI bleeding and unexplained diarrhea and is positive for c.diff is indicative of an opportunistic infection. What is the client education for this pt?
Instruct client about proper collection of stool sampling using a card or a collection cup. The client may be instructed to restrictions before collecting ( red meat, anticoagulants)
Client with decreased albumin ( 3.5-5.0 g/dL)
Decreased albumin indicate hepatic disease
Client with elevated AFP Alpha fetoprotein ( <40 mcg/L) and Ammonia ( 15-110 mg/dL)
Elevated AFP and ammonia found in liver cancer
What diagnostic procedure is used for visualization of the oropharynx, esophagus, stomach and duodenum?
Esophagogastroduodenoscopy
What medications restrictions should the patient follow before having an endoscopy procedure?
NSAIDs, warfarin, aspirin
Client presents with anemia secondary to bleeding, abdominal discomfort, and abdominal distention. What is the nursing action for this patient to have an endoscopy done?
Evaluate the client’s understanding of the procedure
What do you want to ensure the client be prior to most endoscopic examinations?
Client needs to be NPO for 6-8 hrs prior to endoscopic examinations
A client having a colonscopy should be in what position?
Left side with knees to chest
What type of anesthesia should the pt receive before a colonoscopy?
Moderate sedation: midazolam (Versed) usually given with an opiate analgesic
A client that may need laxatives such as bisacodyl (Dulcolax), clear liquid diet, NPO after midnight, will be having what procedure done?
Colonscopy
What would monitor for after a colonoscopy procedure?
Monitor for rectal bleeding
Encourage plenty of fluids
Monitor VS esp, respiratory status
Instruct client that there may be increased flatulence
What position will the pt be lying during an EGD?
left side lying
What type of sedation will the client with an EGD be administered?
Moderate sedation
topical anesthetic
Preparation for this procedure includes NPO 6-8 hrs; removal of dentures
EGD
When performing an EGD advise client to notify PCP when what occurs?
Notify PCP of bleeding, abdominal or chest pain, and any evidence of bleeding
A client receiving a conscious sedation such as a topical anesthetic and initally semi prone with repositioning throughout the which procedure?
ERCP
When performing EGD when can you give fluids?
When gag reflex returns
How is a client receiving a sigmoidoscopy is positioned?
on left side
What complications is a pt at risk for during moderate sedation?
Oversedation
Difficulty arousing the client, poor respiratory effort, evidence of hypoxemia, tachycardia, and elevated or low BP indicate?
Oversedation
What is the nurse’s priority intervention with a client who is oversedated?
Prepare to administer antidotes to the sedatives
Maintain an open airway
administer oxygen
and monitor VS
Symptoms of hemorrhage
bleeding, cool, clammy skin, hypotension, tachycardia, dizziness, and tachypnea
What labs should the nurse monitor after a hemorrhage?
Hgb and Hct
What should the client report to the PCP after a hemorrhage occurs?
Report fever, pain, and bleeding
After any procedure using moderate sedation that affects the gag reflex places the clients at risk for?
aspiration
What is the nursing action for a client at risk for aspiration?
The client should be NPO until the gag reflex returns
A client with potential diagnosis of gastric ulcers, peristaltic disorders, tumors, varices and intestinal enlargements may have what type of study done?
Gastrointestinal studies with barium
Pre procedure Gastrointestinal study
Inform client about medications, food and fluid restrictions (NPO after midnight) and avoid smoking or chewing gum (increases peristalsis)
When do you schedule barium enema studies?
Barium enema studies must be scheduled prior to upper gastrointestinal studies
Client education before GI studies?
Tell the client to restrict food and fluids for bowel preparations
What do you monitor after the GI study procedure?
Monitor elimination of contrast material and administer a laxative if Rx
Force fluids to promote elimination of contrast material
Why are clients receiving chemotherapy immunocompromised?
Immunosupression is due to bone marrow suppression by cytotoxic medications
What lab value do you want to monitor for a client who is immunocompromised?
WBC
If a client’s WBC drops below 1,000 mm3 what precaution should be initiated?
Neutropenic Precautions
- Place client in a private room
- Place a mask on pt if he needs to be transported
- Protect the client form possible sources of infection (plants, visitor restriction), water equipment changed daily
What is a primary prevention that client, staff, and visitors can do to prevent spread of infection?
Perform frequent hand hygiene
What colony stimulating factors stimulates WBC production?
filgrastim (Neupogen, Neulasta)
Client education for a pt that is immunocompromised
- Avoid crowds whil undergoing chemotherapy
- Avoid eating fresh fruits and veggies
- Avoid yard work, gardening or changing a pet’s litter box
- Avoid fluids sitting at room temp for greater than 1 hr
- Wash toothbrush daily in dishwasher or rinse with bleach
- Report fever >37.8 C
A client undergoing chemotherapy is experiencing vomiting, what should the nurse do first?
Give the client antiemetic medications at times that are appropriate, prior to tx, during tx, and after tx
What would you administer to increase appetite for a client undergoing chemotherapy?
megestrol (Megace)
How can you promote adequate nutritional intake to client undergoing chemotherapy?
Provide liquid supplements as needed, add protein powders to food or tube feedings
What technique may be useful adjuncts to antiemetics?
Visual imagery and relaxation techniques
How do you enhance the client’s appetite?
Perform mouth care prior to serving meals
What type of diet is suggested for a client who is going through chemotherapy and has nausea and vomiting?
Encourage consumption of high protein, high calorie, nutrient dense foods and avoidance of low or empty calorie foods
What would you suggest to a client with a metallic taste in the mouth?
Encourage use of plastic eating utensils, sucking on hard candy, and avoidance of red meats
What is the nursing intervention for a client with alopecia?
Discuss the impact of alopecia on self image. Discuss options such as hat, turbans, and wigs to deal with hair loss
After hair loss client education:
Client should protect the scalp form the sun and can cause diaper rash ointment/ cream itching
Mucositis
also known as stomatitis is an inflammation of tissues in the mouth, such as the gums, tongue, roof and floor of the mouth, and inside the lips and cheeks.
What is the nursing action for a client with mucositis?
- Examine the client’s mouth several times a day
- Document the location and sz of lesions
- Avoid using glycerine-based mouthwashes or mouth swabs
- Administer a topical anesthetic prior to meals
- Discourage selection of salty, acidic, or spicy foods on the menu
- Offer mouth care before and after each meal
Client education for a client with mucositis
- Encourage client to rinse mouth with a soln: half 0.9%NaCl and half peroxide at least 2 times a day
- Brush teeth using soft bristles
- Encourage consumption of soft foods (mashed potatoes, scrambled eggs, cooked cereal) or ice cream, bananas, milk shakes
Anemia
Decreased number of circulating RBC
Thrombocytopenia
Decreased number of circulating platelets
Symptoms of Anemia
Fatigue, pallor, dizziness, and SOB
Symptoms of Thrombocytopenia
Petechiae, ecchymosis, bleeding of the gums, nosebleed, occult or frank blood in stools, urine, vomit
Nursing intervention for anemia induced fatigue
Schedule activities with rest periods in between and using energy saving measures (sitting during showering)
What erythropoeitic medications should be administered to a client who is anemic?
erythropoeitn alfa (Epogen) ferrous sulfal (Feosol)
How do you evaluate the effectiveness of the erythropoetitic medications?
Hgb to determine response to medications
What medications should you administer to a client who is thrombopoietic?
oprelvekin (Interleukin 11, Neumega)
What should you instruct the client who has anemia or thrombocytopenia?
- Use an electric razor instead of a razor blade when shaving
- Use soft bristled toothbrush
- Blow nose only when necessary
- Wear shoes when ambulating
- Avoid the use of NSAIDs
Upon receiving a client, the nurse should immediately perform full body assessment giving priority to:
Airway, breathing, and circulation
What to do if wound dehiscence or evisceration occurs?
- Call for help
- Stay with the client
- Cover the wound with sterile towel or dressing that is moist with sterile saline
- Monitor the client for shock
- Notify health care immediately
A client with incision and drain sites should be monitored for:
redness, excessive tenderness, and purulent drainage
What to instruct client after a CABG?
- Avoid strenuous exercise
- Immediately report bleeding from insertion site, chest pain SOB, changes in color or temp of the extremity
- Restrict lifting (<10 lbs) for the prescribed period of time
What to lifestyle changes to instruct client to follow after CABG?
- Manage weight
- Consume a low fat/ low cholesterol diet
- Exercise regularly
- Stop smoking
- Decrease etoh intake
What are signs of complications in a client under hemodialysis?
Hypotension, clotting of vascular access, headache, muscle cramps, bleeding
What to instruct a client who will be having a hysterectomy before procedure?
Maintain NPP
Ensure that informed consent was obtained
After a hysterectomy client should be monitored for vaginal bleeding. What is excess bleeding?
Excess bleeding is more than one saturated pad in 4 hr
After hysterectomy, monitor the client’s VS
VS: fever and hypotension
After hysterectomy, monitor the clients breath sounds
Risk of atelactisis
Turn, cough and deep breath, encourage the use of IS and ambulation
After hysterectomy, monitor bowel sounds
Client at risk for paralytic ileus
After hysterectomy, monitor the clients urine output
Call PCP if less than 30 ml/hr
After hysterectomy, provide IV fluid and electrolyte replacement
Until bowel sounds reture
After hysterectomy, monitor client’s incision site
At risk for infection, look at integrity, and risk of dehiscence
After hysterectomy, monitor client for signs of thrombophlebtitis
warmth, tenderness, and edema will be presesnt
Take thromboembolism precautions
ie: sequential compression devices, ambulation
Client education after hysterectomy
-Instruct the client about a well balanced diet that is high in protein and vit C and high in iron
Psychological reaction to a hysterectomy; nursing action
- Encourage the client to discuss positive aspects of life
- Understand that occasional sadness in the client is normal, but persistent sadness indicates need for counseling assistance
What is a positive Kernig’s sign?
Resistance and pain with extension of the client’s leg from a flexed position
What are findings including in compartment syndrome?
- Increased pain unrelieved with elevation
- Intense pain when passively moved
- Paresthesia or numbness
- Color of tissue is pale (pallor)
What are clinical manifestations of a fat embolism?
- Decreased mental acuity
- Respiratory distress
- Tachycardia
- Tachypnea
- Fever
- Cutaneous petechia (found in the neck, chest, upper arms, and abdomen)
What are S&S of osteomyelitis?
- Bone pain that is worst with movement
- Erythemia and edema
- Fever
- Leukocytosis
Nursing Care for PE (pulmonary embolism)
- Administer oxygen
- Initiate and maintain IV access
- Administer anticoagulants
- Provide emotional support and comfort to control client anxiety
- Monitor changes of LOC
Client education for treatment and prevention of PE:
- Promote smoking cessation
- Encourage the client to avoid long periods of immobility
- Encourage physical activity such as walking
- Encourage the client to avoid crossing legs
What lab findings is indicative of Cushing disease?
Elevated plasma cortisol level in the absence of acute illness or stress
Cushing’s disease lab findings:
Hypersecretion of ACTH by anterior pituitary
- K and Ca decreased
- Glucose increased
- Na increased
- Lymphocytes decreased
Nursing Actions for Phantom Limb Pain
- Recognize the pain is real and manage accordingly
- Described as deep, burning, cramping, shooting or aching
How do you prevent flexion contractures?
- ROM exercises and proper positioning
- Avoid elevating the stump on a pillow after the first 24 hours
- Have the client lie prone several times a day
- Discourage prolonged sitting
What type of medications do you treat phantom limb with?
Beta blockers such as propranolol (inderal) and antiepileptics such as gabapentin (Neurontin)
Complications of intestinal obstruction include dehydration and electrolyte imbalance. What should you notify to PCP?
Hct, BUN, orthostatic vital signs, urine ouput, and specific gravity
(Assessment of hydration)
Monitor client for fluid and electrolyte imbalance in a client with a nasogastric decompression procedure.
Metabolic acidosis: low obstruction
Metabolic alkalosis: high obstruction
What are the laboratory findings for a client with Graves?
TSH decreased
FTI and T3 elevated
Thyrotropin releasing hormone (TRH) stimulation test: failure of expected rise in TSH
What are the signs of digoxin toxicity?
Fatigue, muscle weakness, confusion, and loss of appetite
Client education for pt self administering digoxin:
Count pulse fro 1 min before taking meds. 60-100
Take digoxin at same time ea day
Do not take with antacids
Check digoxin and potassium levels regularly
LAB VALUES EXPECTED REF
Na 136-145 K 3.5-5.0 Cl 98-106 Ca 9.0-10.5 Mg 1.3-2.1 Ph 3.5-4.5
How do you position a pt before a thoracentesis?
Position the client sitting upright with his arms and shoulders raised and supported on pillows and or on an overbed table and with his feet and legs well supported
Results for a Mantoux test shows and induration (palpable, raised, hardened area) of 10 mm or greater in diameter
Positive skin test for TB
An induration of 5 mm is considered what in the Mantoux test?
Positive test for immunocompromised clients
After a liver biopsy how should the client position themselves?
Instruct client to lie on affected side after the biopsy in order for hemostasis to occur
Clinical manifestations of Hep B
Headache, fatigue, arthalgia and myalgia, pruritus, low grade fever, RUQ pain, nausea, vomiting, jaundice, dark urine
What is pain?
Pain is whatever the person experiencing it says it is and it exists whenever the person says it does
Client education on Oxycodone
- Use medication as directed
- Prevent constipation with diet changes and stool softeners
- Be aware that nausea may subside within a few days
Hormonal contraceptives
May be decrease symptoms of PMS and PMDD
May be initial tx for endometriosis
Leuporlide (Lupron)
Can cause birth defects so a reliable form of contraception is advised
May cause decease in libido and increase risk of osteoporosis
Hormone replacement therapy (HRT)
Should not be taken during pregnancy Smoking Hx of Cancer (breast, uterus) Abnormal vaginal bleeding Embolism Stroke Heart disease HTN
Clients with stent placement will receive anticoagulation therapy 6-8 weeks. Client instructions:
Take the medication at the same time each day
Have regular lab tests to determine therapuetic level
Avoid activities that could cause bleeding (use a soft toothbrush, wear shoes when out of bed)
Medication Administration : IV
- Apply a clean tourniquet or BP cuff 4-6 in above the proposed insertion site
- Untie the tourniquet, cleanse the area at the site in a circular motion inward to outward
- Remove the cover from catheter, grasp the plastic hub
- Retie the tourniquet
- Anchor the vein below the site of insertion
- Pull the skin taut and hold it
- Insert the the catheter maintaining a 10-30 angle. flashback of blood
- Lower the hub of the catheter close to the skin
- Advance the catheter into the vein
- Stabilize the IV catheter
- Apply pressure 1 1/4 inch above the insertion site
- Remove the needle and activate safety device.
- Dispose of used equipment
- Document
Medication to control HTN; Thiazide diuretics such as hydrochlorothiazide (Hydrodiuril) side effects
Monitor for hypokalemia watch for muscle weakness, irregular pulse and dehydration
Calcium channel blocker, verapamil hydrochloride (Calan) dilitiazem (Cardizem)
Monitor for hypotension
ACE inhibitor S/E
Monitor for hypotension
Beta blockers such as metoprolol (Lopressor) and atenolol (Tenormin) adverse S/E
These medications can mask hypoglycemia in clients who have DM
Central alpha agonists such as clonidine (Catapres) S/E
S/E include sedation, orthostatic hypotension,and impotence
Alpha adrenergic antagonists such as prazosin (Minipress) S/E
S/E include postural hypotension
What is the therapeutic effects of Furosemide (Lasix)?
Diuretics are used to decrease preload. Promote fluid excretion
Propranolol (Inderal)
Beta adrenergic blocker- Treats sympathetic nervous system nervous system effects (tachycardia, palipations)
What to do if there is a shortage of TPN solution?
Keep dextrose 10% in water at the bed side in case solution is unexpectedly ruined or a new bag is not available.
Nursing Actions for fluid overload in a client receiving hyperosmotic solution
- Assess the client’s lung sounds for crackles
- Monitor clients daily weights and I&O
- Use a controlled infusion pump to administer TPN at a prescribed rate
- Gradually increase the flow rate until prescribed infusion rate is achieved
Client on TPN monitor BS
Check cap glucose every 4-6 hrs for the first 24 hrs.
Need supplemental insulin until pancreas can increase its endogenous production of insulin
A client with hypokalemia
Report abnormal findings to the PCP
Replace K
Encourage foods hight in K (avocados, broccoli, dairy products, dried fruits, cantaloup, bananas)
IV K supplement
Never IV bolus=cardiac arrest
Max: 5-10 mEq/hr
Client with hypokalemia (what to monitor)
Monitor for adequate urine output
Monitor clients receiving digoxin (Lanoxin) hypokalemia increased digoxin toxicity
Monitor Bowel sounds, and abdominal distention
Monitor kidney f(x) (BUN, creatine, GFR)
Monitor Mg, Ca, Phosphorus
ECG for client with hypokalemia
PVC, bradycardia, blocks, v tachy, inverted T waves and ST depression
Client with DM who has impaired vision and blindness
Encourage yearly eye exams to ensure the health of the eyes and to protect vision
Encourage management of Blood glucose levels
Insulin lispro (Humalog) Rapid acting
Onset: less than 15 min
Peak: 0.5-1 hr
Duration:3-4 hr
Regular Insulin (Humulin R) Short acting
Onset: 0.5-1 hr
Peak: 2-3 hr
Duration:5-7 hr
NPH insulin (Humulin N) intermediate acting
Onset: 1-2 hr
Peak: 4-12 hr
Duration: 18-24 hr
insulin glargine (Lantus) Long acting
Onset: 1 hr
Peak: none
Duration: 10.4-24 hr
A nurse is instructing a person who had a left CVA and right lower extremity hemiparesis to use a quad cane. Which of the following is the most appropriate gait sequence?
Place the cane in the patient’s left upper extremity, encourage cane, then right lower extremity, then left upper extremity gait sequence.
What are the dietary guidelines for bariatric surgery?
Provide 6 small meals a day when the client can resume intake. Observe for signs of dumping syndrome (cramps, diarrhea, tachycardia, dizziness, and fatigue). The client’s first feeding may only consist of 30 mL of liquid.
What type of diet should a patient with heart failure have?
Low sodium diet and fluid restrictions
Nontunneled percutaneous central catheter
Indications – Administration of blood, long-term administration of chemotherapeutic agents, antibiotics, and total parenteral nutrition
Insertion location – Subclavian vein, jugular vein; tip in the distal third of the superior vena cava
Peripherally inserted central catheter
Indications – Administration of blood, long-term administration of chemotherapeutic agents, antibiotics, and total parenteral nutrition
Insertion location – Basilic or cephalic vein at least one finger’s breadth below or above the antecubital fossa; the catheter should be advanced until the tip is positioned in the lower one-third of the superior vena cava.
angina
Precipitated by exertion or stress
Relieved by rest or nitroglycerin
Symptoms last < 15 min
Not associated with nausea, epigastric distress, dyspnea, anxiety, diaphoresis
MI
Can occur without cause, often in the morning after rest
Relieved only by opioids
Symptoms last > 30 min
Associated with nausea, epigastric distress, dyspnea, anxiety, diaphoresis
