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Care 1 Final exam

Terms in this set (131)

Things to be done before upper GI test
-NPO for at least 8 hours; No smoking after midnight; Drink contrast; Has to be able to move in different positions during test
Things to teach for after upper GI test
Stool can be white for up to 72 hours; Drink lots of fluid to avoid constipation or impaction may even need a laxative
Before an EGD test?
NPO 8 hours; local anesthesia sprayed down throat; Sedatated
After an EGD test?
NPO until gag reflex returns; monitor Temp and VS Q 15-30 min for 1-2 hours (looking for signs of perforated bowel like spike in temp, S/S of shock, tachypnea change in cognition in elderly)
Considerations for video capsule endoscopy?
NPO after midnight; Have to do bowel prep; Clear liquids for 2 hours after pill is swallowed and reg diet after 4 hours; Monitoring device removed after 8 hours
Common causes of GERD?
Tea, coffee, fatty foods, ETOH, smoking, obesity and some meds (ACh, Beta B, morphine)
Manifestations of GERD?
Pyrosis, hot/bitter taste, hypersalivation, waking up coughing, SOB (air hunger), sore or hoarse throat, dyspepsia, post nasal drip elderly commonly complain of chest pain
Complications of GERD?
Esopagitis-->ulcers and dysphagia; Barrett's esophagus--> Adenocarcinoma; laryngospasms, bronchospasms, pneumonia; posterior dental erosion
Foods to avoid with GERD?
Chocolate, coffee, tomatoes, tea, milk (esp. at night), peppermint, sodas, red wine, citrus drinks
Lifestyle modifications for GERD?
Avoid large meals; Eat low fat meals; avoid tight clothes esp around waist; Eat at least 3-4 hours before bed; raise head of bed 4-8 inches (inc. gastric emptying)
Which type of PUD is most common?
Duodenal
Gastrojejunum ulcers
Only occure after surgery
Causes of PUD?
H.Pylori (most common), NSAIDS (2nd common), Corticosteroids, anticoag, ETOH, Coffee, Stress, smoking, depression
Teachings for PUD?
Avoid coffee, spicy foods, smoking, ETOH; Take NSAIDS and steroids with food to dec. chances of getting an ulcer
Gastric ulcers
Women>men; Burning in epigastric area; pain 1-2 hrs after meal; N/V and weight loss Pain is aggravated by food
Duodenal ulcers
Men>women; burning/cramping in upper abd and/or back pain; Pain 2-4 hours after meals pain relieved with food or antacids
Treatment for PUD?
PPI+Amoxicillin+Clarithromycin X 14 days pain relief in 3-5 days
S/S of ulcer perforation?
Severe sharp pain throught abd, tachycardia, ridid board-like abd muscles, shallow rapid breathing, absent bowel sounds, N/V
Management of ulcer perforations?
NPO and stop all meds, NG tube placement, VS Q 15-30 min, IV fluids, ABX, Surgery
Risk factors for colorectal cancer?
Diet high in red or processed meats and/or low in fruits and vegetables; Obesity, ETOH, physical inactivity, smoking; HX of IBS, polyps or fam hx of colorectal CA; age
S/S of colorectal CA?
rectal bleeding (most common); Changes in stool (alternate between diarrhea and constipation, narrow ribbon like), occult bleeding, iron def
S/S of Rectal CA?
blood in stool, change in bowel habits, rectal pain
S/S of ascending colon CA?
Pain, mass, change in bowel habits, anemia
S/S of transverse colon CA?
pain, obstruction, change in bowel habits, anemia
S/S of descending colon CA?
pain, change in bowel habits, bright red blood in stool, obstruction
What is gold standard screening for colorectal CA?
colonoscopy every 10 years
Stage 3 and 4 Colorectal CA?
3-Spread to lymph nodes; 4-metastesis to distant organs
Reason for temp colostomies?
Peritonitis, perforation, hemodynamically unstable
Stoma should be?
pink or red; no skin irritation or breakdown
Maturational loss is?
Loss of someone from moving away or kids going off to school etc (is a result of growth and development)
Physical changes hours/days before death?
inc. sleeping, skin mottling/cyanosis, incontinance, decreased and dark urine, restlessness, altered and noisy breathing, sagging jaw hearing is last to go
Post-mortem care?
can be delegated to NAP, see if autopsy requested, maintain culture and religious beliefs, identify with 2 identifiers, elevated HOB asap, collect any specimens needed, Ask fam if they want to help prepare the body
Additional post mortem care?
cleanse the body, remove tube/drains/lines, close eyes if possible, cover with clean sheet w/ arms outside, clean room of blood, fluids etc, allow fam to view body and to say goodbye in their own way
Kubler ross stages of dying?
DABDA- Denial, anger, bargaining, depression, acceptance
Wordens grief task model?
Task 1-accept reality of the loss
task 2- experience the pain of grief
task 3-adjust to the world where theyre gone
task 4-emotionally relocate the deceased and move on with life
What is SOLER in communicating?
Sit facing patient
Observe/open posture
lean towards patient
establish and maintain eye contact
relax
Reorient confused patients with straightforwardness
This is esp important with patients who have dementia or delirium because saying things like "your wife passed on" instead of "shes dead" can confuse them more since they forget figures of speech
When speaking to a Dr about a patient, use SBAR
Situation, background, assessment, recommendation
What is ADPIE?
Assessment, Diagnosis, planning, implementation, evaluation
What steps are in the Assessment phase?
Collect data: Patient best source; Ask open-ended questions

Interpret data: Data clustering identifies patterns and isolates relevant info

Validate data: Compare with other sources ie: medical records

documentation: Cant use if its not documented
What steps are in the diagnosis phase?
NANDA diagnosis, R/T that uses pathophysiology or treatment related cause, and AEB (specific facts)
Using risk of in a nursing diagnosis
Can not use R/T or AEB since it hasnt happened yet and is only a risk of
Health promotion in nursing diagnosis
MUST have AEB; can also have R/T
What are high priority needs according to maslows heirachy of needs?
ABCs, Safety, Pain, Life threatening issues
Things to do in the planning phase
Prioritize nursing diagnosis; Identify expected goals and outcomes; interventions to help patient meet goals(Has to be feasible, Evidenced based and acceptable to patient) use SMART goals here
What is the SMART goal?
Specific, measurable, attainable, relevant, time

"pt will name 3 foods low in fat by end of shift"
WHat is done in the implementation phase?
How the patient is treated either by direct or indirect care
What is involved in the evaluation phase?
Was the plan of care effective? If no then reassess and continue or change plan
WHat is done before administering oral meds in someone suspected of dysphagia or after a stroke?
Assess swallowing abilities: sit at 90 degree, Chin to chest and ask them to swallow water

Give meds on stronger side of mouth, one pill at a time and thicken liquids allow them to do it if capable to promote independence
Administering meds through an NG tube
crush meds one at a time and dissolve in sterile water; flush with 15 ml of water before and after
What size do insulin syringes come in?
0.3-1 ml and are calibrated as unites each ml is 100u
What size needs is used for Sub-Q and IM?
Sub-Q: 3/8-5/8

IM: 1-1 1/2
When do you use a filter needle?
When drawing meds from an ampulla. replace with regular needle before injection
Best sub-Q injection sites?
outer posterior aspects of the upper arms; Abd from below costal margins to iliac crest; Anterior aspect of thigh
Things to consider when giving Sub-Q injection
Slower absorption than IM; Use 25 gauge, 5/8 length if inserting at 45 degree angle; Use 25 gauge 1/2 in length if inserting at 90 degree

If able to grasp 2 inches of skin, use 90 degree, otherwise use 45 degree
Needle size for IM?
19-25 gauge 1-1 1/2 in length (can use up to 3 in for larger adults)
Ventrogluteal site?
Preferred and safest IM route admin; Can hold > 2ml; Between greater trochanter and anterior superior iliac crest
Deltoid site?
Can inject up to 2ml; Can potential damage axillary, radial and brachial nerves in deltoid below acromion process
Steps if medication has been given in error?
First assess and examine pt's condition!; Then tell pt about the error, write an incident report, and report to supervisor
Considerations if using restraints
4 side rails up is considered restraints, Assess circulation ever 15 min, remove restraints every 2 hours, order is renewed Q24 hr, Assess pt every 2 hours, do ROM, feed them, provide comfort
Serous fluid
normal; Clear plasma, watery
Purulent
Thick, yellow, green-tan, brown: Infection
Serous Sanguinous
Pale, pink, watery mixture; normal after surgery
Sanguinous
Bright red; indicates active bleeding
What is a primary intention wound?
Surgical wound; WOund is closed by sutures or staples
What is secondary intention wound?
Edges are not approximated; tissue loss; could be from pressure ulcer or bullet
What is tertiary intention wound?
Wound that is left open for several days; closes from the inside out
How often are high risk patients checked for presence of pressure ulcers?
Q4 hr
Stage 1 pressure ulcer
Non-blanchable; skin is intact, warm, red, firm
Stage 2 pressure ulcer
Loss of dermis layer, blister that popped; Shallow open ulceration; red-pink, shiny or dry; Blister could be present with serosanguinous fluid or jsut serous
Stage 3 pressure ulcer
Loss of sub-Q fat; no bone, tendon or muscle exposed; Sloughing may be present
Stage 4 pressure ulcer
Exposed bone, muscle, tendon, fat
Unstagable pressure ulcer
Obscured by sloughing and/or eschar (use wet healing with eschar)
Process for cleaning wounds
Give pain med 30 min prior, irrigate with sterile Normal saline, Use sterile procedure if acute wound (can use clean gloves tho to remove old dressing), Irrigate from least to most contaminated (wound is considered least contaminated)
Where do you hold when doing ROM exercises on a pt?
cradle above and below the joint nearest area
COnsiderations for doing ROM exercises on a pt
Do at least 5 times each exercise period; If pt reports pain stop
How often is someone repositioned
Q 1-2 hrs
How many caregivers to move someone > 200lbs?
3
COnsiderations for use of cane
Length should be equal to legth of hip and floor; Hold on stronger side; Place 6-10 in in front; Weaker leg moves forward first followed by stronger leg
4 point crutch
Requires weight bearing on both legs; each leg moves alternately with opposing crutch so 3 points of support at all times
3 point crutch
Requires all weight bearing on 1 leg; Other leg does not ever touch the ground
2 point crutch
Requires at least partial bearing on each foot; Moves crutch at same time as opposing leg so crutch movement is similar to arm movement when walking
What is active ROM?
COmplete ROM, To maintain and increase muscle strength, Prevents joint problems and contractures
WHat is passive ROM?
Goal is to retain as much joint ROM as possible, muscles do not contract, Muscle strength is not maintained or increased
How close in most cases should the nurse sit next to a pt when communicating with them?
18in-4 ft
Neurovascular assessment in FXs
Color, temp, cap refill, pulses present distal to the FX, Edema?, sensation, motor function, pain (pain should not get worse after a couple of days, if it does, there could be more wrong)
Types of Fxs
Open or closed; Complete (from one end to the other) or incomplete; Direction of FX line; Displaced (out of alignment) of non-displaced
Direction lines of FXs
Oblique: At a diagonal angle
Transverse: Medial to proximal line
Longitudinal: Superior to inferior line
Spiral: Spiral type direction if seen in children or elderly, could indicate abuse
Types of alignments of FXs
Closed (non surgical: External fixation, splints, cast etc); Open (Surgery: plates, screws, pins etc.); Traction
Open alignment Fx considerations
They are at inc risk for infection, Have to have continuous passive motion machine to prevent the joints from stiffening
Traction alignment types
Skin and skeletal traction alignment goal is to reduce pain, muscle spasms and immobilize
Skin alignment considerations
its short term use only (48-72 hrs); Tape, boots or splints applied directly to skin(bucks traction most common type) skin assessment prior to is a must; Weights 5-10 lbs; Assess pressure points Q 2-4hr
Skeletal traction alignment
Pins directly into bone; Long term; 5-45 lbs; Counter weight system; Weights cannot touch floor; inc. risk for infection; Prolonged immobility
Care for a skeletal traction alignment
Clean pins every shift with 1/2 strength peroxide and NS
Body jacket brace considerations
Thoracic immobilization; Watch for Superior mesenteric artery syndrome (aka cast syndrome)
What are s/s and tx of Mesenteric artery syndrome?
Abd pain, N/V; Treat wth gastric decompression (NG tube and suction) or remove brace Can also get this syndrome with the Hip Spica cast
Lower extremity immobilization considerations
Elevate extremity above level of the heart for first 24 hours; Do not place in dependent position (dangle); Observe for s/s of compartment syndrome
6 P's of compartment syndrome
Paresthesia: Tingling/Burning
Pain: usually 1st sign (unrelieved by meds)
Pressure: Skin tense; Cast appears tight
Pallor: Gray or pale
Paralysis
Pulselessness: Weak or absent
Indirect Complications of FXs
Rhabdomylosis, COmpartment syndrome, embolism
COnsiderations for compartment syndrome
Assess kidney and urine output; Ischemia within 4-8 hrs; No ice; No elevation Loosen bandage; reduce traction weight; Fasciotomy
Most common type of emboli from FXs
Fat; Usually occurs from long bone fx, hip/pelvis, or rib will manifest the same as a PE
Nutritional considerations for fractures
Inc. Protein 1g/kg of body weight
Inc. Vit B,C,D, Ca+, Mg++, Phosphorus
Inc. Fluid to 2000-3000 ml/day
Inc. Fiber
only these if not contraindicated
At home cast care
Ice first 24 hrs; Elevate first 48 hrs; Exercise joints above and below; Use hair dryer on cool setting for itching; Dont get it wet
S/S of Low back pain
Sharp shooting pain; Dec. ROM; Inability to stand straight; Possible dec. reflexes esp if disc disease
Considerations for low back pain
Avoid prolonged bed rest; Sleep side lying witg knees flexed (possibly a pillow between the legs too); Stretch the back 15 min in AM and PM; Use lumbar roll or pillow when sitting
The DONTS of low back pain
Nothing above level of elbows; DOnt bend forward without bending knees; Dont sleep prone with legs outstretched
Disc disease Manifestations
Radiculopathy; Dec. or absent reflexes; Dec grip strength if cervical area affected; paresthesia; muscle weakness If multiple nerve roots affected (cauda equina) they could become incontinent. This is an emergency
Post-op care after laminectomy
Lay in a position that reduces pressure in the area ; Maintain alignment
Things to monitor post-op laminectomy
S/S of CSF leak (sever HA); Clear or yellow liquid on bandage (Test it for glucose to see if its CSF); neurological assessment Q2-4 hrs for first 48 hrs; Monitor GI and bowel function; Monitor and assist with emptying bladder
What modalities are associated with the gate control pain theory?
Massage, heat, cold, acupuncture, TENS
6 modalities that are non-invasive, non-pharmacological pain relief meassures?
Heat and cold; TENS; Massage; distraction; relaxation techniques; biofeedback
How much fluid is lost daily through evaporation in the lungs?
300-400 ml
What foods should ppl with hyperkalemia avoid?
Bananas, orange juice, cantaloupe, strawberries, avocados, , potatoes, spinach, fish, salt substitutes
What position for someone with an MI?
Semi fowlers (45 degree)
What position for someone with difficulty breathing?
High fowlers, then reassess, if no improvement administer O2
WHat position if dehiscence or evisceration?
low fowlers
Cold and clammy, get some candy; Hot and dry, sugars high
Ways to remember hypo and hyper glycemia
Mnemonic to remeber S/S for hypokalemia?
A SIC WALT
Alkalosis, Shallow breaths, Confusion, Irritability, weakness, Arrhythmias, Lethargy, thready pulse
Scope of a UAP?
Ambulation, Stool and urine collection, ROM exercises, Positioning, bathing and grooming, companion care assess UAPs skill level and comfort level before assigning
WHat is tertiary care?
ICU, Sub-acute care
What is a client with gastrointestinal suctioning at risk for
Hypokalemia
Hyponatremia S/S
Hyperactive bowel, weakness, inc. urine output, and dec. specific gravity
INsensible water loss occurs?
Skin and lungs
Which food is high in thiamine?
Legumes
Corticoidsteroids prior to surgery
You do give it (if Dr says ok) esp if they have been on them for long periods of time because it is essential in events of withstanding extreme stress, like with surgery
How long do you wait after administering meds through an NG tube before turning on suctioning?
30-60 min
What should pH of gastric content be?
3.5 or less
What residual amount should you hold feedings?
Anything over 100ml unless policy states otherwise
What amount do you not reinstill residual amounts in the NG tube?
Over 250ml
If the pt starts to cough and have resp distress while entering an NG tube, what do you do?
pull back a bit and wait for resp distress to subside and resume
COnversions
Tsp=5ml
Tbsp=15ml
1 oz=30ml
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