Therapeutic Procedures Flashcards
1
Q
why are therapeutic procedures performed?
A
Can be performed for maintenance of nutritional intake and tx of GI obstructions, obesity, and other disorders
2
Q
potential dz that may indicate need for enteral feedings
A
- Inability to eat due to a medical condition (comatose, intubated)
- Pathologies that cause difficulty swallowing or inc risk of aspiration (stroke, advanced Parkinson’s dz, multiple sclerosis)
- Inability to maintain adequate oral nutritional intake and need for supplementation due to inc metabolic demands (cancer therapy, burns, sepsis)
3
Q
client presentation that may indicate need for an enteral feeding
A
- Malnutrition: dec prealbumin, dec transferrin or total iron binding capacity
- Aspiration pneumonia
4
Q
list possible complications of enteral feedings
A
- overfeeding
- diarrhea
- aspiration pneumonia
- refeeding syndrome
5
Q
explain overfeeding as a complication of enteral feedings
A
- results from infusion of a greater quantity of feeding than can be readily digested, resulting in abdominal distention, n/v
- Nursing actions:
- Check residual Q4-6 hour
- Follow protocol for slowing or withholding feedings for excess residual volumes
- Check pump for proper operation and ensure feeding infused at correct rate
6
Q
explain diarrhea as a complication of enteral feedings
A
- occurs secondary to concentration of feeding or its constituents
- Nursing Actions:
- Slow rate of feeding & notify HCP
- Confer with dietitian
- Provide skin care and protection
- Evaluate for c. diff if diarrhea continues, esp if it has a foul odor
7
Q
explain aspiration pneumonia as a complication of enteral feedings
A
- can occur secondary to aspiration of feeding
- Can be life threatening
- Tube displacement is primary cause
- Nursing actions:
- Stop feeding
- Turn client to side and suction
- Administer O2 if indicated
- Monitor V/S for elevated temp
- Auscultate breath sounds for inc congestion and diminishing breath sounds
- Obtain CXR
8
Q
explain refeeding syndrome as a complication of enteral feedings
A
- occurs when enteral feeding is started in a client who is in a starvation state and whose body has begun to catabolize protein and fat for energy
- Nursing Actions:
- Monitor for new onset of confusion or seizures
- Assess shallow respirations
- Monitor for inc muscular weakness
- Obtain serum electrolytes
9
Q
TPN
A
- hypertonic IV bolus soln
- Purpose is to prevent or correct nutritional deficiencies and minimize the adverse effects of malnourishment
- Usually administered thru a central line or PICC line
- Contains complete nutrition, including calories in a high conc (10-50%) of dextrose, lipids/essential fatty acids, protein, electrolytes, vitamins, trace elements
- Std IV bolus therapy: no more than 700 calories/day
10
Q
PPN
A
- Partial parenteral nutrition or peripheral parenteral nutrition (PPN): less hypertonic, intended for short term use, and administered in a large peripheral vein
- Usual dextrose is 10% or less
- Risks include phlebitis
11
Q
indications for TPN
A
- any condition that:
- Affects the ability to absorb nutrition
- Has a prolonged recovery
- Creates a hypermetabolic state
- Creates a chronic malnutrition
12
Q
potential dx that may indicate a need for TPN
A
- Chronic pancreatitis
- Diffuse peritonitis
- Short bowel syndrome
- Gastric paresis from DM
- Severe burns
13
Q
client presentation that may indicate a need for TPN
A
- Weight loss >10% of body weight and NPO or unable to eat/drink for more than 5 days
- Hypermetabolic state
- Muscle wasting, poor tissue healing, burns, bowel dz disorders, acute kidney failure
14
Q
prep and ongoing care for a client w/ TPN
A
- Preparation of client:
- Determine client readiness for TPN
- Obtain daily labs including electrolytes
- Ongoing care:
- Flow rate is gradually inc and dec to allow body adjustment (no more than a 10% hourly inc in rate)
- Never stop abruptly
- Can alter blood glucose significantly
- Assess V/S Q4-8 hours
- Follow sterile procedures to minimize risk of sepsis
- TPN is prepared by pharmacy using aseptic technique w/ a laminar flow hood
- Change tubing and solution bag (even if not empty) Q24 hours
- Filter added to tubing to collect particles from soln
- Do not use line for other IV bolus soln
- Do not add anything to soln due to risk of contamination and incompatibility
- Use sterile procedures (including mask) when changing central line dressing
15
Q
interventions for TPN
A
- Check capillary glucose Q4-6 hr for at least the first 24 hours
- Clients receiving TPN frequently need supplemental regular insulin until the pancreas can inc its endogenous production of insulin
- Keep dextrose 10% in water at the bedside in case the solution is unexpectedly ruined or the next bag is not available
- Minimizes risk of hypoglycemia
- If bag is unavailable and administered late, do not attempt to catch up by inc the infusion rate b/c the client can develop hyperglycemia
- Older adults have inc incidence of glucose intolerance
16
Q
list complications of TPN
A
- metabolic: hyperglycemia, hypoglycemia, vitamin deficiencies
- air embolism
- infection
- fluid imbalance
17
Q
metabolic complications with TPN
A
- hyperglycemia, hypoglycemia, vitamin deficiencies
- Nursing actions:
- Daily lab tests are prescribed and results obtained before a new soln is prepared
- Fluid needs are typically replaced w/ a separate IV bolus to prevent fluid vol excess
- Monitor for hyperglycemia
18
Q
air embolism as a complication of TPN
A
- pressure change during tubing changes can lead to an air embolism
- Nursing actions:
- Monitor for manifestations: sudden onset of dyspnea, chest pain, anxiety, hypoxia
- Clamp catheter immediately and place client on his left side in trendelenburg position to trap air
- Administer O2 and notify HCP so trapped air can be aspirated
19
Q
infection as a complication of TPN
A
- Conc glucose is the medium for bacteria growth
- Nursing actions:
- Observe central line for signs of infection: erythema, tenderness, exudate
- Change sterile dressing Q48-72 hr
- Change IV tubing per protocol (Q24 hr)
- Observe for fever, inc WBC, chills, malaise
20
Q
fluid imbalance as a complication of TPN
A
- TPN is hyperosmotic soln which poses risk for fluid shifts and places client at risk for inc fluid vol excess
- Older adults more vulnerable
- Nursing actions:
- Assess lungs for crackles and monitor for resp distress
- Monitor daily weight and I&O
- Use controlled infusion pump to administer at prescribed rate
- Do not speed up infusion to catch up
- Gradually inc flow rate until prescribed infusion rate is achieved
21
Q
paracentesis
A
- Performed by inserting a needle or trocar thru the abdominal wall into the peritoneal cavity
- Therapeutic goal: relief of abdominal ascites
- Usually performed w/ U/S as a safety precaution
- Once drained, ascitic fluid can be sent for lab culture
22
Q
indications for paracentesis
A
- Potential dx:
- Abdominal ascites:
- Abnormal accumulation of protein rich fluid in the abdominal cavity most often caused by cirrhosis
- Result is inc abdominal girth and distention
- Abnormal accumulation of protein rich fluid in the abdominal cavity most often caused by cirrhosis
- Abdominal ascites:
- Client presentation:
- Compromised lung expansion, inc abdominal girth, rapid weight gain
23
Q
preprocedure nursing actions for a paracentesis
A
- Determine client’s readiness for procedure
- Variables: age, acute/chronic dz can influence ability to tolerate and recover from procedure
- Assess labs: serum albumin, protein, glucose, amylase, BUN, creatinine
- Informed consent
- Have client void and insert indwelling catheter
- Position client in an upright position: either on the edge of the bed with feet supported or a high Fowler’s position in the bed
- If they have ascites, typically more comfortable sitting up
- Review baseline V/S, record weight, and measure abdominal girth
- Administer sedation
- Administer IV bolus fluids or albumin, prior to or after paracentesis, to restore fluid balance
24
Q
preprocedure client edu for a paracentesis
A
- Explain procedure
- Local anesthetics will be used at insertion site
- May be pressure or pain w/ needle insertion
25
intraprocedure nursing actions for paracentesis
* Monitor V/S
* Adhere to std precautions
* Label lab specimens and send to lab
* b/w 4-6 L fluid is slowly drained from the abdomen by gravity
* Nurse must monitor amount and notify of complications
26
postprocedure nursing actions for paracentesis
* Maintain pressure at insertion site for several minutes. Apply a dressing to a site
* If insertion site leaks after a few min, dry sterile gauze should be applied and changed as often as necessary
* Check V/S, record weight, and measure abdominal girth
* Document and compare to preprocedure measurements
* Monitor V/S and insertion site
* Monitor temp every 4 hr for minimum 48 hr
* fever=bowel perforation
* Assess I&O Q4
* Administer medication
* Diuretics such as spironolactone and furosemide can be prescribed to control fluid volume
* Potassium supplements can be necessary when a loop diuretic such as furosemide has been administered
* Administer IV bolus fluids or albumin
* Assist client into a position of comfort with HOB elevated to promote lung expansion
* Document color, odor, consistency, and amt removed; site of insertion; evidence of leakage at insertion site; manifestations of hypovolemia; and changes in mental status
* Continue monitoring of serum albumin, protein, glucose, amylase, electrolytes, BUN, and creatinine levels
27
postprocedure client edu for paracentesis
* Avoid alcohol, maintain a low sodium diet, take meds, monitor puncture site for bleeding or fluid leakage
* Report changes in mental and cognitive status due to change in F&E balance
* Change positions slowly to dec risk of falls related to hypovolemia from removal of ascitic fluid
28
list complications of paracentesis
* hypovolemia
* bladder perforation
* peritonitis
29
hypovolemia as a complication of paracentesis
* albumin levels can drop dangerously low b/c the peritoneal fluid removed contains a large amount of protein
* Removal of this protein rich fluid can cause shifting of intravascular volume, resulting in hypovolemia
* Nursing Actions:
* Preventive measures include: slow drainage of fluid and administration of plasma expanders, such as albumin, to counter albumin losses
* Monitor for hypovolemia: tachycardia, hypoTN, pallor, diaphoresis, dizziness
30
bladder perforation as a complication of paracentesis
* Manifestations:
* Hematuria
* Low or no urine output
* Suprapubic pain or distention
* Symptoms of cystitis
* Fever
* Nursing actions: if suspected, notify HCP
* Client edu: inform client to report any manifestations
31
peritonitis as a complication of paracentesis
* Can occur as a result of injury to the intestines during needle insertion
* Manifestations:
* Sharp, constant abdominal pain
* Fever
* n/v
* Diminished or absent bowel sounds
* Nursing actions: notify HCP
* Client edu: report any manifestations
32
3 types of pharmacological therapies for weight loss
* Orlistat
* Larcaserin
* Phentermine-topiramate
33
Orlistat
* prevents digestion of fats
* ADRs: oily discharge, reduced food and vitamin absorption, dec bile flow
34
Larcaserin
* stimulates serotonin receptors in the hypothalamus in the brain to curb appetite
* ADRs: HA, dry mouth, fatigue, nausea
35
Phentermine-topiramate
* suppresses appetite and induces feeling of satiety
* ADRs: dry mouth, constipation, nausea, change in taste, dizziness, insomnia, numbness and tingling of extremities
* Contraindications: hyperthyroidism, glaucoma, taking MAOI
36
Restrictive Bariatric Surgery
* such as laparoscopic adjustable gastric band (LAGB) or laparoscopic sleeve gastrectomy (LSG)
* Limit the amount of food eaten at one time due to dec volume capacity
* Weight loss is often regained after a period of time unless the client adheres to stringent weight loss protocols and lifestyle modifications
37
explain the difference b/w LAGB and LSG
* LAGB: involves placement of adjustable band at the proximal portion of the stomach to restrict stomach volume to 10-15 mL
* LSG: involves removal of portion of the stomach that secretes ghrelin (hormone that stimulates feelings of hunger)
* Up to 85% of stomach is removed
38
vertical banded gastroplasty
* involves creation of new, smaller stomach pouch using staples to dec its functional size
39
malabsorption surgery
* includes Roux en Y gastric bypass (RNYGB) or simply gastric bypass
* Interfere with the absorption of food and nutrients from the GI tract
* Most maintain 60-70% of weight loss even 20 yrs postprocedure
* RNYGB: involves restricting stomach capacity to 20-30 mL
* Bypasses the majority of stomach and duodenum
* Section of jejunum is anastomosed to smaller section of the stomach, bypassing majority of stomach
40
indications for bariatric surgery
* Diagnosis: hx of morbid obesity w/ unsuccessful attempts at nonsurgical weight loss
* Client presentation: BMI greater than 40 or BMI greater than 35 w/ comorbidities
41
preprocedure nursing actions for bariatric surgery
* Express emotions about eating behaviors, weight, and weight loss to identify psychosocial factors related to obesity
* Ensure the client understands needed diet and lifestyle changes
* Prepare for postop course and potential complications
* Arrange for availability of bariatric bed and mechanical lifting device to prevent client/staff injury
* Assess pertinent labs: CBC, electrolytes, BUN, creatinine, A1C, iron, B12, thiamine, folate
* SCDs
42
postprocedure nursing actions for bariatric surgery
* Monitor for leak of anastomosis: inc back, shoulder, abdominal pain; restlessness; tachycardia; oliguria
* Notify provider
* Notify provider for suspected NG tube displacement
* NG tube is typically sutured in place following stomach surgery
* Do not attempt to manipulate the tube
* Monitor for development of complications that are at inc risk due to obesity: atelectasis, thromboemboli, skin fold breakdown, incisional hernia, peritonitis
* Assess airway and O2 sats
* Maintain client in semi Fowler’s position for lung expansion
* Monitor for bowel sounds
* Apply an abdominal binder as prescribed to prevent dehiscence
* Ambulate client ASAP
* Resume fluids as prescribed: first fluids can be restricted to 30 mL and inc in frequency and volume
* Provide 6 small meals a day when client can resume oral nutrients
* Observe for dumping syndrome: cramps, diarrhea, tachycardia, dizziness, fatigue
43
postprocedure client education for bariatric surgery
* Teach client limitations regarding liquids or pureed foods for the first 6 wks as well as the volume that can be consumed (often not to exceed 1 cup
* Walk for at least 30 min daily
* Teach client that overeating can dilate the surgically created pouch causing weight to be regained
* Take vitamins/mineral
44
complications of bariatric surgery
* dehydration
* malabsorption/malnutrition
45
dehydration as a complication of bariatric surgery
* Warn client that excessive thirst or conc urine can be an indication of dehydration and the surgeon should be notified
* Work with the client to establish goals and schedule for adequate daily fluid intake
46
malabsorption/malnutrition as a complication of bariatric surgery
* b/c bariatric surgeries reduce size of stomach or bypass portions of intestinal tract, fewer nutrients are absorbed/ingested
* Nursing actions:
* Monitor for tolerance to inc amounts of food/fluids
* Dietary management referral
* Encourage client to consume meals in low Fowler’s position and to remain in this position for 30 min after eating to delay stomach emptying and minimize dumping syndrome
* Client edu:
* Eat 2 servings of protein/day
* Eat only nutrient dense foods
* Avoid empty calories like colas and fruit juice
47
NG decompression
* required if client has an intestinal obstruction
* An NG tube is inserted, then suction as applied to relieve abdominal distention
* Tx continues until obstruction is removed or resolves
* Obstruction can be mechanical (tumors, adhesions, fecal impaction) or functional (paralytic ileus)
48
indications for NG decompression
* Potential dx: any disorder that causes a mechanical or functional obstruction (surgery, trauma, GI tract infection, condition in which peristalsis is absent)
* Client Presentation:
* Vomiting: begins w/ stomach contents and continues until fecal material is also being regurgitated
* Bowel sounds absent (paralytic ileus) or hyperactive/high-pitched (obstruction)
* Intermittent, colickly abdominal pain and distention
* Hiccups
* Abdominal distention
49
postprocedure nursing actions/client edu for NG decompression
* Nursing Actions:
* Assess and maintain proper function of NG tube and suction equipment
* Maintain accurate I&O
* Assess bowel sounds and abdominal girth
* Return of flatus
* Encourage repositioning and ambulation to help inc peristalsis
* Monitor tube for displacement: dec in drainage, inc n/v/distention
* Assess labs: electrolytes, Hct
* Oral care and care of nares
* Client edu:
* Maintain NPO status
50
complications of NG decompression
* F&E imbalance:
* Nursing actions:
* Monitor for F&E imbalance:
* metabolic acidosis: low obstruction
* Metabolic alkalosis: high obstruction
* Monitor I&O
* Skin breakdown: assess nasal skin for irritation
51
ostomies
* surgical opening from inside of body to the outside and can be located in many places
* Can be permanent or temporary
* A stoma is artificial opening created
* Types:
* Ileostomy: opening into ileum
* Frequent, liquid stools
* Colostomy: opening into large intestine
* Ascending colon: more liquid stools
* Transverse colon: more formed stools
* Sigmoid colon: near normal stool
52
indications for an ostomy
* Ileostomy: when entire colon must be removed due to dz
* Crohn’s dz, UC
* Colostomy: when a portion of the bowel must be removed (cancer, ischemic injury), or requires rest for healing (diverticulitis, trauma)
53
preprocedure nursing actions/client edu for an ostomy
* Nursing actions:
* Determine client’s readiness: visual acuity, manual dexterity, cognitive status, cultural influences, support system
* Referral for wound ostomy nurse
* Client edu:
* Instruct client and support person about care/mgmt of ostomy
54
postprocedure nursing actions for an ostomy
* Assess type and fit of ostomy appliance
* Monitor for leak (which is a risk for skin integrity)
* Fit ostomy appliance based on: type/location of ostomy, visual acuity and manual dexterity of client
* Assess peristomal skin integrity and appearance of stoma
* Should be pink and moist
* Apply skin barriers and creams (adhesive paste) to peristomal skin and allow to dry before applying new appliance
* Evacuate stoma output: output should be more liquid and more acidic the closer the ostomy is to proximal small intestine
* Empty ostomy bag when it is ¼-½ full of drainage
* Assess for F&E imbalances (esp with new ileostomy)
* Evaluate ability of client to perform care
55
postprocedure client edu for ostomies
* Teach about dietary changes and ostomy appliances that can help manage flatus and odor
* Cause odor: fish, eggs, asparagus, garlic, beans, dark green leafy veggies
* Help dec odor: buttermilk, cranberry juice, parsley
* Cause gas: dark green leafy veggies, beer, carbonated beverages, dairy, corn, chewing gum, skipping meals, smoking
* Help dec gas: yogurt, crackers, toast
* Instruct the client to avoid high fiber foods for first 2 mos, chew food well, inc fluid intake, and evaluate for evidence of blockage when slowly adding high fiber foods
* Proper appliance fit and maintenance prevent odor when ouch is not open
* Filters, deodorizers, or a breath mint can minimize odor when pouch is open
* Provide time for client to talk about feelings
56
what are the 2 complications of ostomies?
* stomal ischemia/necrosis
* intestinal obstruction
57
stomal necrosis/ischemia as a complication of ostomies
* stomal appearance should be pink or red and moist
* Signs of stomal ischemia are pale pink or bluish purple color and dry appearance
* If stoma appears black or purple in color, indicates impairment of blood flow
* Nursing actions:
* Obtain V/S, O2 sats, lab results
* Client edu:
* Watch for stomal necrosis
58
intestinal obstruction as a complication of ostomies
* Nursing actions:
* Monitor and record output
* Assess for manifestations of obstruction:
* Abdominal pain
* Hypoactive or absent bowel sounds
* Distention
* n/v
* Client edu:
* Note indications of intestinal obstruction
59
compare normal post op output of ileostomy, transverse colostomy, and sigmoid colostomy
* ileostomy:
* More than 1000 mL/day
* Can be bile colored and liquid
* transverse colostomy:
* Small semi-liquid w/ some mucus 2-3 days after surgery
* Blood can be present in the first few days after surgery
* sigmoid colostomy:
* Small to moderate amounts of mucus w/ semi-formed stool 4-5 days after surgery
60
compare post op changes in output of ileostomy, transverse colostomy, and sigmoid colostomy
* ileostomy:
* After several days to weeks, the output decreases to approx 500-1000 mL/day
* Becomes more paste like as the small intestine assumes the absorptive function of the large intestine
* transverse colostomy:
* After several days to weeks, output becomes more stool-like, semi-formed, or formed
* sigmoid colostomy:
* After several days to weeks, output resembles semi-formed stool
61
compare pattern of output of ileostomy, transverse colostomy, and sigmoid colostomy
* ileostomy:
* constinuous output
* transverse colostomy:
* resume pattern similar to pre op pattern
* sigmoid colostomy:
* resume pattern similar to pre op pattern
