NU 301 exam 3 Flashcards
You notice a respiratory change in your immobilized postoperative patient. The change you note is most consistent with:
atelectasis
Metabolic NI for an immobilized pt
-high protein, high calorie diet with vitamins B & C
-may need enteral feedings
-assess likes and dislikes
-may need to feed the patient
Respiratory NI for an immobilized pt
-TCDB
-prevention of atelectasis/ pneumonia
-incentive spirometer
-PO hydration
CV NI for an immobilized pt
-TEDs/SCDs
-dangle legs prior to standing
-ambulate
-heparin/ lovenox
-ROM exercises (active and passive
Musculoskeletal NI for an immobilized pt
-assess for muscle atrophy
-ROM exercises (active and passive)
-appropriate diet
Urinary and bowel NI for an immobilized pt
-I&O every 24 hours
-be sure the pt is receiving the right amount and method of fluid (IV or PO)
-assess urine color and consistency
-assess bowel sounds, abdominal distention, and bowel patterns for consistency and frequency
What are the complications of being immobile?
-muscular deconditioning (disuse atrophy, physiological, psychosocial, social)
-endocrine metabolism (decreased appetite/ calorie intake, increased risk of elec imbalances)
-calcium resorption (increased risk of bone fracture)
-GI (constipation, pseudodiarrhea)
-respiratory changes (atelectasis, hypostatic pneumonia)
-CV (ortho hypotension, increased cardiac workload/ o2 consumption, risk of thrombus formation)
-musculoskeletal (joint contractures, disuse osteoporosis)
-urinary elimination (stasis, renal calculi)
-integumentary (pressure ulcers)
-psychosocial effects (depression, sensory alterations)
What are the common patient positions?
Fowler’s, high Fowler’s, semi Fowler’s, supine, prone, lateral, Sim’s, Trendelenburg, reverse Trendelenburg, dorsal recumbent
How to set up a pt with a cane for the first time?
-with pt standing, place cane 4 inches away from side of foot
-top of cane should reach top of hip joint
-want arm flexed about 30 degrees when holding the cane
-use: hold cane on unaffected side, injured leg moves with the cane
-keep cane on stronger side of body
-place cane forward 6-10 inches keeping body weight on BOTH legs
-weaker leg is moved forward, divide weight between cane and stronger leg
-stronger leg is advanced past cane, divide weight between cane and weaker leg
How to set up a pt with a set of crutches for the first time?
-2,3,4 point gait
-stairs= foot first when going up and crutch first when going down
-gradually shift weight to healthy leg
-move crutches in front then shift weight from healthy leg to arms and swing body thru
-NEVER support with armpits
A nurse is teaching a client with left leg weakness to walk with a cane. What teaching points should the nurse include?
-hold cane on uninvolved side of body
-handle should be at hip bone
-avoid leaning on cane to get in and out of a chair
-leg stride should be equal on involved and uninvolved side
A pt with a long standing hx of DM is voicing concerns about kidney disease. Pt asks the nurse where urine is formed in the kidney. The nurse responds:
nephron
What is the desired hourly urinary output for an adult?
30-60 mL/ hour so 720-1440 mL/ day
What intervention is most important for the nurse to implement for a male client who is experiencing urinary retention?
Assess for bladder distention
A health care provider may suspect that a client is experiencing urinary retention when the client has:
small amounts of urine voided 2-3 times per hour
A young girl is having problems urinating postoperatively. You remember children may have trouble urinating:
in the presence of a person that is not their parent
Nutrition for promotion of healing?
proper nutrition provides energy, tissue maintenance, repair, organ function, growth & development, physical activity
Carbs
energy and fiber-1 g
4kcal, provides glucose that burns out with no products of excretion; whole grains, baked potatoes, brown rice, plant food
Fats
energy and vitamins-35% caloric intake from fats
1g=9kcal, olive oil, salmon, egg yolks
Proteins
growth, maintenance, tissue repair, 1g=4kcal, complete proteins include beef, whole milk, poultry
Vitamins
metabolism, FAT= A,D,E,K & WATER= C,B complex (8)
minerals
essential biochemical reactions (Ca, K, Na, Fe)
water
cell function, replaces fluids lost from perspiration, elimination, and respiration
MNT
Medical nutrition therapy
nutrition based treatment that follows evaluation of patient’s nutrition status
What are the S/S of malnutrition?
- Appearance: easily fatigued, listless
- Weight: over/under
- Skin:
dry, flaky, scaly, pale or pigmented, petechiae/bruising, lack of subcu fat, edema - Nails:
brittle, pale, ridged, spoon-shaped (iron) - Hair:
dry, dull, sparse, loss of color, brittle - Eyes:
pale or red, dry, soft/dull cornea, night blindness (Vit A deficient) - Lips:
swollen, red cracks at the side, vertical fissures - Tongue:
swollen, red/magenta colored or smooth (B Vit related), change in size - Gums:
spongy, swollen, inflamed, bleed easy (Vit C deficient) - Muscles:
underdeveloped, flaccid, wasted, soft - GI:
anorexia, indigestion, diarrhea, constipation, enlarged liver, protruding abdomen - Nervous System:
decreased reflexes, sensory loss, burning/tingling of hands/feed (Vit B related), mental confusion/irritability
What is diet progression?
A change in diet as a patient’s food tolerance improves
clear liquid diet consists of…
You can eat or drink only things you can see through. Plain water, clear fruit juices without pulp, soup broth/bouillon, clear sodas, tea or coffee with no cream or milk added, gelatin, popsicles, or sports drinks. Patients are started on a clear liquid diet typically after surgery. Anesthetic agents and opioid medication along with being NPO before surgery causes peristalsis to slow and delays gastric emptying, which leads to nausea and vomiting. Once bowel sounds return, a clear liquid diet is started.
full liquid diet consists of…
As peristalsis improves, the diet can be advanced to a full liquid. A full liquid diet adds to the clear liquid diet with the addition of smooth-textured dairy products, strained or blended cream soups, custards, refined cooked cereals, vegetable juice, pureed vegetables, all fruit juices, sherbets, puddings, and frozen yogurt.
pureed diet consists of..
A pureed diet allows for the addition of items such as pureed meats, vegetables, and fruits, or mashed potatoes and gravy. Used with patients that have dysphagia or for patients that need to conserve energy while eating.
mechanical soft diet consists of..
A mechanical soft diet allows for everything included in a clear liquid, full liquid and pureed diet with the addition of items such as cream soups, ground or finely diced meats, flaked fish, rice, potatoes, light breads, cooked vegetables, cooked or canned fruits, peanut butter, and cottage cheese. This diet can also be issued for patients with dysphagia.
low residue diet
Residue refers to the food that does not digest in the GI tract, primarily fiber. In a low residue or low fiber diet, the stool bulk is reduced. This diet is used in patients with Crohn’s disease, ulcerative colitis, or diverticulitis. It includes easily digested foods such as pastas, moist tender meats, and canned cooked fruits and vegetables, and desserts, cakes, and cookies without nuts or coconut.
high fiber diet
High fiber diets can be used to regulate the GI tract and help in normal elimination patterns. The majority of the fiber that is ingested does not digest and pulls water into the GI tract. High fiber foods include items such as uncooked or dried fruit, steamed vegetables, bran, and oatmeal.
regular diet
A regular diet is one with no restrictions, unless specified.
TPN
total parenteral nutrition
What are some safety guidelines for tube feedings?
Wear gloves when handling feeding tubes and avoid touching can tops, container openings, spikes and spike ports. Label equipment: Labels should include the patient’s name and room number, the formula type and rate, the date and time of administration and the nurse’s initials.
NGT
A special tube that carries food and medicine to the stomach through the nose
Colostomy care
Keep the patient as free of odors as possible; empty the appliance frequently.
Inspect the patient’s stoma regularly.
Note the size, which should stabilize within 6 to 8 weeks.
Keep the skin around the stoma site clean and dry.
Measure the patient’s fluid intake and output.
Explain each aspect of care to the patient and self-care role.
Encourage patient to care for and look at ostomy.
General anesthesia complications?
-aspiration of vomitus
-cardiac irregularities
-decreased cardiac output
-hypotension
-hypothermia
-hypoxemia
-laryngospasm
-malignant hyperthermia
-nephrotoxicity
-respiratory depression
Sore throat
Nausea and vomiting
Damage to teeth
Lacerations (cuts) to the lips, tongue, gums, throat
Nerve injury secondary to body positioning
Awareness under anesthesia
Anaphylaxis or allergic reaction
Malignant hyperthermia
Aspiration pneumonitis
Respiratory depression
Stroke
Hypoxic brain injury
Embolic event
Cardiovascular collapse, cardiac arrest
Death
What is malignant hyperthermia?
life threatening complication of anesthesia
-hypermetabolic state occurring within skeletal muscle cells that become triggered by anesthesia
-it results in an increase in intracellular calcium ion concentration
-potentially lethal that can occur in pts receiving inhaled anesthetic agents and succinylcholine
-results in high carbon dioxide levels, metabolic and respiratory acidosis, increased oxygen consumption, production of heat, activation of sympathetic nervous system, high serum potassium levels, and multiple organ dysfunction and failure
What are the early signs of malignant hyperthermia?
tachypnea, tachycardia, heart arrhythmias, hyperkalemia, hypercarbia, and muscular rigidity
What are the late signs of malignant hyperthermia?
elevated temp, myoglobinuria, multiple organ failure
When does MH typically present itself during surgery?
in the OR, during induction of anesthesia most often
however, MH may also occur in the early postop period or after repeated exposures to anesthesia
What is included in the care of a post op pt?
-conduct an assessment: neuro, skin integrity, wound condition, metabolism, genitourinary function, GI function(mobility), comfort, sleep
review orders from provider about pt care
Whose responsibility is it to obtain informed consent?
Surgeon, physician
What is informed consent?
permission granted in the knowledge of the possible consequences, typically that which is given by a patient to a doctor for treatment with full knowledge of the possible risks and benefits.
Whose responsibility is it to obtain written consent?
nurse
What is written consent?
Must be written and signed by the patient or legal guardian. An example would be an HIV test or pregnancy test. All of these situations must be documented.
What is the lab draw order?
First - blood culture bottle or tube (yellow or yellow-black top)
Second - coagulation tube (light blue top). …
Third - non-additive tube (red top)
Last draw - additive tubes in this order:
14G
orange/ trauma only
16G
grey/ heart attack
18G
green/ surgery
20G
Pink/ normals
22G
Blue/ small veins
24G
Yellow/ pediatrics
What is included in CAUTI prevention?
-Hand hygiene
-maintenance of a closed system
-prevent pooling of urine in the drainage system
-avoid kinks in tubing
-keep drainage bag below level of bladder
-secure the cath
-routine perineal care/hygiene
What is included in foley care?
-soap and water at insertion site
-cleanse cath at least three times per day and after defecation
-monitor patency of the cath
What are some internal urinary devices?
intermittent (straight or curved)
indwelling retention (foley)
suprapubic
What are some external urinary devices?
condom cath
pure wick
urinal
Lordosis (swayback)
abnormal, inward curvature of a portion of the lower portion of the spine
kyphosis
excessive outward curvature of the spine, causing hunching of the back.
Scoliosis
abnormal lateral curvature of the spine
When does the brain get a signal that the bladder is full?
150-200mLs of urine in bladder
anuria
less than 100 ml/day
oliguria
btwn 100-500mL/day
scanty urination
dysuria
painful or difficult urination
hematuria
blood in the urine
incontinence
inability to control bladder and/or bowels
nocturia
fall risk
excessive urination during the night
urgency
fall risk
lasix can cause this
feeling the need to urinate immediatel
suprapubic pain
over pubic bone, in btwn hip bones
polyuria
greater than 2000mL/day
urinary retention
dribbling when feels full, post residual void scanner
residual urine
can use a straight cath to empty remaining contents, then measure
urine that remains in the bladder after urination
What is bladder scanning?
great, noninvasive way to see what is left in the bladder, always Dr. ordered, only go to 90 degrees, 3-5cm
Average daily intake of fluids
2200-2700mL unless contradicted
-minumum is 1200-1500mL
Average daily output of urine
<1200mL= consider renal failure
>1500mL= consider fluid intake
1200-1500 mL
Urine colors and causes
Normal=straw
amber=dehydration
light straw=overhydration
orange=meds (peridium, a UTI med)
Red=blood, injury, meds, kidney stone
urine odors
Normal=faint
abnormal=infection, possibly meds
urine consistency and clarity
normal=clear
abnormal=cloudy, thick, may indicate infection
Types of urinary diagnostic exams?
-KUB= kidneys, ureter, bladder; noninvasive
-IVP=intravenous pyelogram; noninvasive
-ultrasound renal and bladder=noninvasive
cystoscope= scope to see; invasive
What are the types of incontinence?
-functional=caused by factors outside of urinary tract; environmental barriers, mobility
-stress=caused from intrabdominal pressure; sneezing, coughing
-urge=occurs often with frequency
What is the pH of urine?
4.6-8.0, average=6
Should not have protein, ketones, glucose, blood
What is indicative of an UTI?
pH is off, protein, glucose and ketones
What does a normal urinary analysis look like?
pH=4.6-8
protein less than or equal to 8mg/100mL, glucose, ketones, blood
specific gravity=1.0053-1.030
RBCs/WBCs= scant
bacteria= none
Lower UTI
remember FUB
frequency, urgency, burning
Upper UTI
kidney infection, fever, flank pain
The nurse is assisting the client in caring for her ostomy. the client states “oh this is so disgusting, ill never be able to touch this thing”, what is the nurses best response?
it sounds like you are really upset
a newly admitted pt states that he has recently had a change in meds and reports that his stool is now dry and hard to pass. this type of bowel pattern is consistent with?
constipation
the nurse knows that the results of a fecal occult blood test can be inaccurate if
client takes high does of vitamin C, menstruating, client has had an excessive intake of red meat
which of the medications in a pt med history possibly causes GI bleeding?
aspirin, cathartics, antidiarrheal opiate agents, NSAIDs
during a nursing assessment the pt reveals that he has diarrhea and cramping every time he has ice cream. These symptoms are associated with?
lactose intolerance
What would be an emergent finding in an ostomy?
Not being beefy and red- if the ostomy is pale and pasty (could indicate bowel death, emergency surgery right away)
a pt starts to experience pain while receiving an emena. the nurse notes blood in the return fluid and rectal bleeding. What action does the nurse first take?
stop instillation and obtain VS
What are fine NGTs?
small bore for med admin enteral feedings
What are large bore NGTs?
12F and above, for gastric decompression or removal of gastric secretions
To maintain normal elimination patterns in the hospitalized patient, you should instruct the patient to defecate 1 hour after meals because:
A. the presence of food stimulates peristalsis.
B. mass colonic peristalsis occurs at this time.
C. irregularity helps to develop a habitual pattern.
D. neglecting the urge to defecate can cause diarrhea.
b. mass colonic peristalsis occurs at this time
How does the body absorb nutrients?
passive diffusion, osmosis, active transport, and pinocytosis
How does the body eliminate excess?
chyme moves by peristaltic action thru ileocecal valve into the large intestine, where it becomes feces
What are some alternative food patterns?
based on religion, cultural backgrounds, ethics, health beliefs and preferences
-vegetarian= mainly plant based
-ovolactovegetarian= avoids meat, fish, poultry but eats eggs and milk
-lactovegetarian= drinks milk but avoids eggs
-vegan= consumes only plant based foods
-fruitarian= consumes fruits, nuts, honey, and olive oil
What is parenteral nutrition?
Referred to as total parenteral nutrition (TPN) or intravenous hyperalimentation. Its the IV fusion of dextrose, water, fats, proteins, electrolytes, vitamins, and trace elements.
What are the surgical risk factors?
-Smoking
-Age
-Nutrition
-Obesity
-Obstructive sleep apnea (OSA)
-Immunosuppression
-Fluid and electrolyte imbalance
-Postoperative nausea and vomiting (PONV) -Venous thromboembolism (VTE)
What is hypovolemia?
fluid volume deficit, may need a blood transfusion
How can you counteract PONV?
Zofran
When would you admin TEDs/ SCDs to an operative pt?
preop
What is Versed (Midazolam)?
Midazolam is used before surgery or a procedure. It helps to cause drowsiness, decrease anxiety, and to decrease your memory of the surgery or procedure. This medication may also be used to help with anesthesia or to sedate people who need a tube or machine to help with breathing.
What is an extrinsic risk?
skin shearing, injury (what we are in charge of)
What is an intrinsic risk?
we dont have control over like nutrition
What is the antidote for malignant hyperthermia?
Dantrolene (Dantrium)
What are some meds that are given preop?
pepcid, reglan, bictra- these help empty stomach contents, prevent vomiting and aspirations, less acidic
What is the role of the PCU nurse?
IV, preop meds, cath, monitors VS
What is the role of the circulating nurse?
Prepares equipment and supplies
Arranges supplies—sterile and nonsterile
Sends for patient
Visits with patient preoperatively: verifies operative (op) permit, identifies patient, and answers questions
Performs patient assessment
Checks medical record
Assists in transfer of patient
Positions patient on operating table
Counts sponges, needles, and instruments before surgery
Assists scrub nurse in arranging tables for sterile field
Maintains continuous astute observations during surgery to anticipate needs of patient, scrub nurse, surgeon, and anesthesiologist
Provides supplies to scrub nurse as needed
Observes sterile field closely
Cares for surgical specimens
Documents operative record and nurse’s notes
Counts sponges, needles, and instruments when closure of wound begins
Transfers patient to the stretcher for transport to recovery area
Must be careful to slowly change patient’s position to prevent hypotension
Accompanies patient to the recovery room and provides a report
When conducting preop pt and family teaching, you demonstrate proper use of the incentive spirometer. How do you know the pt understands why they need to use this?
expand my lungs after surgery
PARS
postanesthesia recovery score
postop, the nurse instructs that patient to perform leg exercises every hour to
1. maintain muscle tone
2. asses range of motion
3. exercise fatigued muscles
4. increase venous return
D increase venous return
How long do you have to recover from muscle atrophy?
4 weeks
If your pt is getting 100-200cc IV fluids, how often should they go?
every 4 hours
Illeostomy will have what type of bowel?
liquid bowels, leakage if not sealed properly
colonoscopy will have what type of bowel?
thicker bowel
What are muscular distrophies?
a group of disorders that cause degeneration of skeletal muscle fibers, most prevalent of muscle diseases in childhood, pts experience progressive symmetrical weakness and wasting of skeletal muscle groups with increasing disability and deformity
CNS
-damage to cerebellum, problems with balancee
-damage to motor strip, motor impairment
-neurodegenerative, parkinsons, rigidity, tremors, postural instability
Joint disesase
-one of the most common pathological influences on mobility
-prevalence of arthritis in US expected to increase
What percent of muscle is lost every day for the pt on bedrest?
3%
What is abnormal reactive hyperthermia?
-transient (brief) increase in blood flow following a brief period of ischemia
-characteristics: 1 nonblanchable area, 2 reddened area for 1+ hours
Why would a pt need a urinary catheter?
-close monitoring of urine output
-facilitate bladder emptying when bladder function is compromised
PVR
post void residual
What is acute urinary retention?
feelings of pressure, pain and discomfort, tenderness over pubic synthesis, restlessness, diaphoresis
What is chronic urinary retention?
-decrease in voiding volume, straining to void, frequency, urgency, incontinence, sensations of incomplete emptying
UTI
-4th most common HA
-common cause= e coli
-lower=bladder, urethra
-upper= kidney
S/S of a UTI in an elderly pt
-delirium, confusion, fatigue, incontinence, falls, loss of appetite, decline in function, mental status changes, low temp
bacteriuria
-if asymptomatic, not an infection and no antibiotics
What is a cystectomy?
removal of the bladder
What is nocturnal enuresis?
Releasing urine during the night without waking up(bed-wetting)
Sigmoid ostomy stool consistency
more formed stool
transverse ostomy stool consistency
thick liquid to soft
