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ECU NURS CAPSTONE EXAM 1 (Peri-operative, GI Alterations, Musculoskeletal disorders, renal alterations )
Terms in this set (147)
Who is responsible for explaining that surgical procedure to the client and answering the clients questions?
Who is most often responsible for obtaining the signature for the consent of the client for the surgical procedure?
Client teaching: Deep breathing and coughing
Promotes ventilation & gas exchange, mobilizes secretions
Client teaching: incentive spirometry
a common postoperative breathing therapy to encourage the patient to inhale and hold an inspiratory volume to exercise the lungs and prevent pulmonary complications
Client teaching: splinting incision
minimizes pain during coughing, helps support incision area, and helps avoid dehiscence
List medical conditions that increase risk during surgery
Obstructive sleep apnea
Upper respiratory infection
Abuse of street drugs
Substances that can affect the client in surgery: Antibiotics
Potentiate the action of anesthetic agents
Substances that can affect the client in surgery: Anticholinergics
Increase the potential for confusion, tachycardia, and intestinal hypotonicity and hypomotility
Substances that can affect the client in surgery: Anticoagulants, antiplatelets, and thrombolytics
Increase the risk of hemorrhaging
How long should Anticoagulants, antiplatelets, and thrombolytics be discontinued before surgery?
at least 48 hours
Substances that can affect the client in surgery: Anticonvulsants
long term use of these medications can alter the metabolism of anesthetic agents
Substances that can affect the client in surgery: Antridysrhythmics
can reduce cardiac contractility and impair cardiac conduction during anesthesia
Substances that can affect the client in surgery: Antihypertensives
can interact with anesthetic agents and cause bradycardia, hypotension, and impaired circulation
Substances that can affect the client in surgery: Corticosteroids
cause adrenal atrophy and reduce the ability of the body to withstand stress
inadequate steroid levels during surgery can lead to hypotension or low blood pressure.
Substances that can affect the client in surgery: Diuretics
potentiate electrolyte imbalances after surgery
Substances that can affect the client in surgery: Herbal substances
they can interact with anesthesia and cause a variety or adverse effects, so this needs to be discussed/addressed prior to surgery to determine if they need to be stopped a specific period time before the procedure
Substances that can affect the client in surgery: Insulin
The need of this may need to be decreased due to the reduction in the clients nutritional status, or increased because of the stress response increase blood sugar
Why do vitals needs to be taken prior to a a procedure?
To establish a baseline
What is a first indication of shock?
An increased or change in pulse (followed by a decrease/change in blood pressure)
Where are narcotics metabolized in the body?
The liver and kidney
A patient with an oral airway is constantly swallowing, what is appropriate at that time?
To take it out
If the pulse is high you would consider...
If the pulse is low you would consider...
With acute pain how would you start the medication?
Start it out high and gradually decrease the amount
With Chronic pain how would you start the medication?
Start it low and gradually increase the amount PRN
What is normal urinary output
(at least) 30 mL/hr
Ways to encourage urinary elimination
-encouraging pt to drink something
-encourage sitting on commode
List postoperative complications that should be considered
Pneumonia and atelectasis
Usually temporary paralysis of intestinal wall that may occur after surgery due to anesthetic medication that causes cessation of peristalsis; leads to abdominal distention and symptoms of obstruction
inflammation of the alveoli
A collapsed or airless state of all or part of the lung
A patient is presenting with symptoms of: dyspenia, increase respiratory rate, crackles in lungs, elevated temp, productive cough and chest pain, what could you suspect based on these assessment findings?
Pneumonia and/or atelectasis
What are some interventions for Pneumonia and/or atelectasis
1. Asses lung sounds
2. reposition patient every 1-2 hrs
3. Encourage client to deep-breathe, cough, and use incentive spirometer
4. provide chest physiotherapy and postural drainage as prescribed
5. encourage fluid intake and early ambulation
6. use suction to clear secretions if client is unable to cough
A pt is restless and having a difficult time breathing. Upon assessment you find he is sweating, tachycardic, and has HTN. What would you suspect this pt is presenting with?
A blood clot that breaks off from a large vein and travels to the blood vessels of the lung, causing obstruction of blood flow.
A pt is suddenly presenting with dyspnea and describes a sudden sharp pain in her chest. She appears to be cyanotic and has tachycardia and a drop in blood pressure. What do you suspect she has?
a Pulmonary Embolism
A pt is 3 hours post op. When you go into her to assess her urine you find only 25 mL in the catheter bag. She is restless and complains of being cold. Upon assessment, you find her skin clammy with a weak and rapid pulse and a blood pressure of 90/60. this could indicate...
hemorrhage or shock (hypovolumic)
A pt presses the call bell. He complains of pain around is IV. You find it is inflamed and tender to touch. When you check his temperature, it reads 101 F, what could this be?
A women is 5 hours post op and states she has not used the restroom. She is hypertensive and her bladder is noticeably distended, what post op complication is she presenting with?
Vomiting postoperatively, abdominal distension, and absence of bowel sounds may be signs of what?
Bursting open of a wound, especially a surgical abdominal wound
The displacement of organs outside of the body.
What are NG tubes used for?
-Decompression of the stomch by removing gas and fluids
-Decrease risk of aspiration
-Provide nutrion for pts unable to eat/swallow properly
-Admin medications to clients who are unable to swallow, to treat intestinal obstruction, or control bleeding
instillation of liquid nourishment in less than 30 minutes four to six times a day
feeding continually for 24 hours that is regulated by a feeding pump
feeding is administered in the daytime or nighttime for approx. 8-16 hours
A single lumen nasogastric tube used to remove gastric contents via intermittent suction or to provide tube feedings
Salem sump tube
A double lumen nasogastric tube with an air vent used for decompression with intermittent continuous suction
A three-lumen tube used in treating esophageal bleeding
What actions should be taken before administering medication in a pts. NG tube?
-check residual volume/contents followed by pH indication by aspirating
-turn off suction
gastric aspirations should be around what pH?
3.5 or lower
Length of NG tube
Nose to ear to xyphoid process
Following an endoscopic procedure what should be monitored before giving the client any oral substances?
Gag reflex (to prevent risk of aspiration)
Why must heart rate and BP be monitored closely after a paracentesis?
The rapid removal of fluid from the abdominal cavity leads to a decreased abdominal pressure which can cause vasodilation and result in shock.
swollen, varicose veins at the lower end of the esophagus
What causes esophageal varices?
Hep A transmission
Fecal/Oral (shellfish in contaminated water, contaminated food handlers etc.)
Hep B transmission
blood, semen, saliva, mom to baby
Hep C transmission
blood and body fluids
Hep D transmission
co-infects w/ Hep B
Hep E transmission
similar to Hep A
Complications of Hepatitis
Fulminating hepatitis (acute liver failure)
Cirrhosis of the liver
What does a
dusky blue stoma
a compromised circulation which requires immediate HCP notification
a chronic autoimmune disorder that is most often found in the ileum and in the colon
List things that can affect Bowl sounds
-lack of movement
A patient has a suspected nic/clot in their bowel, what bowel sounds would be heard to support this?
Hyperactive sounds above the suspected area with hypoactive sounds below
outpouching of herniation of the intestinal mucosa
inflammation of 1 or more diverticula that occurs from penetration of fecal matter through the thin-walled diverticuli.
normal thrombin time
ecchymosis in umbilical area, seen with pancreatitis
symptoms of pancreatitis
Pain UQ radiating to back
Swollen, tender abdomen
Rigid board-like abdomen
Ecchymosis in the flank or around umbilicus (+ Cullens sign)
Dehydration, shock (severe)
Weight loss (chronic)
Flank--greyish blue. (turn around to see your flanks) Seen with pancreatitis
List aggravating substances for GERD
Coffee, chocolate, peppermint, fried/fatty foods
risk for osteoporosis
-women (usually in smaller stature/frame)
-older--> declining reproductive hormones
A break (to a bone)
Scrape of the skin due to something abrasive
blood vessels in a paralyzed patient are..
muscles in a paralyzed patient are..
atrophied and ridgid
Why are paralyzed patients at risk for losing limbs? (having to get them amputated)
from blood pooling that resulted in lack of oxygen or clots
What does arterial congestion present as?
-Pale in color
-Starvation of tissues and cells results in painful ulcers
What does venous congestion present as?
-Blue/grey skin color
6 p's assessing Musculoskeletal injury
rest, ice, compression, elevation
children <3 y <65 lbs with femur fx
Swelling in a confined space that produces dangerous pressure; may cut off blood flow or damage sensitive tissue.
an area of bone tissue death caused by insufficient blood flow
A condition resulting from damaging a muscle or tendon
injury to a ligament
reduction of a fracture
return of a fractured bone to a normal position
fracture treatment in which pins or a plate are placed directly into the bone to hold the broken pieces in place
the fixation of a fractured bone from the outside
a pull to the arm or leg muscles to bring a bone back into place when it is dislocated or fractured
Interventions for traction
-maintain proper alignment
-ensure weights are hanging freely and not touching the floor
-do not remove or lift weights without HCP orders
-check ropes for fraying
interventions for skeletal traction
-monitor color, motion, and sensation of affected extremity
-monitor insertion sites of redness, swelling, drainage, or pain
-clean insertion site as prescribed
Freely floating fat globule in the blood stream, which can obstruct blood circulation to vital organs (e.g., heart, brain). Usually caused by injury to subcutaneous tissue or a bone fracture that allows fat release.
A patient with an arm fracture is complaining of increasing pain in that is unrelieved when you provide interventions. You check his fingers to see a pale/bluish color, an increased capillary refill, and little to no pulse. What can you suspect?
increase in the number of white blood cells
inflammation of bone and bone marrow
Your patient with an external fixation to a femur fracture is running a fever of 102 F. His is insertion site is red and swollen and when you get the labs back his WBC and ESR are elevated. You call the HCP suspecting?
a chronic autoimmune disorder in which the joints and some organs of other body systems are attacked
progressive cartilage degeneration and loss of cushioning
A pt with osteoporosis is at risk for what?
hereditary metabolic disease that is a form of acute arthritis, characterized by excessive uric acid in the blood and around the joints
Normal BUN levels
normal serum creatinine
What test provides the best estimate for GFR
IVP (intravenous pyelogram)
Is a special x-ray examination of the kidneys, bladder, and ureters
What does painless bleeding usually indicate?
the dilation (swelling) of one or both kidneys
Treat of hydronephrosis
-Nephrostomy Tube to empty the kidneys
-Cycstopic kidney biopsy (to determine the cause/cause)
-nephrectomy and removal of lymph glands (if biopsy cancer)
Acute Kidney Injury
the rapid loss of kidney function from renal call damage
Prerenal causes of AKI
Ischemia of the kidney
Intrarenal causes of AKI
prolonged prerenal ischemia
Postrenal causes of AKI
Obstruction of urine flow
Oliguric phase (AKI)
Sudden drop in urine output results in BUN/creatinine elevations, increase sodium, fluid retention
Diuretic phase (AKI)
-urine output goes up...pees a lot
-the patient is in a fluid volume deficit (shock)
-The potassium will decrease
-Follow up with Acute renal patients, because the recovery could take a year
recovery phase (AKI)
Injury repaired and normal renal function reestablished
Normal PSA level
less than 20
transurethral resection of the prostate
dialysis in which the lining of the peritoneal cavity acts as the filter to remove waste from the blood
What is the main complication of peritoneal dialysis
in a fistula for hemodialysis you should...
Feel the thrill and hear the bruit
rapid change of extracellular fluid composition during dialysis resulting in cerebral edema
normal potassium levels
Normal sodium levels
disequilibrium syndrome s/s
change in level of consciousness!!!!
excessive potassium in the blood
M - Muscle weakness
U - Urine, oliguria, anuria
R- Respiratory distress
D - Decreased cardiac contractility
E - ECG changes
R - Reflexes, hyperreflexia, or areflexia (flaccid)
Side effects of steroids
thinning of skin
thinning of mucus membranes
decrease of lining in the stomach
Arterial steal syndrome
arterial perfusion to hand is compromised due to too much blood diversion associated with AV fistula placement
surgical crushing of a stone
the inability to control the voiding of urine under physical stress such as running, sneezing, laughing, or coughing
emptying of the bladder without the sensation of the need to void
state in which a person experiences involuntary passage of urine that occurs soon after a strong sense of urgency to void
state in which a person experiences an involuntary, unpredictable passage of urine
continuous, unpredictable loss of urine
inflammation of the bladder
inflammation of the renal pelvis and the kidney
inflammation of the urethra
inflammation of a ureter
inflammation of the glomeruli of the kidney
polycystic kidney disease
condition in which the kidney contains many cysts and is enlarged
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