Therapeutic Procedures

Question 1

why are therapeutic procedures performed?

Answer 1

Can be performed for maintenance of nutritional intake and tx of GI obstructions, obesity, and other disorders

Question 2

potential dz that may indicate need for enteral feedings

Answer 2

• 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)

Question 3

client presentation that may indicate need for an enteral feeding

Answer 3

• Malnutrition: dec prealbumin, dec transferrin or total iron binding capacity
• Aspiration pneumonia

Question 4

list possible complications of enteral feedings

Answer 4

• overfeeding
• diarrhea
• aspiration pneumonia
• refeeding syndrome

Question 5

explain overfeeding as a complication of enteral feedings

Answer 5

• 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

Question 6

explain diarrhea as a complication of enteral feedings

Answer 6

• 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

Question 7

explain aspiration pneumonia as a complication of enteral feedings

Answer 7

• 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

Question 8

explain refeeding syndrome as a complication of enteral feedings

Answer 8

• 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

Question 9

TPN

Answer 9

• 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

Question 10

PPN

Answer 10

• 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

Question 11

indications for TPN

Answer 11

• any condition that:
  
  • Affects the ability to absorb nutrition
  • Has a prolonged recovery
  • Creates a hypermetabolic state
  • Creates a chronic malnutrition

Question 12

potential dx that may indicate a need for TPN

Answer 12

• Chronic pancreatitis
• Diffuse peritonitis
• Short bowel syndrome
• Gastric paresis from DM
• Severe burns

Question 13

client presentation that may indicate a need for TPN

Answer 13

• 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

Question 14

prep and ongoing care for a client w/ TPN

Answer 14

• 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

Question 15

interventions for TPN

Answer 15

• 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

Question 16

list complications of TPN

Answer 16

• metabolic: hyperglycemia, hypoglycemia, vitamin deficiencies
• air embolism
• infection
• fluid imbalance

Question 17

metabolic complications with TPN

Answer 17

• 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

Question 18

air embolism as a complication of TPN

Answer 18

• 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

Question 19

infection as a complication of TPN

Answer 19

• 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

Question 20

fluid imbalance as a complication of TPN

Answer 20

• 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

Question 21

paracentesis

Answer 21

• 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

Question 22

indications for paracentesis

Answer 22

• 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
• Client presentation:
  
  • Compromised lung expansion, inc abdominal girth, rapid weight gain

Question 23

preprocedure nursing actions for a paracentesis

Answer 23

• 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

Question 24

preprocedure client edu for a paracentesis

Answer 24

• Explain procedure
• Local anesthetics will be used at insertion site
• May be pressure or pain w/ needle insertion

Question 25

intraprocedure nursing actions for paracentesis

Answer 25

• 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

Question 26

postprocedure nursing actions for paracentesis

Answer 26

• 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

Question 27

postprocedure client edu for paracentesis

Answer 27

• 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

Question 28

list complications of paracentesis

Answer 28

• hypovolemia
• bladder perforation
• peritonitis

Question 29

hypovolemia as a complication of paracentesis

Answer 29

• 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

Question 30

bladder perforation as a complication of paracentesis

Answer 30

• 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

Question 31

peritonitis as a complication of paracentesis

Answer 31

• 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

Question 32

3 types of pharmacological therapies for weight loss

Answer 32

• Orlistat
• Larcaserin
• Phentermine-topiramate

Question 33

Orlistat

Answer 33

• prevents digestion of fats
• ADRs: oily discharge, reduced food and vitamin absorption, dec bile flow

Question 34

Larcaserin

Answer 34

• stimulates serotonin receptors in the hypothalamus in the brain to curb appetite
• ADRs: HA, dry mouth, fatigue, nausea

Question 35

Phentermine-topiramate

Answer 35

• 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

Question 36

Restrictive Bariatric Surgery

Answer 36

• 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

Question 37

explain the difference b/w LAGB and LSG

Answer 37

• 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

Question 38

vertical banded gastroplasty

Answer 38

• involves creation of new, smaller stomach pouch using staples to dec its functional size

Question 39

malabsorption surgery

Answer 39

• 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

Question 40

indications for bariatric surgery

Answer 40

• 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

Question 41

preprocedure nursing actions for bariatric surgery

Answer 41

• 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

Question 42

postprocedure nursing actions for bariatric surgery

Answer 42

• 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

Question 43

postprocedure client education for bariatric surgery

Answer 43

• 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

Question 44

complications of bariatric surgery

Answer 44

• dehydration
• malabsorption/malnutrition

Question 45

dehydration as a complication of bariatric surgery

Answer 45

• 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

Question 46

malabsorption/malnutrition as a complication of bariatric surgery

Answer 46

• 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

Question 47

NG decompression

Answer 47

• 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)

Question 48

indications for NG decompression

Answer 48

• 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

Question 49

postprocedure nursing actions/client edu for NG decompression

Answer 49

• 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

Question 50

complications of NG decompression

Answer 50

• 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

Question 51

ostomies

Answer 51

• 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

Question 52

indications for an ostomy

Answer 52

• 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)

Question 53

preprocedure nursing actions/client edu for an ostomy

Answer 53

• 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

Question 54

postprocedure nursing actions for an ostomy

Answer 54

• 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

Question 55

postprocedure client edu for ostomies

Answer 55

• 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

Question 56

what are the 2 complications of ostomies?

Answer 56

• stomal ischemia/necrosis
• intestinal obstruction

Question 57

stomal necrosis/ischemia as a complication of ostomies

Answer 57

• 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

Question 58

intestinal obstruction as a complication of ostomies

Answer 58

• 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

Question 59

compare normal post op output of ileostomy, transverse colostomy, and sigmoid colostomy

Answer 59

• 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

Question 60

compare post op changes in output of ileostomy, transverse colostomy, and sigmoid colostomy

Answer 60

• 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

Question 61

compare pattern of output of ileostomy, transverse colostomy, and sigmoid colostomy

Answer 61

• ileostomy:
  
  • constinuous output
• transverse colostomy:
  
  • resume pattern similar to pre op pattern
• sigmoid colostomy:
  
  • resume pattern similar to pre op pattern