Care Exam 2 Notes

MEDICATION ADMINISTRATION (chap. 35) Medication legislation and standards

o Federal regulations- role is to protect the health of the people by ensuring that medication are safe and effective

Food and drug administration- current enforcers that ensure all medications undergo vigorous testing before going public

o State and local regulation- these laws must conform to federal legislation, often have additional controls, including control of substances not regulated by federal government (alcohol, tobacco)

o Health care institutions and medication laws- health care industries can establish their own policies to meet federal, state, and local regulations.

o Medication regulations and nursing practice- state Nurse Practice Acts have the most influence over nursing practice by

defining scope of nurses professional functions and responsibilities. Primary intent of NPA is to protect the public from unskilled, undereducated and unlicensed personnel

Pharmacological conceptso Drug names- can be the chemical name (N-acetyl-para-aminophenol), generic name

(acetaminophen) and trade name (Tylenol)o Classification- indicates the effect of medication on body system, symptoms the

medication relieves, or desired effect. Usually each class contains more than one drug listed for same health problem

o Medication forms- tablets, capsules, elixirs and suppositories Pharmacokinetics as basis of medication action

o Absorption- the passage of medication molecules into blood from site of medication administration

Route Ability of medication to dissolve Blood flow to site of administration Body surface area Lipid solubility of medication

o Distribution- med. Is distributed to body tissues and organs and specific sites, depends on

Circulation Membrane permeability Protein binding

o Metabolism- after medication reaches site it is metabolized into less active/inactive form that is easier to excrete.

The kidneys, liver, lungs, blood and intestines metabolize medications. If client has problem with an organ that metabolizes medications then the client is

at risk for medication toxicityo Excretion- exit the body through kidneys, liver, bowel, lungs, and exocrine glands.

Chemical makeup up med determines its excretion route Kidneys are main organ for excretion

Types of medication actiono Therapeutic effects- predictable phsyiological response a medication causes.

Knowing desired therapeutic effect for each medication allows the nurse to provide client education and accurately evaluate medications desired effect

o Side effects/adverse effects - side effects are predictable while adverse effects are unintended

Toxic effects- when medication accumulates in blood due to impaired metabolism or excretion

Idiosyncratic- unpredictable effects (child takes benadryl and instead of becoming drowsy they become hyper or agitated)

Allergic reactions- unpredictable responses, some clients can become sensitized to medication and develop allergic response to medication.

Routes of administration- o Oral- easiest and most common

Sublingual- drugs are absorbed under the tongue (nitroglycerin) Buccal- solid medication placed in mouth against the mucous membrane of

cheek. o Parenteral- injections

Intradermal (ID)- inject into the dermis, just under the epidermis Subcutaneous (sub-Q)- inject into tissue below dermis Intramuscular (IM)- inject into muscle Intravenous (IV)- inject into vein Some are administered to other body cavities

Epidural- epidural space via catheter Intrathecal- catheter in subarachnoid space or into one of the ventricles of

brain. Intraosseous- infusion of meds directly into bone marrow (commonly used

in emergencies when IV access is impossible) Intraperitoneal- administered in the peritoneal cavity and absorbed by

ciculation Intrapleural- injection or chest tube directly into pleural space Intrarterial- administered directly into arteries

o Topical- applied to skin and mucous membraneso Inhalation- readily absorbed and work rapidlyo Intraocular- inserting medication similar to contact lens into the eye

Nursing Knowledge base

Know clinical calculations Prescribers role - prescribers must document the diagnosis, condition, or need for use for

EACH medication ordered. Types of orders in acute care agencies

o Standing orders- carried out until prescriber cancels it or until prescribed number of days elapse. Often has final date or number of doses

o Prn orders- given only when client needs it. Use objective and subjective assessment in determining whether or not the client needs it.

o Single-(ex: valium before a surgery)o STAT - single dose of med is to be given immediately

o Now orders- when client needs a medication quickly but not right away. Nurse has up to 90 minutes to administer.

o Prescriptions- taken out of hospital Distribution systems

o Unit dose- use carts with drawer of 24 hour supply for each client. Cart is filled by pharmacist or pharmacy tech.

o Automated medication dispensing system- control the dispensing of meds including narcotics. Clients name is pulled up then the med is pulled out, charging that med to that client.

Medication errorso Steps to take

Follow 6 rights of med administration Read labels at least 3 times Use at least 2 client identifiers Allow no interruptions Double check calculations Don’t interpret illegible handwriting; clarify with prescriber Question unusually large or small doses Document all meds AS SOON as they are given If error is made reflect what went wrong Evaluate context or situation error occurred

o Medication reconciliation- comparison of all meds current meds with previous settingVERIFY- obtain current list of clients medsCLARIFY- make sure list of med, dosages and frequencies is accurate, clarify with othersRECONCILE- compare new med orders with current list; investigate discrepanciesTRANSMIT- communicate the updated and verified list to caregivers and client

Critical thinking Knowledge- know why physician prescribed med and how med will alter clients physiology

to have therapeutic effect Experience Attitudes- through discipline you take adequate time to prepare and administer meds. Standards- be aware of hospitals limitations and follow the 6 rights

o Right medication- compare prescribers order with MAR, verify med information whenever new MARs are written, or pt transfers. When verified it is accurate, then use the MAR to prepare and administer. Compare the label of medication with MAR 3 times.

o Right dose- have another qualified nurse check calculations, use graduated cups, syringes, and scaled droppers to measure accurately

o Right client- use 2 client identifiers, these include the clients name, identification number, or telephone number

In acute setting you can use the MAR with client identification while at bedside The TJC does not require clients to state their names and other identifiers when

administering meds, you can use this once they are admitted (with wristband) o Right route-

o Right time- know why a medication is ordered for certain times of the day and if it can be altered at all.

o Right documentation- ensure accurate and appropriate documentation exists before and after giving meds.

Before administering ensure that documentation in MAR clearly reflect clients full name, the name of ordered med written in full form, the time med is to be given, and meds dosage, route and frequency. Nurses have 6 rights for safe medication administration

o Right to a complete and clearly written ordero Right to have correct drug route and dose dispensedo Right to have access to informationo Right to have policies on medication administrationo Right to administer medication safely and to identify problemso Right to stop, think, and be vigilant

o Maintaining clients rights... Right to be informed of medications name, purpose, action and potential

undesired effects To refuse medication regardless of consequences To have qualified nurses and physicians assess a medication hx To be properly advised of experimental nature of med therapy To receive labeled medications safely without discomfort in accordance with 6

rights of med administration To not receive unnecessary medications To be informed if medication are a part of research study

NURSING PROCESS AND MEDICATION ADMINISTRATION

Assessmento Obtain or review clients medical hxo Hx of allergies- o Medication data- assess information about each medication client takes, including how

long they have been taking it, current dose, and whether or not client experienced adverse effects.

o Diet hx- this reveals normal eating patterns and food preferences to allow the nurse to plan the dosage schedule more effectively and teaches client to avoid foods that will interact with meds

o Clients perceptual/coordination problems- assess clients ability to prepare doses and take medications correctly

o Clients current condition- assess a client carefully before giving any medication!o Clients attitude about medication use- observe clients behavior for evidence of

medication dependence or avoidanceo Clients knowledge and understanding of medication therapyo Clients learning needs

Diagnosiso Select the dx then identify the related factors. Diagnosis in med administration could

be Anxiety, ineffective health maintenance, health seeking behaviors, deficient

knowledge, noncompliance, disturbed visual sensory perception… Planning

o Goals and outcomes Ex: Goal- the client will safely administer all ordered medications before

discharge. Outcomes- client with verbalize understanding of desired effects and

adverse effects of medication The client will state s/s and treatment of hypoglycemia Client will be able to monitor blood glucose level

o Set priorities- o Collaborative care

Implementationo Health promotion- teach the client and family about the benefits of a medication and

the knowledge needed to take it correctly, and integrate clients health beliefs and cultural practices into treatment plan.

o Acute care- when med order is received many interventions are essential for safe and effective med administration.

Ensure med order contains… Clients full name Date and time order is written Medication name Dose Route of administration Signature of physician, NP, or PA

Correct transcription and communication of orders Accurate dose calculation and measurement Correct administration- use aseptic techniques and proper procedures when

handling meds Record medication administration IMMEDIATELY on appropriate record form

Evaluationo Monitor clients response on an ongoing basis

Review purple pages to learn how meds can be administered.

Safe and accurate administration of medications is one of your most important responsibilities. You are responsible for understanding the following about medications:

Expected actions Dosage Desired effects and/or purpose Possible adverse reactions Interactions

Contraindications Precautions Pharmacokinetics

Mechanism of Action

When a medication is administered to a client, a predictable chemical reaction changes the physiologic activity of the body. This most commonly occurs when a medication bonds chemically to a specific site called a receptor site. These reactions are possible only when the receptor site and the chemical fit together like a key in a lock.When the chemical fits well, the chemical response is good. We call these medications agonists.Some medications attach at the receptor site without producing a new chemical reaction. These medications are called antagonists.Other medications attach and produce only a small response or prevent other reactions from occurring. These medications are called partial agonists. Peak and Troughs The therapeutic levels of certain medications, such as antibiotics, can be monitored by laboratory tests:

The lowest serum level is the trough level. Blood samples for trough levels are usually drawn 30 minutes before the medication is administered.

The highest serum concentration or peak concentration of medication usually occurs just before the last of the medication is absorbed.

Blood samples for peak levels are drawn to coincide with the time that the medication is expected to reach its peak concentration. This varies with medication pharmacokinetics.

Precise coordination with the laboratory is essential for drawing blood specimens for the peak and trough levels on time and thus obtaining meaningful information. These data allow physicians to modify medication dosages.

Safe Medication Administration Pre-Procedure Preparation

• Before you begin: Use good medical aseptic technique.o Perform hand hygiene before preparing a dose of medication andbefore administering it.o Wear clean gloves if there is a chance of contacting body fluids.o Avoid touching tablets and capsules.o Use sterile technique for parenteral medications.• Identify your client by inspecting the ID bracelet and asking the client tostate his or her name.• Explain what you will be doing and why, which should resolve anyconcerns and fears that your client has about what you are going to do.• If appropriate, provide privacy.

6 RIGHTS OF MEDICATION ADMINISTRATION 6 Rights for Administration of MedicationRight Client: The right client can be ensured by verifying that the medication record and the client wristband agree. This means that the client's name, health care provider's name, and the client's facility number are the same on both. You also verify the "right client" by asking the client to state his or her name. Two identifiers (e.g., comparing the MAR to the client's ID bracelet and asking the client to state name) are required to identify the client (neither identifier can be the client's room number) when administering medications (JCAHO, 2004).Right Drug: The right medication can be ensured by reading the label or medication form carefully three times:

When picking up the medication or bottle Just before preparing the medication for dispensing Before either throwing the unit-dose package away or before putting the

bottle back in the drawer or cupboard where it is storedYou must know the use of the specific medication and the expected dosage ranges and compare these to the client's health conditions being treated and the dosage ordered. If at any time you identify an incorrect spelling of a medication name, a medication label that fails to match the order or is unreadable, or a dosage outside the accepted range for that medication, you should clarify the order with either the pharmacy that dispensed the medication or the health care provider who ordered the medication. This aspect of the "6 rights" cannot be emphasized enough. Many medication errors could be avoided with full adherence to this step in administering medications.Right Dose: Check the right dose by looking the medication up in a drug reference. If the medication is relatively new to the market and unavailable in a drug reference, check with the pharmacy that dispensed the medication. The pharmacy will have the information you need to ensure the correct medication in the correct dosage. If you note a discrepancy between the recommended dose and the dose ordered, you must contact the pharmacy that dispensed the medication or the health care provider that ordered the medication. You must be able to calculate, accurately, the correct dosage to be given.Right Time: The right time for administration involves administering the correct medication in the correct dose within the acceptable time frame. Once medication administration is started, the goal is to maintain therapeutic serum

levels of the medication. In most instances, the medication can be considered given "on time" if administered within one-half hour before to one-half hour after the time the medication is ordered to be given.Right Route: The right route refers to the route by which the medication is to be administered. If a prescriber's order does not designate a route, or if the route is not the recommended one, you must consult the prescriber.Right Documentation: The right documentation refers to the charting of the time that the medication is given as soon as possible after the medication has been administered. This documentation should be placed on the MAR under the correct date and time. Common Dosage Administration Schedules

Dosage Schedule Abbreviation

Before meals AC, ac

As desired ad lib

Twice a day BID, bid

Hour h

At bedtime hs (hour of sleep)

After meals PC, pc

Whenever there is a need prn

Every morning, every am Qam

Every day, daily daily

Every hour Qh

Every 2 hours q2h

Every 4 hours q4h

Every 6 hours q6h

Every 8 hours q8h

4 times a day QID, qid

Every other day every other day

Give immediately STAT

3 times a day TID, tid

MEDICATION ADMINISTRATION

1. The nurse is having difficulty reading a physician's order for a medication. The nurse knows the physician is very busy and does not like to be called. The nurse should:A) Call a pharmacist to interpret the order.B) Call the physician to have the order clarified.C) Consult the unit manager to help interpret the order.D) Ask the unit secretary to interpret the physician's handwriting. It is the nurse's responsibility to ensure that the medication orders are correct. Asking a unit manager or pharmacist to help interpret an order is always helpful, but the nurse is still responsible. A unit secretary can help with reading handwriting, but the nurse is still responsible.Points Earned: 1.0/1.0 Correct Answer(s): B 2. The client has an order for 2 tablespoons of milk of magnesia. The nurse converts this dose to the metric system and gives the client:A) 2 mlB) 5 mlC) 16 mlD) 30 ml Each teaspoon is 5 ml and 2 tablespoons is 6 teaspoons, so 5 × 6 = 30 ml.Points Earned: 1.0/1.0 Correct Answer(s): D 3. Most medication errors occur when the nurse:A) Is caring for too many clientsB) Fails to follow routine proceduresC) Is administering unfamiliar medicationsD) Is responsible for administering numerous medications Medication errors occur most often when the nurse fails to follow the routine procedures that are in place to ensure client safety. The other options are not correct if the nurse follows the protocols.Points Earned: 0.0/1.0 Correct Answer(s): B 4. A client is to receive cephalexin (Keflex) 500 mg by mouth. The pharmacy has sent 250-mg tablets. The nurse gives:A) ½ tabletB) 1 tablet

C) 1½ tabletsD) 2 tablets Two 250-mg tablets = 500 mg.Points Earned: 1.0/1.0 Correct Answer(s): D 5. When identifying a new client before administering medications, the nurse asks the client to state his name. The client does not give the correct name. The nurse asks again and the client states still another name. What is the nurse's next action?A) Laugh at the client and tell him to "quit kidding."B) Give the medications without any further questioning.C) Investigate the client's mental status before administering any further medications.D) Look at the client's arm band to identify the client and disregard what the client said. The ongoing physical and mental status of a client affects whether a medication is given or how it is administered. The client should be assessed carefully before administering any medication. The nurse should always check the client's arm band to ensure that this is the correct client for the given medication, even if the client responds with the correct name. The client should always be identified using at least two identifiers before administering medication, preferably by comparing the client identifiers on the MAR with the client's arm band at the bedside.Points Earned: 1.0/1.0 Correct Answer(s): C 6. A client is transitioning from the hospital to the home environment. A home health referral has been obtained. In terms of safe medication administration, what is a priority for the discharge nurse?A) Set up the follow-up physician appointments for the client.B) Ensure that someone will provide housekeeping for the client at home.C) Make sure that the client has plenty of diapers and blue pads to take home.D) Ensure that the home health care agency is aware of medication and health teaching needs. The home care agency should be aware of the medication and health teaching needs of all clients. The other options are issues that should be addressed, but the question is specifically asking regarding safe medication administration, so this answer is the only one that answers the question correctly.Points Earned: 1.0/1.0 Correct Answer(s): D 7. A nursing student takes a client's antibiotic to his room. The client asks the nursing student what it is and why he should take it. The nursing student should:

A) Inform the client that only the client's physician can give this information.B) Provide the name of the medication and a description of its desired effect.C) Tell the client that information about medications is confidential and cannot be shared.D) Explain that, because of the limits placed on nursing students, the client will have to speak with his assigned nurse about this. The nursing student should know the name, dose, and purpose of all medications that he or she is responsible for administering. Part of client teaching is sharing this information with the client, so the student should be able to verbalize this information to the client. This information is not confidential, and the student nurse should present this information without waiting for a physician or the client's assigned nurse.Points Earned: 0.0/1.0 Correct Answer(s): B 8. The nurse is administering a sustained-release capsule to a new client. The client insists that he cannot swallow pills. The best course of action for the nurse is to:A) Ask the physician to change the order.B) Crush the pill with a mortar and pestle.C) Hide the capsule in a piece of solid food.D) Open the capsule and sprinkle it over pudding. Sustained-release medications should never be crushed or sprinkled on food. Hiding the capsule in a piece of solid food is not an appropriate nursing step. The nurse should contact the physician for an order change.Points Earned: 0.0/1.0 Correct Answer(s): A 9. The nurse selects the route for administering medication according to:A) Hospital policyB) The prescriber's ordersC) The type of medication orderedD) The client's size and muscle mass Facilities have protocols for medication administration that the nurse must follow. If a physician's order contradicts the protocols, then the order must be clarified with the physician and the protocol explained. The protocol will include specifics for the type of medication ordered and the client's size and muscle mass.Points Earned: 0.0/1.0 Correct Answer(s): B

10. A client is receiving an intravenous (IV) push medication. If this type of drug infiltrates into the outer tissues the nurse will:A) Continue to let the IV run.B) Apply a warm compress to the infiltrated site.C) Follow facility policy or the drug manufacturer's directions.D) Not worry about this because vesicant filtration is not a problem. The infusion of the medication should be halted and the facility policy or drug manufacturer's directions followed. Infiltration of some medications will create no harm. For others, harm can be averted by the application of warm compresses. Still others may require other treatments if infiltration occurs.Points Earned: 0.0/1.0 Correct Answer(s): C 11. If a client who is receiving intravenous (IV) fluids develops tenderness, warmth, erythema, and pain at the site, the nurse suspectsA) Sepsis.B) Phlebitis.C) Infiltration.D) Fluid overload. Warmth, redness, and tenderness of an IV site indicate phlebitis. Infiltration usually presents as a cool, swollen, and pale IV site. Sepsis is an infection, and signs of sepsis may or may not be present at the site. Fluid overload will not produce specific changes at the IV site.Points Earned: 0.0/1.0 Correct Answer(s): B 12. A nurse administering medications has many responsibilities. Among these responsibilities is a knowledge of pharmacokinetics. Which statement is the best description of pharmacokinetics?A) The passage of medication molecules into the blood from the site of administrationB) The degree to which medications bind to serum proteins, which affects distributionC) The study of how medications enter the body, reach their site of action, metabolize, and exit the bodyD) The method by which a medication, after absorption, is moved within the body to tissues, organs, and specific sites of action Pharmacokinetics is the study of how medications enter the body, travel to the site of action, metabolize, and exit the body. Distribution refers to the method by which medication, after absorption, is moved within the body. Absorption is the passage of medication molecules into the blood from the site of administration. The degree to which medications bind to serum protein is protein binding.Points Earned: 0.0/1.0 Correct Answer(s): C

13. A nurse provides a medication to a client. Who has the ultimate responsibility for the medication that is being administered?A) The client taking the medicationB) The nurse administering the medicationC) The pharmacist providing the medicationD) The physician, advanced practice nurse, or physician's assistant prescribing the medication The nurse does not have sole responsibility for medication administration. However, the nurse administering the medication is accountable for knowing which medications are prescribed for the client, their therapeutic and nontherapeutic effects, the nursing implications, and the level of the client's knowledge. The prescriber and the pharmacist also help to ensure the right medication gets to the right client.Points Earned: 0.0/1.0 Correct Answer(s): D 14. The following orders were written by a prescriber (physician, advanced practice nurse, physician's assistant). Which order is written correctly?A) Aspirin 2 tablets prnB) Haloperidol (Haldol) ½ tablet at bedtimeC) Zolpidem (Ambien) 5 mg PO at bedtime prnD) Levothyroxine (Synthroid) 0.05 mg 1 tablet The order for zolpidem is the only medication order that contains the essential components of a drug order—name of medication, dose, route of administration, and frequency.Points Earned: 0.0/1.0 Correct Answer(s): C 15. To better control the client's blood glucose level, the physician orders a high regular insulin dosage of 20 units of U-500 insulin. The nurse has only a U-100 syringe. How many units will be given?A) 4B) 5C) 10D) 20 U-500 insulin is 5 times as strong as U-100 insulin. Therefore the amount of U-500 insulin should be divided by 5; 20 units ÷ 5 = 4 units.Points Earned: 0.0/1.0 Correct Answer(s): A

16. The nurse is administering an intramuscular (IM) injection. The Z-track method is recommended for IM injections because:A) It is easier for the nurse to use.B) It allows for repeated injections into the same site.C) It does not require the nurse to aspirate before injecting the medication.D) It minimizes local skin irritation by sealing the medication in muscle tissue. The Z-track method minimizes local skin irritation, providing more comfort for the client. Repeated injections in the same muscle can cause severe discomfort and poor absorption. The Z-track method of injection is not easier but requires practice by the nurse to achieve a smooth injection technique because of the increased number of steps in the method. Aspiration is still required when the Z-track method is used.Points Earned: 0.0/1.0 Correct Answer(s): D 17. What is the best nursing practice for administrating a controlled substance if part of the medication must be discarded?A) The nurse documents on the medication administration record.B) The nurse discards the unused portion and documents on the control inventory form.C) The nurse does not discard any controlled substance to prevent environmental contamination.D) The nurse documents on the medication administration record and the control inventory form, and has a second nurse witness the medication being discarded. The nurse signs both records and has a second nurse witness the discarding of the controlled substance and also sign the control inventory form. Agency policy dictates how the substance is discarded to avoid environmental concerns.Points Earned: 0.0/1.0 Correct Answer(s): D 18. When administering medications, it is essential for the nurse to have an understanding of basic arithmetic to calculate doses. The physician has ordered 250 mg of a medication that is available in 1-g amount. The vial reads 2 ml = 1 g. What dose would be given by the nurse?A) 0.25 mlB) 0.5 mlC) 1 mlD) 2.5 ml 0.5 ml = 250 mg of this medication.(Dose ordered/dose on hand) × amount on hand = amount administered[250 mg/1000 mg (1 g)] × 2 ml = 500/1000 = ½ ml or, in decimals, 0.5 mlPoints Earned: 0.0/1.0 Correct Answer(s): B

19. While the nurse is administering medication, the client says, "This pill looks different from what I usually take." What is the nurse's best action?A) Go recheck the medication order, taking along the medication.B) Ignore the statement because the client has a history of confusion.C) Leave the medication at the bedside and go recheck the order.D) Tell the client that pill manufacturers often change the color of pills. This is a safety issue and should not be ignored. Leaving the medication at the bedside is an unsafe practice and does not demonstrate the nurse's responsibility. If checking the medication order does not clarify the situation, then the nurse should check with the pharmacist regarding pill shape, color, and so on. Different manufacturers will design their own brands to look different from their competitors' brands. Checking the client's statement can avoid a potential medication error, and the client appreciates the efforts of the nurse.Points Earned: 0.0/1.0 Correct Answer(s): A 20. The client is a 40-year-old man who weighs 160 lb and is 5 feet 9 inches tall. The order is for 5 ml of a medication to be given as a deep intramuscular (IM) injection. What size of syringe and gauge and length of needle should the nurse use for best practice?A) One 5-ml syringe, 20- to 23-gauge 1-inch needleB) Two 2-ml syringes, 25-gauge 1-inch needleC) Two 3-ml syringes, 23-gauge, ½-inch needleD) Two 3-ml syringes, 20- to 23-gauge, 1½-inch needle A medication dose of 5 ml administered IM is unlikely to be absorbed properly. Therefore, dividing the dose is correct. Dividing the doses equally allows 2.5 ml to be given in two different sites, so the nurse will need two 3-ml syringes. A deep IM injection must pass through subcutaneous tissue and penetrate deep muscle; therefore the needle must be long enough (1½ inch) and the gauge heavy enough (20 to 23 is the best choice).Points Earned: 0.0/1.0 Correct Answer(s): D 21. A site that was a traditional location for intramuscular (IM) injections in the past is no longer recommended because its use carries the risk of striking the underlying sciatic nerve or major blood vessel. What is the name of this site?A) PlexorB) DorsoglutealC) VentroglutealD) Vastus lateralis

The dorsogluteal is the not-so-safe traditional site. The ventrogluteal muscle is situated deep and away from major nerves and blood vessels. The vastus lateralis muscle is thick and well developed. The plexor is the middle finger of the dominant hand used during percussion or a percussion hammer used to strike the pleximeter and is not related to IM sites.Points Earned: 0.0/1.0 Correct Answer(s): B

ACTIVITY AND EXERCISE (chap. 37) Principals of safe client transfer and positioning

When client is able to assist…o The wider the base of support, the greater your stabilityo The lower the center of gravity, the greater your stabilityo The equilibrium of an object is maintained as long as the line of gravity passes through its

base supporto Facing the direction of movement prevents abnormal twisting of the spineo Dividing balanced activity between arms and legs reduces the risk of back injuryo Leverage, rolling, turning, or pivoting requires less work than liftingo When friction is reduced between the object to be moved and the surface on which it is

moved, less force is required to move it.

Nursing processAssessment:

Assess the clients body alignment (standing and sitting), posture, and mobility (ROM, gait) Identify the impact of activity and exercise pattern on clients overall level of health Assess clients routine exercise pattern Observe the clients body systems' response to activity and exercise

Diagnosis:

Examples of nsg dx.- activity intolerance, ineffective coping, impaired gas exchange, risk for injury, impaired physical mobility, imbalanced nutrition, acute or chronic pain. Planning:

Consult/collaborate with members of health care team to increase activity Involve the client and family in designing an activity and exercise plan Consider clients ability to increase activity level

Implementing:

Health promotion- promotion of engagement in exercise routine Body mechanics-teach proper technique with assistive equipment, and body mechanics Acute care-

o Musculoskeletal system- encourage stretching and isometric exerciseo Join mobility- ROM exerciseso Walkingo Helping client to walk

Restorative and continuing care

o Assistive devices for walkingo Walkerso Caneso Crutches- teach the client….

not to lean on crutches About the dangers of pressure on axillae Explain why clients need to use crutches that were measured for them specifically Show client how to routinely inspect crutch tips Explain the crutch tips need to remain dry Show client how to inspect the structure of crutches

Some of the conditions that oxygen therapy is used for include: documented hypoxemia severe respiratory distress (e.g., acute asthma or pneumonia) severe trauma acute myocardial infarction short-term therapy, such as post-anesthesia recovery

OXYGENATION

1. Apply knowledge of normal anatomy and physiology of the respiratory system.

Nasal cannula 1-6 L/min; 24-44% oxygen delivered

Simple face mask 5-10 L/min; 30-60& oxygen delivered

Applying a Nasal Cannula or an Oxygen Masko Clients with sudden changes in their vital signs, level of consciousness, or

behavior are often experiencing profound Hypoxia. Inspect client for signs and symptoms associated with hypoxia and

presence of airway secretions. Left untreated, hypoxia produces cardiac dysrhythmias and death.

Presence of airway secretions decreases effectiveness of oxygen therapy.

Obtain clients most recent Sp02 or ABG value. Gives baseline to compare outcome of 02 therapy

Explain to client and family what is happening Decreases anxiety and increases cooperation

Perform Hand Hygiene Reduces transmission of infection

Attach nasal cannula to into clients nares, adjust elastic, attach to humidified O2 source, adjust to prescribed flow rate.

Prevents drying of the nasal and oral mucosa and airway secretions Place tips in the nares, adjust headband, until it is snugly fit and

comfortable. If using an O2 mask, adjust elastic headband until mask fits comfortably over the clients face and mouth

Maintain sufficient slack on O2 tubing, and secure to clients clothes. Allows client to turn head without dislodging.

Check cannula every 8 hours or with changes in clients cardiopulmonary status. Keep humidification jar filled at all times.

Ensures patency and of cannula and O2 flow. Prevents inhalation of dehumidified O2

Observe clients nares and superior surface of both ears for skin break down.

O2 therapy causes drying of the nasal mucosa. Pressure on ears from cannula or tubing or elastic causes skin irritations.

Check O2 flow rate and Physicians orders at least every 8 hours or with changes in the clients Cardiopulmonary status.

Ensures delivery of prescribed O2 flow rate and patency of cannula Inspect client for relief of symptoms associated with hypoxia.

Indicates that hypoxia was corrected or reduced. Venturi mask

2-14 L/min; 24-55% oxygen delivered

Non-rebreather mask 10-15 L/min; 80-100% oxygen delivered

Appropriate nursing interventions for the patient receiving oxygen therapy.Nursing Interventions

NO SMOKING, sparks or igniting agents Oral care & humidification Assess/prevent oxygen toxicity

o Prolonged high percentage oxygen causing cell damage Monitor dosage of oxygen delivered Patient teaching: care and cautions

Procedure for using a pulse oximeter.

A pulse oximeter permits the indirect measurement of oxygen saturation. It is a probe light with a LED and a photodetector connected by a cable to an oximeter. Oxygenated and deoxygenated Hg molecules absorb light differently. It detects the amount of O2 bound to the Hg molecules. It measures (Sp02) Pulse Oxygen Saturation.

Oxygen saturation Noninvasive technique that measures continuous oxygenated hemoglobin in arterial

blood Less expensive Clean, dry, warm finger, ear lobe, toe; remove every 2hrs for skin care Remove nail polish, artificial nails select alternative site Range 95 – 100%

Differentiate between the different types of artificial airways. Oropharyngeal airway

Measurement importanto Measure distance from the corner of the mouth to the angle of the jaw below

the earo Insert with curved tip upward toward roof of mouth then rotate to move

tongue

o

Nasopharyngeal airway Measurement same as oropharyngeal

Reasons for Chest Tubes

Pleural space is incised Trauma, Surgery, Disease process, spontaneous

Atmospheric air enters pleural space Negative pressure changes to a positive pressure Lung collapses

Purposes

Remove air &/or fluids from pleural spaceo Pneumothorax

o

o Hemothorax

o

Prevent air or fluid from reentering Reestablish normal pressures

Prioritize nursing actions appropriate for a patient with a chest tube(s) Nursing Interventions

Assist (ONLY!) with insertion & removal - is pain medication important during this procedure?

Assess chest drainage Observe for bubbling

o Intermittento Continuouso Rapid/Excessive

While chest tube in placeo Monitor respiratory status & vital signso Check dressingso Maintain patency & integrity of systemo Do not empty drainage system

Removal of chest tubeo Lung reexpandedo Verified by chest x-ray, auscultation

Pleural Drainageo 3 Compartments

Collection Chamber, receives fluid and air from chest cavity. Fluid stayes in this chamber while air moves to the second chamber

Water-seal chamber, contains 2 cm of H2O, which acts as a one way valve. The incoming air enters from the collection chamber and bubbles up from the water. The air then exits the water-seal and enters the suction control chamber

Suction control chamber, applies controlled suction to the chest drainage system. When the negative pressure generated by the suction source exceeds the 20 cm, air from the atmosphere enters the chamber vent on top and the air bubbles up through the water.

Plan, implement, and evaluate nursing care of the patient with a chest tube(s) in terms of: Assessment of respiratory status.

Assess respirations, presence of chest pain, breath sounds over affected area S/S of increased respiratory distress and or chest pain.

Marked cyanosis, asymmetrical chest movements, hypotension, tachycardia Vital Signs and SpO2 Comfort level

Ensuring proper function of the closed chest drainage system. Check chest tube dressing and site of surrounding tube insertion.

Apply clean gloves if drainage is present Keep chest drainage system upright and below level of insertion or you will get backflow

into chest. Assessing level of fluid drainage.

Note amount of drainage in system. Maintaining patency of the chest tube(s)

Check tubing for kinks, dependent loops of knots

Position client in Fowlers position to evacuate Air High-Fowlers to drain fluid.

EVOLVE QUESTIONS1. A person who starts smoking in adolescence and continues to smoke into middle age:A) Has an increased risk for alcoholismB) Has an increased risk for obesity and diabetesC) Has an increased risk for stress-related illnessesD) Has an increased risk for cardiopulmonary disease and lung cancer Feedback: INCORRECT The risk of lung cancer is 10 times greater for a person who smokes than for a nonsmoker. Cigarette smoking worsens peripheral vascular and coronary artery disease. Inhaled nicotine causes vasoconstriction of peripheral and coronary blood vessels, increasing blood pressure and decreasing blood flow to peripheral vessels.

Points Earned: 0.0/1.0

Correct Answer(s): D

2. Carbon monoxide (CO) is a toxic inhalant that decreases the oxygen-carrying capacity of blood by:A) Forming a weak bond with hemoglobinB) Forming a strong bond with hemoglobinC) Forming a weak bond with carbamino compoundsD) Forming a strong bond with carbamino compounds Feedback: INCORRECT CO is the most common toxic inhalant and decreases the oxygen-carrying capacity of blood. In CO toxicity, hemoglobin strongly binds with carbon monoxide, creating a functional anemia. Because of the strength of the bond, carbon monoxide does not easily dissociate from hemoglobin, which makes hemoglobin unavailable for oxygen transport.


Correct Answer(s): B

3. Conditions such as shock and severe dehydration resulting from extracellular fluid loss cause:A) HypoxiaB) HypovolemiaC) HypervolemiaD) Uncontrolled bleeding Feedback: INCORRECT Conditions such as shock and severe dehydration cause extracellular fluid loss and reduced circulating blood volume (hypovolemia).



4. Fever increases the tissues' need for oxygen, and as a result:A) Metabolic demands decreaseB) Blood glucose stores stabilizeC) Carbon dioxide production increasesD) Carbon dioxide production decreases Feedback: INCORRECT Fever increases the tissues' need for oxygen, and as a result, carbon dioxide production increases. When fever persists, the metabolic rate remains high and the body begins to break down protein stores, which results in muscle wasting and decreased muscle mass.


Correct Answer(s): C

5. Left-sided heart failure is characterized by:A) Increased cardiac outputB) Lowered cardiac pressuresC) Decreased functioning of the left atriumD) Decreased functioning of the left ventricle Feedback: INCORRECT Left-sided heart failure is an abnormal condition characterized by decreased functioning of the left ventricle. If left ventricular failure is significant, the amount of blood ejected from the left ventricle drops greatly, which results in decreased cardiac output.



6. Cyanosis, the blue discoloration of the skin and mucous membranes caused by the presence of desaturated hemoglobin in capillaries, is:A) A late sign of hypoxiaB) An early sign of hypoxiaC) A sign of a non–life-threatening condition

D) A reliable measure of oxygenation status Feedback: INCORRECT Cyanosis, blue discoloration of the skin and mucous membranes caused by the presence of desaturated hemoglobin in capillaries, is a late sign of hypoxia. The presence or absence of cyanosis is not a reliable measure of oxygen status.


Correct Answer(s): A

7. A simple and cost-effective method for reducing the risks of stasis of pulmonary secretions and decreased chest wall expansion is:A) Administration of antiinfectivesB) Chest physiotherapyC) Oxygen humidificationD) Frequent change of position Feedback: INCORRECT Changing the client's position frequently is a simple and cost-effective method for reducing the risk of pneumonia associated with stasis of pulmonary secretions and decreased chest wall expansion. Oxygen humidification, chest physiotherapy, and use of antiinfectives are all helpful, but are not cost effective.



8. The nurse is concerned when a client's heart rate, which is normally 95 beats per minute, rises to 220 beats per minute, because a rate this high will:A) Exhaust the clientB) Decrease metabolic rateC) Reduce coronary artery perfusionD) Provide too much blood flow to major organs Feedback: INCORRECT Coronary arteries fill and perfuse the myocardium (heart muscle) during diastole. When the heart rate is elevated, more time is spent in systole and less in diastole; hence, the myocardium may not be perfused adequately. The client may be exhausted, but the primary concern is myocardial perfusion. Major organs will adjust to increased blood flow. This is usually not a problem. With a heart rate this high, metabolic rate will be increased, not decreased.



9. A client is admitted to the emergency department with a suspected cervical spine fracture at the C3 level. The nurse is most concerned about the client's ability to:A) BreatheB) AmbulateC) Maintain cardiac outputD) Be oriented to person, place, and time Feedback: INCORRECT

Spinal cord injury at the level of C5 or above often results in damage to the phrenic nerve, which innervates the diaphragm and permits breathing. Cardiac output is not usually affected by spinal cord injury; however, cardiac output may be reduced as a result of trauma and blood loss. It is too early to be concerned with ambulation. Life-threatening problems take priority. Level of consciousness is certainly an important consideration, because this client most likely sustained a head injury. However, this is not a certainty given the data provided.



10. When suctioning secretions that are collecting in an endotracheal tube, the nurse does not apply suction for longer than:A) 5 secondsB) 10 secondsC) 15 secondsD) 20 seconds Feedback: INCORRECT Applying suction for too long can result in complications such as hypoxemia and cardiac dysrhythmias. Thus the nurse is always aware of the length of time that suctioning is applied to an airway. If the suctioning time is too short, the suction catheter may not remove the secretions. If the suctioning time is too long, hypoxemia and/or cardiac dysrhythmias could result.



11. The nurse is caring for a client with a chest tube in the right thorax. On first assessment the nurse notes that there is bubbling in the water-seal chamber. This client is scheduled to undergo a chest x-ray examination, and the transporters have arrived to take him by wheelchair to the radiology department. The nurse considers whether the chest tube should be clamped or not during the trip to the radiology department. The nurse makes the which correct decision?A) Clamp the chest tube, but vent the system to air.B) Clamp the chest tube and disconnect it from the wall suction.C) Do not clamp the chest tube and disconnect it from the wall suction.D) Do not clamp the chest tube and connect it to temporary intermittent suction. Feedback: INCORRECT A bubbling chest tube (in the water-seal portion) should never be clamped because it provides the only exit for air accumulating in the pleural space. If the tube is clamped, tension pneumothorax could occur, which could be fatal. There is no advantage to clamping the chest tube but venting the system. Clamping of the chest tube prevents communication of the chest tube with the venting system or with the wall suction. There is no such thing as "temporary suction" for a chest tube system.



12.

A client is receiving oxygen via a nonrebreathing mask. A crucial nursing assessment the nurse performs is to be sure that:A) The oxygen flow meter is set at 2 L/min.B) The mask is connected to a heating element.C) The bag attached to the mask is inflated at all times.D) The straps securing the mask are not causing skin ulcers over the top of the ears. Feedback: INCORRECT If the bag attached to a nonrebreathing mask is deflated, the client is at risk for breathing in large amounts of exhaled carbon dioxide. The bag should be maximally inflated at all times. Checking the straps to make sure they are not causing skin ulcers is important but not crucial. For a nonrebreathing mask 2 L/min is far too low a flow setting. The oxygen flow should be set at 10 L/min or more. Otherwise, the bag will collapse. Heating the fluid used to increase humidity is not essential.



13. A client with known chronic obstructive pulmonary disease (COPD) is admitted to the emergency department with multiple minor injuries following an automobile accident. To ensure adequate ventilation the nurse applies a nasal cannula providing oxygen at what rate and for what reason?A) 6 L/min to provide sufficient oxygen to the myocardium following traumaB) 3 L/min to stimulate the respiratory chemoreceptors, which will result in increased respiratory rateC) 10 L/min to suppress the respiratory drive, which is necessary for adequate artificial ventilationD) 2 L/min to prevent elevating the arterial oxygen tension (PaO2), which would suppress the hypoxic drive Feedback: INCORRECT Clients without COPD rely on low PaO2 as a stimulus to breathe. Thus, increasing the PaO2 would stop the client from breathing. Low oxygen therapy is recommended for clients with COPD who are severely hypoxic. Options 1 and 2 give the client too much oxygen and might suppress the client's breathing. Because the client experienced only minor injuries, the client presumably is still breathing on his or her own; therefore, option 3 is incorrect because artificial ventilation is not necessary.



14. The nurse is caring for a client who has undergone cardiac catheterization. The client says to the nurse, "The doctor said my cardiac output was 5.5 L/min. What is normal cardiac output?" Which of the following is the nurse's best response?A) "It is best to ask your doctor."B) "Did the test make you feel upset?"C) "The normal cardiac output for an adult is 4 to 6 L/min."D) "Are you able to explain why are you asking this question?" Feedback: INCORRECT The client asked a direct question that the nurse should be able to answer. Normal cardiac output for an adult is 4 to 6 L/min. Questions regarding diagnosis and prognosis may be

referred to physicians. There is no harm in answering this question. When using therapeutic communication, the nurse should never ask a client to justify his or her feelings by inquiring why a question was asked. There is no evidence that this client is upset



15. A client asks why smoking is a major risk factor for heart disease. In formulating a response, the nurse incorporates the understanding that nicotine:A) Causes vasodilationB) Causes vasoconstrictionC) Increases the level of high-density lipoproteinsD) Increases the oxygen-carrying capacity of hemoglobin Feedback: INCORRECT Nicotine causes vasoconstriction, which restricts blood flow to the heart and peripheral tissues and increases the risk of hypertension and subsequently heart disease as a complicating factor. Nicotine does not cause vasodilation. Nicotine decreases the oxygen-carrying capacity of hemoglobin. Nicotine decreases the level of high-density lipoproteins and elevates the level of harmful low-density lipoproteins, which leads to atherosclerosis.



16. Symptoms associated with anemia include which of the following? (Select all that apply.)A) Increased breathlessnessB) Decreased breathlessnessC) Increased activity toleranceD) Decreased activity tolerance Feedback: INCORRECT Clients with anemia have fatigue, decreased activity tolerance, and increased breathlessness, as well as pallor (especially seen in the conjunctiva of the eye) and an increased heart rate.


Correct Answer(s): A, D

17. Which of the following assessment data indicate that the client's airway needs suctioning? (Select all that apply.)A) DroolingB) Production of thin, watery sputumC) Decreased coughing abilityD) Secretions that clear with coughingE) Abnormal lung sounds only in left lower lobe Feedback: INCORRECT Suctioning is necessary when the client is unable to clear respiratory secretions from the airways. Signs that a client's airway needs suctioning include a change in respiratory rate

or adventitious sounds, nasal secretions, gurgling, drooling, restlessness, gastric secretions or vomitus in the mouth, and coughing without clearance of secretions from the airway.


Correct Answer(s): A, C, E

18. The nurse suspects left-sided heart failure in a newly admitted client when the nurse notes which of the following symptoms? (Select all that apply.)A) Distended neck veinsB) Bilateral crackles in the lungsC) Weight gain of 2 lb in past 2 daysD) Shortness of breath, especially at night Feedback: INCORRECT Left-sided heart failure results in ineffective ejection of blood from the left ventricle. This causes a backup of blood into the lungs. Thus, symptoms of left-sided heart failure are usually related to the lungs.


Correct Answer(s): B, D

19. A client with chronic obstructive pulmonary disease (COPD) is experiencing dyspnea and anxiety. The nurse helps the client to breathe better by doing which of the following? (Select all that apply.)A) Implementing guided imageryB) Instructing the client to perform pursed-lip breathingC) Elevating the head of the bed to semi-Fowler's or Fowler's positionD) Encouraging the client to drink a full glass of water to liquify secretions Feedback: INCORRECT Elevating the head of the bed to Fowler's position (45-degree angle) or semi-Fowler's position (30- to 45-degree angle) causes the diaphragm to lower from gravity and thus increases the space for lung expansion. Pursed-lip breathing prolongs exhalation and maintains the alveoli open longer, thus extending the period of oxygen and carbon dioxide exchange. Too high an elevation of the head of the bed could force the diaphragm into the thorax and reduce lung expansion. Fluids could help liquify the pulmonary secretions in the future, but right now the client needs more acute care. Guided imagery may help in the future, but now is not the time to implement this intervention.


Correct Answer(s): B, C

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Nutrition (chap. 44)Nursing process and nutrition AssessmentClients who are malnourished on admission are at greater risk of life threatening complications during hospitalization such as arrythmias, sepsis, or hemorrhage

Identify the signs and symptoms associated with altered nutrition Gather data from clients regarding nutritional practices Determine clients nutritional energy needs

o REE x activity or illness factor Obtain clients dietary history

Use:

Screenings Objective measures (height, weight, weight change, primary dx.)

Combine with multiple objective measures Subjective global assessment - uses client hx, weight and physical

assessment data to evaluate nutritional status Mini nutritional assessment- older adults, has 18 items that are

divided into screening and then assessment Anthropometry

Measurement system of size and makeup of the body. Height and weight are taken at the same time each day with same scale, clothing,

etc. Compare height and weight with the standards for Height weight relationship

IBW Lab and biochemical tests

Measures of plasma proteins such as albumin, transferring, prealbumin, retinol binding protein, total iron binding capacity, and hemoglobin

Dietary hx and health hx Physical examination

See table pg. 1102 Dysphagia

Difficulty when swallowing Causes can include

Myogenic Myasthenia gravis aging Muscular dystrophy Plymyositis

Neurogenic Stroke cerebral palsy Guillain barre syndrome multiple sclerosis Lou gehrig disease parkinsons disease

Obstructive Benign peptic stricture lower esophageal ring Candidiasis head and neck cancer Inflammatory masses trauma/surgical resection

Anterior mediastinal masses cervical sponhylosis Other

Gastrointestinal or esophageal resection Rheumatologic disorders Connective tissue disorders Vagotomy

Nursing diagnosis

Dx are related to either the actual nutrional problems or problems that place the client at risk for nutritional deficiencies such as oral trauma, severe burns, or infectionso Risk for aspirationo Constipationo Diarrheao Deficient knowledge

Planning

Select nursing interventions to promote optimal nutrition Select nursing interventions consistent with therapeutic diets Consult with other health care prof. to adopt interventions that reflect the clients needs Involve family when designing interventions

Implementation

Health promotiono Incorporating knowledge of nutrition into lifestyle serves as prevention against developing

diseases. Acute care

o Advancing diets - clients with decreased immune function require special diets that decease their exposure to microorganisms and are higher in selected nutrients

o Promoting appetite- provide an environment that promotes nutritional intakeo Assisting clients with oral feedingo Enteral tube feeding

Nutrients given in the GI tract, less metabolic problems Have four different types of formulas. Feeding this route reduces sepsis, minimizes the hypermetabolic response to trauma,

and maintains intestinal structure and function A serious complication is aspiration of formula into tracheobronchial tree

The formula irritates the bronchial mucosa, decreasing the blood supply to affected pulmonary tissue, this lead to necrotizing infection (b/c high glucose), pneumonia, potential abscess formation.

ADVANTAGES Promotes some satiety Protects GI tract

IgA secretion < atrophy of GI/Pancreas < Infection (bacterial translocation) < gallbladder sludge/stones Less sepsis/GI problems Better vitamin absorption

Vit K production B vitamins

Less expensive/ home use Disadvantages

Need GI access with tube Tube problems Patient comfort

Risk for aspiration Metabolic problems

o Enteral access tubes Nose - nasogastric, Nasoduodenal, Nasojejunal

4 weeks or less Large bore >12 french Small bore 8-12 french

Surgically - gastrostomy, jejunostomy Endoscopically- percutaneous endoscopic gastrostomy (PEG), or (PEJ)

Surgically or endoscopically for more than 4 weeks

Check Residual:o If tube is in stomach! Because it holds fluido Pt. should be put on right side 20 min before checkingo Check approx. every 4-6 hours, especially with continuous feedingso Always use 50-60 mL syringeo Flush line with air/water firsto If more than 60mL dump in cup and pull out againo Secretions alone = 140 - 190 ml/hro If secretions less or equal to 200mL then reinstill all of it

If over then put 200 ml back and count as outputo If residual is high then recheck in 1 houro Parenteral nutrition

Nutrients are provided IV Clients that are unable to absorb or digest from enteral Short term needs receive solutions less than 10% dextrose via peripheral vein (arm) Needs greater than 10 % solution requires central venous catheter/ PICC

Goes into superior vena cava Make sure it is sutured in!

Complications of PN Infection

Fungus Gram positive, gram negative bacteria

Metabolic problems Hyperglycemia, hypoglycemia, hyperosmolar Prerenal azotemia Essential fatty acid deficiency Electrolyte and vit excesses and deficiencies Hyperlipidemia

Mechanical problems Insertion

Air embolus Pneumothorax, hemothorax,

Dislodgement Thrombosis of great vein phlebitis

Evaluation

Reassess signs and symptoms associated with altered nutrition Determine clients satisfaction with nutritional therapy

EVOLVE QUESTIONS (NUTRITION) 1. The nurse is teaching a client about healthy nutrition. The nurse recognizes that the

client understands the teaching when the client makes which of the following statements?

A) "I need to stop eating red meat." B) "I will increase the servings of fruit juice to four a day." C) "I will make sure that I eat a balanced diet and exercise regularly."

D) "I will not eat so many dark green vegetables and eat more yellow vegetables." Feedback: INCORRECT The client should adopt a balanced eating pattern that includes a variety of nutrient-

dense foods and beverages among the basic food groups. The nurse should encourage the client to consume fruits, vegetables, whole-grain products, and fat-free or low-fat milk while staying within energy needs. Total fat intake should be kept between 20% and 35% of total calories with most fats coming from polyunsaturated or monounsaturated fatty acids. The client should choose and prepare foods and beverages with little added sugars or sweeteners and foods with little salt while at the same time eating potassium-rich foods.



2. The nurse teaches a client who has had surgery to increase intake of which nutrient

to help with tissue repair? A) Fat B) Protein C) Vitamins D) Carbohydrate Feedback: INCORRECT Proteins provide a source of energy and are essential for synthesis (building) of body

tissue in growth, maintenance, and repair. Proteins are also required for blood clotting, fluid regulation, and acid-base balance. Fats are important for metabolic processes. Vitamins are chemicals used as catalysts in biochemical reactions. They are essential to normal metabolism and are present in small amounts in foods. Carbohydrates are used for energy.



3. Which action should the nurse take initially to verify correct positioning of a newly

placed small-bore feeding tube? A) Place an order for a radiograph to check position. B) Confirm the distal mark on the feeding tube after taping. C) Test the pH of the gastric contents and observe the color. D) Auscultate over the gastric area as air is injected into the tube. Feedback: INCORRECT Radiography will confirm placement more reliably than other methods of checking

placement.



4. Based on knowledge of peptic ulcer disease (PUD), the nurse anticipates the

presence of which bacteria when reviewing the laboratory data for a client suspected of having PUD?

A) Micrococcus B) Staphylococcus C) Corynebacteria D) Helicobacter pylori Feedback: INCORRECT H. pylori is a bacterium that causes peptic ulcers, and its presence can be confirmed

by laboratory tests. It is treated with antibiotics that control the bacterial infection. The other bacteria listed are not associated with PUD.



5. The nurse is assessing a client receiving enteral feedings via a small-bore

nasointestinal tube. Which assessment finding needs further intervention? A) Gastric pH of 3.0 during placement check B) Weight gain of 1 lb over the course of a week C) Active bowel sounds in the four abdominal quadrants D) Gastric residual aspirate of 300 mL for the second consecutive time Feedback: INCORRECT Gastric residual aspirate of 300 mL indicates that the client is not digesting the food.

Active bowel sounds in all four quadrants is a positive sign. Weight gain of 1 lb in a week is an appropriate weight variance. A gastric pH of 3.0 is expected.



6. The nurse evaluates laboratory findings for a client hospitalized because of chronic

obstructive pulmonary disease. Which finding is consistent with poor nutrition? A) Nitrogen balance of 3 g B) Transferrin level of 370 mg/dl C) Hemoglobin level of 13.8 g/dl D) Serum albumin level of 2.5 g/dl Feedback: INCORRECT Factors that affect serum albumin levels include hydration; hemorrhage; renal or

hepatic disease; large amounts of drainage from wounds, drains, burns, or the gastrointestinal tract; steroid administration; exogenous albumin infusions; age; and trauma, burns, stress, or surgery. A normal serum albumin level is 4.0 g/dl. The other options are incorrect.



7. The home health nurse is seeing the following clients. Which client is at greatest risk

for experiencing inadequate nutrition? A) A 55-year-old obese man recently diagnosed with diabetes mellitus B) A recently widowed 76-year-old woman recovering from a mild stroke C) A 22-year-old mother with a 3-year-old toddler who underwent tonsillectomy D) A 46-year-old man recovering at home following coronary artery bypass surgery

Feedback: INCORRECT The 76-year-old woman has multiple issues confronting her that put her at a higher

risk for inadequate nutrition, including the recent death of her spouse and her recent stroke. The other clients do have some risk of inadequate nutrition, but not as great a risk as the older widow.



8. The nurse is measuring the pH of fluid from a jejunostomy tube and suspects that the

tube has migrated into the stomach when the pH reading is: A) 3.0 B) 4.0 C) 5.0 D) 6.0 Feedback: INCORRECT The pH of gastric contents is low and acidic (3 or less), whereas the pH of the small

intestine is higher because of the bicarbonate released.



9. The nurse wants to begin feeding a client through a small-bore feeding tube that was

recently placed. Before initiating feedings through this tube, the nurse confirms tube placement by:

A) Aspirating fluid contents from the stomach B) Requesting confirmation of placement via radiographic examination C) Measuring the pH of the fluid aspirated through the small-bore tube D) Injecting air through the feeding tube while auscultating for air in the stomach Feedback: INCORRECT The most reliable method for verifying the placement of a small-bore feeling tube is

radiographic examination. None of the other methods is as reliable.



10. The nurse is caring for a client experiencing dysphagia. Which interventions will help

decrease the risk of aspiration during feeding? (Select all that apply.) A) Have the client sit upright in a chair. B) Give liquids at the end of the meal. C) Place food in the strong side of the mouth. D) Provide thin foods to make it easier to swallow. E) Feed the client slowly, allowing time for the client to chew and swallow. F) Encourage the client to lie down to rest for 30 minutes after eating. Feedback: INCORRECT The nurse should have the client sit upright or in high-Fowler's position and then feed

the client slowly, allowing the client time to chew and swallow. Thin foods should be

thickened to the consistency of mashed potatoes to make swallowing easier, and the food should be placed in the strong side of the mouth. Liquids should be thickened, but the client should be allowed to have them as desired. The client should sit upright for 30 minutes after eating to ensure digestion and prevent reflux of the food.


Correct Answer(s): A, C, E

11. Which of the following statements about water-soluble vitamins is true? (Select all

that apply.) A) They cannot be stored. B) They often cause toxicity. C) They must be consumed daily. D) Supplements must be taken to reach the recommended daily allowance of these

vitamins. Feedback: INCORRECT Water-soluble vitamins are eliminated daily; they are not stored. Thus they must be

consumed daily. Although toxicity may occur with megavitamin intake, the possibility of toxicity is low. A healthy diet should provide the necessary amount of water-soluble vitamins without the need for supplementation.


Correct Answer(s): A, C

12. When evaluating the history of a client who has gastrointestinal (GI) upset, the nurse

is sure to assess the client for routine ingestion of which of the following? (Select all that apply.)

A) Beer B) Aspirin C) Acetaminophen D) High-fiber foods Feedback: INCORRECT Alcohol and aspirin are two substances directly absorbed through the lining of the

stomach. This can contribute to GI upset. High-fiber foods should reduce GI symptoms because they stimulate peristalsis. Acetaminophen does not commonly cause GI symptoms. It is more likely to cause problems with the liver.


Correct Answer(s): A, B

13. A woman is considering becoming pregnant. The nurse practitioner recommends that

the client begin to consume which of the following before attempting pregnancy to prevent neural tube defects in the fetus?

A) Calcium B) Folic acid C) Vitamin C D) Riboflavin Feedback: INCORRECT

The importance of consuming folic acid to prevent neural tube deficits has been proven. The other vitamins and minerals are important but not essential.



14. A client has gained 2 lb of weight in the past day. The nurse calculates this weight

gain to be __________ ml of fluid.


Correct Answer(s): 1000

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PREOPERATIVE (MODULE 16) Classification of surgery:

Seriousnesso Major - extensive reconstruction or alteration in body parts; poses great risk to well being.

(coronary artery bypass, colon resection…)o Minor - minimal alteration in body parts; designed to correct deformities, minimal risk

compared with major (cataract extraction, facial plastic surgery…) Urgency

o Electiveo Urgent - necessary for clients health, often prevents additional problems from developing

(excision of cancerous tumor, removal of gallbladder for stones…)o Emergency- must be done immediately to save life or preserve function of body part

(perforated appendix, repair of traumatic amputation…) Purpose

o Diagnostico Ablative - excision or removal of diseased body part (amputation…)o Palliative - relieves or reduces intensity of disease symptoms; will not produce cure

(colostomy..)o Reconstructive/restorative- restores function or appearance to traumatized or malfunctioning

tissues (internal fixation of fractures, scar revision)o Procurement for transplant- removal of organs/tissue from person pronounced brain dead for

transplantation into other person.o Constructive

o Cosmetic

PREOPERATIVEThe nursing process in preoperative surgical phase

ASSESSMENT The aim of the assessment is to establish clients normal preoperative function and to prevent

postoperative complications

Assess: Physical examination focused on the clients hx and planned surgery Assessment of factors that pose surgical risks for client Clients previous experience with surgery Clients coping resources Results of preoperative diagnostic tests

Risk factors:

o Age - very young or very old - immune system are immature and then decliningo Nutrition - with surgery they have increased energy requirements so in wound healing it

makes nutrition very important. o Obesity - reduces ventilatory and cardiac function.

Embolus, stelectasis and pneumonia are the more frequent postop complicationso Obstructive sleep apnea - partial or complete obstruction of airway during sleepo Immunocompromised - o Pregnancyo Fluid and electrolyte imbalance-

As result from adrenocortical stress response the body retains sodium and water and loses potassium within the first 2-5 days after surgery

Main - Na, K, Cl If depletion of K can have heart arrhythmias…

o Poor physical condition

Medication hx- certain medications have special implications for the surgical client, creating greater risks for complications.

Antibiotics Antidysrhythmics Anticoagulants Anticonvulsants Antihypertensives Corticosteroids Insulin Diuretics Nsaids Herbal therapies

Smoking - those that smoke have increased secretions that can block airway Allergies- Alcohol and substance use and abuse -

o Delirium tremens - abrupt cessation of alcohol, will see agitation, tremors, hallucination that can last 3-6 days followed by deep sleep

o Alcohol causes malnutritiono Substance abuse - usually have difficult peripheral veins so need central line

Support services - check that there are family or friends to provide support Occupation - assess clients occupation hx to anticipate possible side effects of surgery on recovery Preoperative pain assessment Psychosocial assessment Culture Client expectations Physical examination Laboratory and diagnostic testing

o Hgb - 13.1 - 17.2 g/dl (males) 11.7 - 16 g/dl (females)o Hct - 35%- 47%o K+ - 3.5 - 5.0 mEq/Lo Na - 136-146 mEq/Lo Cl - 98-107 mEq/Lo BUN - 8-23 mg/dlo Creatinine - 0.6 - 1.2 mg/dlo Glucose - 60-100 mg/dl

DIAGNOSIS

Client with preexisting health problems is likely to have variety of risk diagnosis PLANNING

Involve the client and family in preop instruction Provide therapies aimed at minimizing the clients fear or anxiety regarding surgery Plan therapies to reduce surgical risks Consult with other health care professionals

IMPLEMENTATION

Informed consent- outlines need for surgery, steps, risks, expected results and alternativeso Physicians role is to inform pt. Nurses role is to witness surgeons explanation and pt

signature, and testifies to pts understanding of benefits/risks Health promotion

o Preoperative teaching - Deep breathing and coughing Insentive spirometry Turning Leg exercises, ambulation Pain meds What to expect - Ivs, dressings, tubes, oxygenation

Physical preparationo Maintenance of normal fluid electrolyte balance - NPO o Reduction of risk for surgical wound infectiono Prevention of bowel and bladder incontinenceo Promotion of rest and comfort

Preparation on day of surgeryo Hygiene vital signso Hair and cosmetics documentationo Removal of prostheses performing special procedureso Safeguarding valuables administering preop medso Preparing the bowel and bladder latex sensitivity/allergyo Eliminating wrong site and wrong procedure

EVALUATION

Evaluate clients knowledge of surgical procedure and planned postoperative care Have the client demonstrate postoperative exercises Observe behaviors or nonverbal expressions of anxiety or fear Ask if the clients expectations are being met

Intraoperative surgical phaseNursing process in intraoperative surgical phase:ASSESSMENT

In presurgical care unit conduct focused preoperative assessment to verify client is ready for surgery and to plan intraoperative care.

Verify with the client the planned surgical procedure and the surgical site before anesthesia is administeredDIAGNOSIS

Review preop dx, and modify them to individualize care plan in the operating roomPLANNING

Ex; maintain skin integrityIMPLEMENTATION

Acute careo Physical preparation - apply monitoring devices, antiembolism stockingso Monitor IV fluid infusions, monitor urinary nasogastric output, maintain surgical asepsis,

monitor for cardiac and respiratory arrest, allergic reactionso Introduction of anesthesia

General - immobile, quiet client who does not recall the surgical procedure. IV/inhalation agents produce unconsciousness;

Regional - loss of sensation to the are of body, no loss of consciousness, but may be sedated

Local - loss of sensation at specific site, injection locally or applied topically Conscious sedation - decreased LOC Side effects of anesthetic agents

CV depression or irritability Respiratory depression Liver and kidney damage

EVALUATION Evaluate intervention implemented during intraoperative phase throughout surgical procedure

Postoperative surgical phase

Clients who undergo general anesthesia are more likely to face comlications than those who have only local

Client who has undergone regional or general anesthesia usually transfers to PACU to be stabilized before discharge, whereas client who has had local goes directly to the nursing unit or back to ambulatory surgery center.

Immediate postop recoveryo Surgery tem reports to PACU nurse

Anesthesia used Ivs, blood administered Complications during surgery - excess blood loss, cardiac dysrhythmias

o Monitor VS, ECG, pulse oximetryo PROTECT THE AIRWAYo Maintain BPo Monitor return of consciousness, sensation and motiono Assess for normothermiao Assess perfusion, surgical site,

Surgical site note drainageo Promote fluid electrolyte balanceo Manage drainage systems

Check what is coming outo Promote comforto Transfer from PACU when stable

Discharge from postanesthesiao Based on vital sign stability in comparison with preoperative datao Postanesthesia recovery score (PARS) - pt must have 8-10 score before being releasedo Handoff communication occurs between PACU nurse and nurse on nursing unit.

Recovery in ambulatory surgeryo Initiate post op teaching with clients and family memberso Monitor clients but not at the same intensity as phase I (PACU)

Postoperative convalescenceo Focus is on returning client to relatively functional level of wellness as soon as possible

Nursing process postoperative careASSESSMENT

Upon arrival to recovery, measure viral signs and key observations at least every 15 min depending on clients condition and unit policy

Airway and respirationo Assess patency, respiratory rate, rhythm, depth of ventilation, symmetry of chest wall

movements, breath sounds, color of mucous membraneso Pulse ox at least 92%o Maintain adequate postioningo Great concern is airway obstruction

Circulationo Assess perfusion by capillary refill, , pulses, skin coloro Assess HR, rhythm, BPo Peripheral pulse checks distal to surgical siteo Check for bleedingo Prevent DVT

Temperature control Fluid and electrolyte balance

o Check IV fluid rateo Electolyteso Daily weight -accurate assessment of fluid status

Neurological functionso Oriented to person, place, time, follows commandso Check pupil reflexes, hand grips, movement of extremitieso Check sensation along dermatomes - touch client bilaterally in same dermatome and

document if the client feels touch Skin integrity and condition of the wound -

o note rashes, petechiae, abrasions, or burnso Observe amount and color, odor, and consistency of drainage on dressingso Many surgeons change the first dressing themselves

Genitourinary functiono Bladder distentiono Foleyo Expect void 6-8 hr after sx/catheter removal

Note color of urine, freely draining from catheter Gastrointestinal function

o Anesthesia slows GI motility and often causes nauseao Assess bowel soundso Look for abdominal distentiono Avoid sudden movemento Maintain NG tube patency/suction; monitor outputo Dietary progression- ice chips, clear liquids then solids.

Comforto Pain medso IV, PCA, IM, POo Avoid pain peaks and troughso Nonpharmacological measureso Work with pt/family/physician to get pain under control

Client expectationso Assess pt and family expectations for recovery

Postoperative complications:

Respiratory - Atelectasis - collapse of alveoli with retained mucous secretions. S/S include elevated

resp. rate, dyspnea, fever, crackles Pneumonia- inflammation of alveoli (s/s include fever, chills, productive cough, chest

pain, purulent mucus) Hypoxemia - inadequate concentration of oxygen in arterial blood (s/s restlessness,

confusion, dyspnea, high or low BP Pulmonary embolism - emolus blocking pulmonary arterial blood flow to one or more

lobes of lung (s/s sudden chest pain, dyspnea, cyanosis,, drop in BP) Circulatory -

Hemorrhage- (s/s hypotension, weak and rapid pulse, cool and clammy skin, rapid breathing, restlessness and < urine output

Hypovolemic shock (s/s same as hemorrhage) Thrombophlebitis- inflammation of vein (s/s inflammation of involved site, aching or

cramping pain, vein feels hard) Thrombus (s/s localized tenderness along distribution of venous system) Embolus

Gastrointestinal- Paralytic ileus - nonmechanical obstruction of bowel ( Abdominal distention- retention of air within intestines and abdominal cavity (s/s

increased abdominal girth, tympanic percussion over ab quadrants Nausea and vomiting

Genitourinary - Urinary retention (s/s inability to void, restlessness, bladder distention) appears 6-8h

after surgery UTI (s/s dysuria, itching, abdominal pain, possible fever, cloudy urine, wbc and

leukocyte esterase positive Integumentary

Wound infection (s/s warm, red , tender skin around incision) Wound dehiscence- separation of wound edges at suture line (s/s increased drainage

and appearance of underlying tissue) Wound evisceration - protrusion of internal organs and tissues through incision Skin breakdown

Nervous- Intractable pain- pain that is not amenable to analgestics and pain alleviating

interventions DIAGNOSIS

cluster new post op assessment data and identify relevant new diagnoses. Fear, pain, risk for infection, knowledge deficit...

PLANNING Goals and outcomes - consider effects of stress of surgery and limitations it produces when

establishing goals, expected outcomes and interventions. Set priorities - as client progresses, focus priorities on advancement of client activity to return client

to preop functioning Collaborative care

IMPLEMENTATIONEVALUATION

EVOLVE QUESTIONS1. An obese client is at risk for poor wound healing postoperatively because:A) Risk for bleeding is increasedB) Ventilatory capacity is reducedC) Fatty tissue has a poor blood supply

D) Resumption of normal physical activity is delayed Feedback: INCORRECT The obese client is susceptible to poor wound healing and wound infection because of the structure of fatty tissue, which contains a poor blood supply. This slows delivery of the essential nutrients, antibodies, and enzymes needed for wound healing. Ventilatory capacity could affect postoperative healing but is not decreased by obesity. Risk for bleeding would not affect wound healing. If there were poor wound healing, the resumption of normal activity could be delayed, but this delay would be caused by the poor wound healing, not vice versa.



2. The nurse asks each client preoperatively for the name and dose of all prescription and over-the-counter medications taken before surgery because these medications:A) May cause allergies to develop.B) Are automatically ordered postoperatively.C) May increase the risks for anesthetic and surgical complications.D) Should always be taken the morning of surgery with sips of water. Feedback: INCORRECT All medications must be reviewed to ensure that they will not increase the risks associated with anesthesia and surgery. Medications will not cause allergies to develop during or after surgery. Not all medications are automatically ordered postoperatively. Medications are taken as prescribed, or held as necessary, at the appropriate time, not just in the morning.



3. A client who smokes two packs of cigarettes per day is most at risk postoperatively for:A) Atelectasis, fever, and pneumoniaB) Hypotension, confusion, and elevated glucose levelC) Hypotension, cardiac dysrhythmias, and feverD) Urinary infection, fever, and malignant hyperthermia Feedback: INCORRECT After surgery clients who smoke have greater difficulty than nonsmokers in clearing the airways of mucous secretions, and the importance of postoperative deep breathing and coughing should be emphasized to such clients. Urinary infection, hypotension, confusion, and elevated glucose levels are not necessarily associated with smoking.



4. Family members should be included when the nurse teaches the client preoperative exercises so they can:A) Coach the client postoperatively.B) Demonstrate the exercises to the client at home.C) Relieve the nurse by getting the client to do the exercises every 2 hours.

D) Practice the exercises with the client while the client waits to be taken to the operating room. Feedback: INCORRECT Often a family member serves as the client's coach when the client performs postoperative exercises after returning from surgery. The coach may also help at home, but the client should be able to do his or her exercises correctly before surgery and should not need demonstration. Practicing exercises while waiting to be taken to the operating room may not be practical. The nurse is always responsible for ensuring that the exercises are initiated as ordered.



5. Maintaining normal glucose levels during the postoperative period reduces which complication?A) IleusB) BleedingC) Wound infectionD) Deep vein thrombosis Feedback: INCORRECT Evidence indicates that maintaining normal glucose levels during the postoperative period reduces the incidence of infections. Glucose levels are not associated with ileus, bleeding, or deep vein thrombosis.



6. In the postanesthesia care unit the nurse notes that the client is having difficulty breathing because of an obstruction. The nurse would first:A) Suction the pharynx and bronchial tree.B) Give oxygen through a mask at 10 L/min.C) Ask the client to use an incentive spirometer.D) Position the client so that the tongue falls forward. Feedback: INCORRECT In clients recovering from anesthesia the tongue causes the majority of airway obstructions. Clients should remain lying on their sides until they are able to maintain their own airways. Suctioning before removing a structural obstruction will not be helpful. Supplemental oxygen may be helpful after the obstruction is removed. Clients in this state will not be able to use the incentive spirometer.



7. Because an older adult is at increased risk for respiratory complications after surgery, the nurse should:A) Withhold pain medications and ambulate the client every 2 hours.B) Monitor fluid and electrolyte status every shift and measure vital signs including temperature every 4 hours.

C) Orient the client to the surrounding environment frequently and ambulate the client every 2 hours.D) Encourage the client to turn, deep breathe, and cough frequently, and ensure adequate pain control. Feedback: INCORRECT The nurse should encourage the client to perform coughing exercises every 2 hours while awake and should maintain pain control to promote deep, productive coughing. Pain medications should never be withheld from a client. Checking vital signs every 4 hours is appropriate.



8. A client with a longer than normal prothrombin time (PT) or activated partial thromboplastin time (APTT) is at risk postoperatively for:A) BleedingB) InfectionC) Low urine outputD) Cardiac dysrhythmias Feedback: INCORRECT Both PT and APTT are measures of clotting ability. A client with a prolonged PT or APTT is at risk of bleeding. These tests do not measure urine output, infection, or cardiac rhythm.



9. When a nonbariatric client is deep breathing and coughing the client should be sitting because this position:A) Is more comfortableB) Facilitates expansion of the thoraxC) Helps the client to splint with a pillowD) Increases the client's view of the room and is more relaxing Feedback: INCORRECT The thorax can expand better when the client is upright. This position may or may not be more comfortable for the client. The changed view of the room may or may not be of interest to the client. It is easier for the client to splint when upright, but the primary purpose for having the client sit upright is to facilitate expansion of the thorax.



10. The nurse notes that a postsurgical client has a heart rate of 130 beats per minute and a respiratory rate of 32 breaths per minute. The nurse also assesses jaw muscle rigidity and rigidity of the limbs, abdomen, and chest. What does the nurse suspect and what intervention is indicated?A) The nurse suspects infection and should notify the surgeon and anticipate administration of antibiotics.

B) The nurse suspects pneumonia and should listen to breath sounds, notify the surgeon, and anticipate an order for chest radiography.C) The nurse suspects hypertension and should check blood pressure, notify the surgeon, and anticipate administration of antihypertensives.D) The nurse suspects malignant hyperthermia and should notify the surgeon/anesthesiologist immediately, prepare to administer dantrolene sodium, and monitor vital signs frequently. Feedback: INCORRECT Malignant hyperthermia is a potentially lethal condition that can occur in clients receiving general anesthesia. It should be suspected when there is unexpected tachycardia and tachypnea; elevated carbon dioxide levels; jaw muscle rigidity and rigidity of the limbs, abdomen, and chest; and hyperkalemia. The nurse will immediately administer dantrolene sodium ordered by the health care providers. The other options are incorrect.



11. Through experience and knowledge, the nurse knows that the client will commonly experience the most severe postoperative pain at what time?A) The third postoperative dayB) The fourth postoperative dayC) Immediately after the surgeryD) The first 12 to 36 hours after surgery Feedback: INCORRECT Postoperative pain generally decreases after the second or third day. Immediately following surgery the anesthetic is still effective. Commonly the most severe pain is experienced 12 to 36 hours after surgery. The nurse must keep in mind that all clients should be treated individually.



12. Surgical procedures are classified in terms of seriousness, urgency, and purpose. The designation of a procedure as an "emergency surgical procedure" relates to which of the following categories?A) PurposeB) UrgencyC) DiagnosticD) Seriousness Feedback: INCORRECT "Emergency surgery" as well as "elective surgery" and "urgent surgery" are designations based on urgency. The urgency classification describes a time factor. The seriousness of a surgical procedure is designated by the terms major and minor, which indicate extensive and minimal alteration of body parts, respectively. Diagnostic is one of seven descriptors indicating the purpose of a surgical procedure. The others are ablative, palliative, reconstructive/restorative, procurement for transplant, constructive, and cosmetic.



13. The American Society of Anesthesiologists has assigned surgical classifications to clients based on what characteristic?A) Physical status of the clientB) Type of anesthesia usedC) Purpose and seriousness of the procedureD) Seriousness and urgency of the procedure Feedback: INCORRECT The American Society of Anesthesiologists has assigned classifications to clients based on the client's physiological condition independent of the proposed surgical procedure. Difficulties during surgery occur more frequently for clients whose assigned classifications reflect poor physical status. Clients in classes I and II and stable clients in class III are considered acceptable candidates for ambulatory or outpatient surgery. The surgical procedure itself is classified according to seriousness, urgency, and purpose.



14. On admission to the ambulatory surgical unit the client tells the nurse, "I take naproxen for arthritic pain." Why should the nurse inform the surgeon of this?A) Nonsteroidal antiinflammatory drugs (NSAIDs) do not interfere in any way.B) NSAIDs may cause mild respiratory depression.C) NSAIDs inhibit platelet aggregation and may prolong bleeding time.D) NSAIDs impair cardiac conduction during anesthesia. Feedback: INCORRECT NSAIDs increase the client's susceptibility to postoperative bleeding by inhibiting platelet aggregation and prolonging bleeding time. Antidysrhythmics, not NSAIDs, impair cardiac conduction during anesthesia. Antibiotics may cause mild respiratory depression by depressing neuromuscular transmission, but NSAIDs do not.



15. While assessing a client after surgery, the nurse notes dull breath sounds and dyspnea. What are the most appropriate nursing interventions?A) Continue observations.B) Promote adequate fluid intake but avoid the use of straws.C) Apply antiembolism stockings and turn the client every 1½ hours.D) Encourage deep breathing and coughing exercises and increase mobility. Feedback: INCORRECT Dull breath sounds and dyspnea may suggest atelectasis. Therefore it is important for the client to do deep breathing and coughing exercises and to increase mobility and activity. Turning the client is beneficial. Sudden chest pain is associated with pulmonary embolism. Antiembolism stockings are used as a preventative measure for emboli. Gastrointestinal complications can be lessened or prevented by adequate fluid intake and avoidance of the use of straws.



16. Nursing has made significant contributions in what areas promoting positive client outcomes after surgery?A) Discovery of effective anestheticsB) Development of the germ theoryC) Discovery of multiple aseptic techniquesD) Demonstration of the benefits of preoperative education Feedback: INCORRECT Nursing knowledge has made important contributions to the perioperative care of the client. Structured preoperative teaching and return demonstrations of postoperative exercises have been shown to improve outcomes in such areas as pain management, pulmonary function, length of stay, and the client's level of anxiety. The other contributions listed were not based specifically on nursing assessments, but rather were physician driven.



17. The nurse taking a medication history preoperatively asks the client about allergies. Which of the following is the most appropriate way of asking the client about this issue?A) "Do any medications make you sick?"B) "Do you have any medication allergies?"C) "Have you ever had a problem with a medication or substance?"D) "Have you ever had difficulty breathing after taking medication?" Feedback: INCORRECT "Have you ever had a problem with a medication or substance?" is a broad question that may elicit more information from the client than the other styles of question. The nurse needs to distinguish allergies from unpleasant side effects. For example, codeine may cause nausea (a side effect) or hypotension and confusion (an allergy) in a client. The term allergy can be confusing to some clients. Therefore the nurse will get more information from the client by asking about any problems instead of being so specific.



18. Surgical procedure permitting, in what position should the client be placed during the immediately postanesthetic stage of recovery?A) High-Fowler'sB) Semi-Fowler'sC) Supine with pillowD) Side-lying, face down Feedback: INCORRECT Placement in a side-lying position with the face slightly down (recovery position) protects the client from possible aspiration, and in this position the client's tongue falls forward. Placement in a supine position may increase the possibility of aspiration. Both Fowler's positions would fail to prevent an unconscious client from falling.



19. The nurse conducts a partial or complete physical examination depending on the amount of time available. The nursing assessment should complement the physical examinations performed by the surgeon and anesthetist or anesthesiologist. Which of the following assessments should the nurse perform immediately in the postanesthesia stage?A) Airway, family support, and safetyB) Respiratory, neurological, and mental statusC) Anxiety, pain, and presence of coping mechanismsD) Airway, level of consciousness, cardiovascular status, and safety Feedback: INCORRECT Clinical assessments to be completed immediately in the postanesthetic phase include assessments for adequate airway, cardiovascular status, level of consciousness, pain, and safety. Assessments of anxiety, presence of coping mechanisms, family support, and emotional, and mental status are not a priority at this time.



20. Encouraging the client to perform coughing exercises every 2 hours while awake is an appropriate measure for the majority of postsurgical clients. After what surgical procedures may coughing exercises be contraindicated?A) Abdominal and spinalB) Abdominal and thoracicC) Thoracic, rectal, and eyeD) Eye, intracranial, and spinal Feedback: INCORRECT For clients who have had eye, intracranial, or spinal surgery coughing may be contraindicated because of the potential increase in intraocular or intracranial pressure. Coughing exercises are recommended after other surgeries to promote removal of pulmonary secretions, if present.



SKIN INTEGRITY AND WOUND CARE (MODULE 17)

Pressure ulcerso Impaired skin integrity related to unrelieved prolonged pressure. o Any client experiencing decreased mobility, decreased sensory perception, fecal or urinary

incontinence, and or poor nutrition is at risk for pressure ulcerso Pathogenesis of pressure ulcers

1. Pressure intensity - if pressure over capillary exceeds normal capillary pressure range and the vessel is occluded then tissue ischemia can occur.

2. Pressure duration - low pressure over long period or high pressure over short period

3. Tissue tolerance -ability of tissue to endure pressure depends upon integrity of the tissue and supporting structures

o Risk factors for pressure ulcer development Impaired sensory perception Impaired mobility Alteration in LOC Shear - the force exerted parallel to skin resulting from gravity and resistance between the

client and surface. (when head of bed is elevated and pt. slides down but skin is fixed because of friction

Friction Moisture

o Classification Stage 1 - intact skin with nonblanchable redness, usually over bony prominence. Darkly

pigmented may not have visible blanching Stage 2- partial thickness skin loss, involving epidermis, dermis, or both Stage 3 - full thickness tissue loss. Bone, tendon or muscle is NOT exposed Stage 4 - full thickness tissue loss with exposed bone, tendon, or muscle. Slough or escar

may be present Unstageable - full thickness tissue loss which the base of ulcer is covered by slough (yellow,

tan, gray, green, or brown)and or eschar (tan, brown, or black) in wound bed. Until enough slough/eschar is removed to expose base of wound the depth can not be determined

o Wound classification Onset and duration

Acute - wound that proceeds through an orderly and timely reparative process that results in sustained restoration of anatomical and functional integrity

Chronic - wound that fails to proceed through an orderly and timely process to produce anatomical and functional integrity

Healing process Primary intention - wound that is closed Secondary intention - wound edges are not approximated Tertiary intention - wound left open for several days, then wound edges are

approximatedo Wound repair

Partial thickness - 3 components Inflammatory response Epithelial proliferation (reproduction) and migration Reestablishment of epidermal layers

Full thickness wound repair Inflammatory phase Proliferative phase Remodeling

o Complications of wound healing Hemorrhage- Infection Dehiscence Evisceration Fistulas - abnormal passage between 2 or more organs or between organ and the outside of

the body.

o Risk assessment Norton scale - score five risk factors; physical condition, mental condition, activity, mobility

and incontinence. Score ranges from 5-20, lower score indicates risk for pressure ulcer Braden scale

Quantifies the risk factors for development of ulcers in chair and bed bound pt. For all pts. Use upon admission and every 24 hours unless indicated differently Sensory perception

Ability to respond meaningfully to pressure related discomfort Completely limited (unresponsive) Very limited (responds only to painful stimuli) Slightly limited (responds to verbal commands but cant always

communicate discomfort) No impairment

Moisture Degree to which skin is exposed to moisture

Constantly moist Moist Occasionally moist Rarely moist

Activity Degree of physical activity

Bedfast (confined to bed) Chairfast Walks occasionally Walks frequently

Mobility Ability to change and control body position

Completely immobile Very limited Slightly limited No limitations

Nutrition Usual food intake pattern

Very poor Probably inadequate Adequate Excellent

Friction and shear Problem (requires moderate to max assistance in moving) Potential problem (moves feebly or requires min assistance) No apparent problem

Factors influencing pressure ulcer formation and wound healing

Nutrition Tissue perfusion Infections Age

Psychosocial impact of wounds

EVOLVE QUESTIONS

1. When repositioning an immobile client, the nurse notices redness over a bony prominence. When the area is assessed, the red spot blanches with fingertip touch, indicating:A) A local skin infection requiring antibioticsB) A stage III pressure ulcer needing the appropriate dressingC) Sensitive skin that calls for the use of special bed linenD) Reactive hyperemia, a reaction that causes the blood vessels to dilate in the injured area Feedback: INCORRECT This observation is indicative of reactive hyperemia. This is not a local skin infection or a stage III pressure ulcer. Not enough information is given to determine whether the client has sensitive skin.



2. Which type of pressure ulcer consists of an observable pressure-related alteration of intact skin that may show changes in skin temperature (warmth or coolness), tissue consistency (firm or beefy feel), and/or sensation (pain, itching) compared with an adjacent or opposite area on the body?A) Stage IB) Stage IIC) Stage IIID) Stage IV Feedback: INCORRECT In stage I the ulcer appears as a defined area of persistent redness in lightly pigmented skin and as a darker red, blue, or purple area in darker pigmented skin, with no open skin areas. The skin will be warmer or cooler than other areas, with a change in consistency and sensation. A stage II ulcer is characterized by partial-thickness skin loss involving the epidermis and possibly the dermis. In stage III the ulcer appears as a full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, the underlying fascia. In stage IV the ulcer shows as a full-thickness loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures.



3. When a wound specimen is obtained for culture to determine whether infection is present, the specimen should to be taken from:A) Necrotic tissueB) Wound drainageC) Drainage on the dressing

D) The wound after it has first been cleansed with normal saline Feedback: INCORRECT The wound should be cleaned with saline, then a culture specimen should be obtained from the wound. Necrotic tissue, drainage on the dressing, and old wound drainage can harbor old bacteria that may not necessarily be infecting the wound.



4. Postoperatively a client with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the nurse sees that the sutures are open and that pieces of small bowel are visible at the bottom of the now opened wound. The correct intervention would be to:A) Allow the area to be exposed to air until all drainage has stopped.B) Place several cold packs over the area, with care taken to protect the skin around the wound.C) Cover the area with sterile saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration.D) Cover the area with sterile gauze; place a tight binder over the areas; ask the client to remain in bed for 30 minutes because this is a minor opening in the surgical wound and should reseal quickly. Feedback: INCORRECT In wound evisceration, the bowel extrudes from the body. The nurse should cover the visible bowel with sterile saline-soaked towels and notify the surgical team. The area should not be allowed to be exposed or to dry out. Cold packs and binders are not acceptable options.



5. Serous drainage from a wound is defined as:A) Fresh bleedingB) Thick and yellow drainageC) Clear, watery plasmaD) Beige to brown and foul-smelling drainage Feedback: INCORRECT Serous drainage is clear, watery plasma. Bleeding is not serous. A thick, yellow drainage or beige to brown drainage is indicative of an infection.



6. For a client who has a muscle sprain, localized hemorrhage, or hematoma, application of which of the following helps to prevent edema formation, control bleeding, and anesthetize the body part?A) BinderB) Ice bag

C) Elastic bandageD) Absorptive diaper Feedback: INCORRECT The application of cold will help constrict blood vessels, which will reduce swelling that occurs with bleeding and edema formation in a muscle sprain. It also provides a numbing effect. Binders and elastic bandages are not initial treatments for a sprain. A diaper would not be used for a muscle sprain.



7. Which of the following interventions is most appropriate in managing fecal and urinary incontinence in a client?A) Keeping the buttocks exposed to air at all timesB) Applying a large absorbent diaper that is changed when completely saturatedC) Using an incontinence cleanser, followed by application of a moisture barrier ointmentD) Cleansing frequently, applying an ointment, and covering the areas with a thick absorbent towel Feedback: INCORRECT The use of an incontinence cleanser followed by application of a moisture barrier helps protect the skin when a client is incontinent. A diaper should be used to collect the feces and urine; however, the diaper should be changed as soon as it is wet—the nurse should not wait until the diaper is completely saturated. The client's dignity should be maintained by keeping the client covered.



8. Which of the following is the best description of a hydrocolloid dressing?A) A dressing containing a seaweed derivative that is highly absorptiveB) Premoistened gauze placed over a granulating woundC) A dressing containing a débriding enzyme that is used to remove necrotic tissueD) A dressing that forms a gel which interacts with the wound surface Feedback: INCORRECT The wound contact layer of a hydrocolloid dressing forms a gel as fluid is absorbed and maintains a moist healing environment. It does not contain a débriding enzyme, a seaweed derivative, or premoistened gauze.



9. Placement of a binder around a surgical client with a new abdominal wound is indicated for:A) Collection of wound drainageB) Reduction of abdominal swellingC) Reduction of stress on the abdominal incisionD) Stimulation of peristalsis (return of bowel function) from direct pressure Feedback: INCORRECT

The binder helps support the abdominal muscles and prevent stress on the incision. It should be used with proper dressings that will collect wound drainage. A binder will not reduce swelling and will not stimulate peristalsis.



10. Application of a warm compress is indicated:A) To relieve edemaB) For a client who is shiveringC) To improve blood flow to an injured partD) To protect bony prominences from pressure ulcers Feedback: INCORRECT Warm compresses are used to improve blood flow to an affected part. Warm compresses are typically not used for edema relief. A warm compress will not necessarily help with shivering; extra blankets should be used instead. A warm compress will not protect from pressure ulcers.



11. Prolonged, intense pressure affects cellular metabolism by decreasing or obliterating blood flow, which results in tissue ischemia and ultimately tissue death. There are four stages of pressure ulcer formation. The nurse observes partial-thickness skin loss involving the epidermis and possibly the dermis. What stage of ulcer will the nurse document?A) Stage IB) Stage IIC) Stage IIID) Stage IV Feedback: INCORRECT Partial-thickness skin loss involving the epidermis and possibly the dermis is classified as a stage II ulcer. In stage I the ulcer appears as a defined area of persistent redness in lightly pigmented skin or a darker red, blue, or purple area in darker pigmented skin, with no open skin areas. In stage III the ulcer appears as a full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, the underlying fascia. In stage IV the ulcer appears as a full-thickness loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures.



12. There are three phases of wound healing. The nurse observes granulation tissue in a client's pressure ulcer. What phase of wound healing is represented by granulation tissue?A) Maturation phaseB) Hemostasis phaseC) Proliferative phaseD) Inflammatory phase Feedback: INCORRECT

Tissue granulation occurs in the proliferative phase. Maturation is the final stage of wound healing. Hemostasis occurs during the inflammatory phase.



13. The nurse observes all wounds closely. At what time is the risk of hemorrhage the greatest for surgical wounds?A) Between 48 and 60 hours after surgeryB) Between 60 and 72 hours after surgeryC) During the first 24 to 48 hours after surgeryD) 7 days after surgery, when the client is more active Feedback: INCORRECT The risk is highest during the first 24 to 48 hours after surgery because of the possibility of poor clot formation, slipped surgical suture, or trauma to a blood vessel by a foreign object. The more time that passes after surgery, the greater the amount of healing, which lessens the risk of hemorrhage.



14. The autolytic, mechanical, chemical, and surgical methods that are often used during wound management are all methods of accomplishing what?A) Wound dressingB) Wound cleansingC) Wound débridementD) Stimulation of growth factors Feedback: INCORRECT Methods of débridement include mechanical, autolytic, chemical, and surgical methods. All of these methods share the common objective of removing nonviable, necrotic tissue. Dressing, cleansing and stimulation of growth factors are not part of débridement.



15. Several instruments are available for assessing clients who are at high risk for developing a pressure ulcer. The Braden Scale is the most commonly used. What risk factors are assessed using the Braden Scale?A) Infection, hemorrhage, dehiscence, evisceration, and fistulasB) Physical condition, mental condition, activity, mobility, and incontinenceC) Sensory perception, moisture, activity, mobility, nutrition, friction, and shearD) Nutrition, tissue perfusion, infection, age, shear force and friction, and moisture Feedback: INCORRECT The Braden Scale measures the following risk factors: sensory perception, moisture, activity, mobility, nutrition, friction, and shear. The Norton Scale measures five risk factors: physical condition, mental condition, activity, mobility, and incontinence. Infection, hemorrhage, dehiscence, evisceration, and fistulas are the complications of wound healing.

The factors that influence pressure ulcer formation and wound healing are nutrition, tissue perfusion, infection, age, shear force and friction, and moisture.



16. A 40-year-old client is a new paraplegic. The client is about to be discharged from the rehabilitation center. Prevention of pressure ulcers has been an important part of the client's education. In providing this education, the nurse should have included which of the following guidelines?A) The client should sit in chair for no longer than 3 hours.B) The client should use a donut-shaped chair cushion.C) The client should use a rigid cushion for full support.D) The client should shift the weight in a chair every 15 minutes. Feedback: INCORRECT Shifting weight frequently prevents prolonged pressure that may lead to pressure ulcer formation. The guideline for sitting up in a chair is to sit for 2 hours or less, but it is only a guideline. The nurse should individualize activity for each client. Sitting on rigid or donut-shaped cushions is contraindicated because they reduce blood supply to the area, which increases the area of ischemia.



17. During the skin assessment of an older adult client who had a stroke, the nurse noted a reddened area over the coccyx. The next actions of the nurse for this client should include:A) Massaging the reddened area and repositioning the clientB) Placing the client in Fowler's position and returning in 2 hoursC) Inserting a urinary catheter to prevent accumulation of moisture from urinary incontinenceD) Repositioning the client off the coccygeal area and reassessing the area in 1 hour Feedback: INCORRECT Repositioning the client and reassessing the area in 1 hour is the most appropriate action for the nurse. When pressure is relieved from an area, the blood flow returns and the redness will disappear if no damage has occurred. This is the appropriate assessment. Placement in Fowler's position would only increase pressure on the coccyx. Massaging of a reddened area is not recommended because it could cause further injury if the tissue is already compromised. Insertion of a urinary catheter will not relieve pressure on the coccyx.



18. The nurse is to collect a specimen for culture after assessing the client's wound drainage. The best technique for obtaining the culture is to:A) Cleanse the wound first.B) Send the soiled dressing to the laboratory.C) Swab from the outside skin edge inward.D) Collect the specimen from accumulated drainage.

Feedback: INCORRECT Cleansing the wound first and swabbing the granulation tissue will provide a culture specimen that will show a more accurate picture of any causative organisms of wound infection. Sending a soiled dressing and collecting a specimen from accumulated drainage are not appropriate, because old and new drainage are mingled, and the drainage is possibly growing organisms of its own and may not provide a true reflection of the wound flora. Swabbing from the outer edge of the skin inward may introduce organisms into the wound and contaminate the culture specimen.



19. The nurse applies a hydrogel dressing to a client with radiation-damaged skin. Why is a hydrogel dressing the best choice for this client?A) It provides a wicking action.B) It permits the nurse to view the wound.C) It is soothing and reduces pain in the wound.D) It can be used as a preventative dressing for high-risk friction areas. Feedback: INCORRECT Hydrogel dressings are gauze or sheet dressings impregnated with a water- or glycerin-based amorphous gel. They are very useful in managing painful wounds because they are very soothing to the client and do not adhere to the wound bed, so that dressing removal causes little trauma. A hydrocolloid dressing may be used as a preventative dressing for clients with high-risk friction areas. A self-adhesive, transparent film dressing allows for viewing of the wound. The oldest and most common wound dressing is the gauze sponge, which is especially useful in wicking away wound exudates.



20. The nurse places an aquathermia pad on a client with a muscle sprain. The nurse informs the client that the pad should be removed in 30 minutes. Why will the nurse return in 30 minutes to remove the pad?A) A local response occurs.B) A systemic response occurs.C) Reflex vasodilation occurs.D) Reflex vasoconstriction occurs. Feedback: INCORRECT If heat is applied for 1 hour or longer, blood flow is reduced by reflex vasoconstriction. Vasoconstriction is the opposite of the desired effect of heat application. Reflex vasodilation occurs when an application of cold is left on too long. Reflex vasodilation is the opposite of the desired effect of cold application. Systemic response and local response are general and vague terms.



OSTOMY CARE:Ostomy- surgically created opening, a stoma is created to drain urine or feces.

Location determines the consistency of the ostomyo As you move up the large intestine you have to worry about dehydrationo Ileostomy byspasses the entire large intestine so stools are frequent and liquid, usually on

right side Same for colostomy of ascending colon

o Colostomy of transverse colon- results in a more solid, formed stool, rareo Sigmoid colostomy releases near normal stoolo Jejunostomy- rare, need parenteral nutrition

Three types of colostomy constructiono Loop colostomy

Ex: higher rectal cancer Usually performed in emergency when the closing of colostomy is anticipated. A loop of bowel is pulled onto the abdomen, an external supporting device (plastic rod)

is placed under the loop to keep it from slipping back. The surgeon opens the bowel and sutures it to the skin of abdomen, the bowel will have

a proximal and distal end in one stoma The proximal end drains stool, the distal end drain mucus

o End colostomy One stoma formed from proximal end of bowel with the distal portion either removed

or sewn closed (hartmanns pouch) and left in cavityo Double barrel

Bowel is surgically severed in double barrel colostomy, the two ends are brought out onto the abdomen.

2 distinct stomas Proximal functioning stoma Distal nonfunctioning stoma

o Alternative procedures Ileoanal pouch anastomosis

Used for pt that have ulcerative colitis or familial polyps Removal of the colon, the a pouch is created from the end of the small intestine,

and attaches to the anus The pouch serves as a collection of waster material, similar to the rectum.

Kock continent ileostomy Using the clients small intestine, detubularizing its cylindrical shape and creating a

spherical reservoir. Used in tx of ulcerative colitis Pouch has continent stoma, nipple type valve that is drained with external

catheter, which client places intermittently in the stoma Macedo-malone antegrade continence enema

Used to improve continence in clients with fecal soiling associated with neuropathic or structural abnormalities of anal sphincter

3 cm flap of left colon is isolated A foley is placed on the surface of the flap creating a tubular passage Distal end of tube is made into a V shape to the skin flap Enema begins 7-10 days post op

Psychological considerationso Anxiety self esteemo Coping body imageo Sexual relations diet

Nursing process and bowel eliminationASSESSMENT

Assessment includes a nursing hx, physical assessment of abdomen, inspection of fecal characteristics, review of relevant test results

o Obtain diet and medication hxo Identify signs and symptoms associated with altered elimination patternso Determine impact of underlying illness, activity patterns, and diagnostic tests on bowel

elimination patterns.DIAGNOSIS

Disturbed body image Ineffective health maintenance Risk for constipation Risk for diarrhea

PLANNING Select nursing interventions to promote normal bowel elimination Consult with dietitians and enteral stoma therapists Involve the client/family in designing nursing interventions

IMPLEMENTATION Health promotion

o Promotion of normal defecation Sitting position Positioning on bedpan Privacy

Acute careo Medicationso Cathartics and laxativeso Anti diarrheal agentso Enemas

Cleansing hypertonic solutions- Tap water soapsuds Normal saline oil retention Other

o Enema administrationo Digital removal of stoolo Inserting and maintaining a nasogastric tube because is decompresses the GI tract

Continuing and restorative careo Care of ostomieso Irrigating a colostomyo Pouching ostomies

Pouch collects fecal material Effective pouching protects the skin, contains fecal material, remains odor free, and is

comfortable and inconspicuous Decisions about pouching:

Drainable vs. closed end One piece vs. two piece Filter vs. non-filter Stomahesive vs. durahesive barrier Clamp tail or velcro Spickett for urostomy Cut to fit

Pre-cut Moldable Convex Change wafer every 4-5 days

EVALUATION

Observe characteristics of stool and evaluate defecation pattern Observe for signs and symptoms of altered elimination Ask client to report perception of bowel elimination patterns following interventions Ask if the clients expectations are being met

CLASS NOTES

Gastrointestinal tracto Responsible for ingestion, digestion, and absorption of nutrientso Storage and elimination of fecal wasteo Significant impact on fluid electrolyte balance

Small intestineo Duodenum - neutralizes acidic gastric contentso Jejunum - major organ for nutrient absorptiono Ileum - nutrient absorption

Diseases that may lead to ostomieso Cancer familial adenomatous polyposiso Diverticulitis inflammatory bowel disease (crohns ulcerative colitis)o Congenital defects traumao Ischemic bowel disease

Inflammatory bowel diseaseo Systemico Not always confined to GI tracto Innappropriate immune response to environmental triggerso Leads to cascade of bodily responses that lead to disease symptomso Arthritis most common EM of IBD

Fewer than 6 joints, involves ankles, knees, wrists, hips, and elbowso Often subsides when bowel symptoms are in remission

Crohns disease Ulcerative colitis

Anywhere along GI tract Colon only

Abdominal pain, diarrhea, weight loss, and growth failure

Diarrhea, rectal bleeding, weight loss

Blood not visible if proximal disease Blood usually visible

Weight loss common due to malabsorption Some weight loss

Perianal disease Perianal disease uncommon

Some increase risk for cancer Significant increase risk for cancer

Surgery to remove disease but not curative Surgical removal of colon may be curative except of EMs

Post operative assessment

o Stomal viabilityo Surrounding contours - ideally smooth surface, below the beltline

Away from bony prominences, umbilicus or suture lineo Stomal height - may appear big due to inflammation

Stoma should be moist and pink About 2.5cm

o Mucocutaneous suture line - the suture should be right up against skino Ileus - peristalis "goes to sleep"o Anastomotic leak - renal failure, perforation, sepsis!

Abdominal distention Will require systemic antibiotic therapy

EVOLVE QUESTIONS:

1. Most nutrients and electrolytes are absorbed in:A) The colonB) The stomachC) The esophagusD) The small intestine Feedback: INCORRECT The small intestine (specifically the duodenum and jejunum) absorb most of the nutrients and electrolytes. The ileum absorbs certain vitamins, iron, and bile salts. The colon absorbs water, sodium, and chloride from the digested food that has passed from the small intestine. The esophagus moves food from the mouth to the stomach.



2. During the nursing assessment the client reveals that he has diarrhea and cramping every time he eats ice cream. He attributes this to the cold temperature of the food. However, the nurse begins to suspect that these symptoms might be associated with:A) Food allergyB) Irritable bowelC) Lactose intoleranceD) Increased peristalsis

Feedback: INCORRECT Lactose intolerance occurs in individuals who lack the enzyme needed to digest the milk sugar lactose. Diarrhea and cramping following dietary ingestion are signs of lactose intolerance. This is the most specific answer.



3. In assessing a 55-year-old client who is in the clinic for a routine physical, the nurse instructs the client about the need to provide a stool specimen for guaiac fecal occult blood testing:A) If the client notices rectal bleedingB) If there is a family history of intestinal polypsC) As part of a routine screening for colon cancerD) If a palpable mass is detected on digital examination Feedback: INCORRECT Routine screening for colon cancer includes fecal occult blood testing. There does not need to be a reason for routine screening, such as a family history, masses, or bleeding, although these can indicate the need for further testing.



4. Diarrhea that occurs with a fecal impaction is the result of:A) A clear liquid dietB) Irritation of the intestinal mucosaC) Inability of the client to form a stoolD) Seepage of stool around the impaction Feedback: INCORRECT Although a mass of solid matter may obstruct the large intestine, liquid stool may leak around the obstruction (impaction). A clear liquid diet is not the cause of the diarrhea, nor is irritation of the intestinal mucosa. This type of diarrhea is not caused by the inability of the client to form stool.



5. A cleansing enema is ordered for a 55-year-old client before intestinal surgery. The maximum amount of fluid used is:A) 150 to 200 mlB) 200 to 400 mlC) 400 to 750 mlD) 750 to 1000 ml Feedback: INCORRECT The maximum volume of enema to be administered to an adult is 750 to 1000 ml. An infant is given 150 to 200 ml; a toddler, 250 to 350 ml; and a school-aged child, 300 to 500 ml. An adolescent is given 550 to 750 ml.



6. During the enema the client begins to complain of pain. The nurse notes blood in the return fluid and rectal bleeding. The nurse's next action is to:A) Stop the instillation.B) Slow down the rate of instillation.C) Stop the instillation and measure vital signs.D) Tell the client to breathe slowly and relax. Feedback: INCORRECT If bleeding occurs on enema administration, the nurse should stop the infusion, measure vital signs, and notify the health care provider.



7. A nurse trained to care for ostomy clients is:A) A gastrointestinal therapistB) A nurse practitioner.C) An ostomy practitionerD) A wound-ostomy-continence nurse Feedback: INCORRECT A wound-ostomy-continence nurse (WOCN) is a nurse with special training in caring for ostomy clients. The other options are incorrect.



8. Soon after the client's abdominal surgery the nurse includes in the plan of care which of the following interventions, which is essential for promoting peristalsis?A) Consumption of a high-fiber dietB) Early ambulationC) Restriction of fluid intakeD) Administration of large doses of opioids Feedback: INCORRECT Early ambulation is essential for maintaining peristalsis through improved abdominal muscle tone and stimulation. Large doses of opioids may suppress peristalsis. The dosage of opioid should be that which adequately controls pain with the fewest side effects. A high-fiber diet is inappropriate immediately following surgery. The bowel is inflamed from surgery. Restriction of fluids could contribute to constipation. Intake of fluids should be started as soon after surgery as possible, once bowel sounds have returned.



9.

The nurse is instructing the client about the use of opioids for pain relief. Included in the teaching is the fact that opioids may cause:A) HeadachesB) ConstipationC) HypertensionD) Muscle weakness Feedback: INCORRECT Constipation is a known side effect of opioids to which the client often does not become tolerant. Headaches, hypertension, and muscle weakness are not known side effects of opioids.



10. When irrigating a colostomy, the nurse is sure to use which of the following equipment?A) An enema setB) A cone-tipped irrigatorC) A 50-ml irrigation syringeD) A 16-French Foley catheter with a 30-ml balloon Feedback: INCORRECT Using a cone-tipped irrigator is important to prevent irritation of or injury to the stoma. It prevents bowel perforation and backflow of irrigating solution. The other options are inappropriate for colostomy irrigation because they could cause injury to the bowel mucosa and/or allow backflow of the irrigating solution.



11. A client who recently experienced a bout of diarrhea is requesting something to drink. There is an order to force clear liquids to prevent fluid and electrolyte imbalance. The nurse decides to give the client:A) Ice creamB) A cold fruit popC) A cup of hot coffeeD) Room-temperature bouillon Feedback: INCORRECT Hot and cold foods (options 1, 2, and 3) stimulate peristalsis, which can cause abdominal cramping and further diarrhea. Thus room-temperature liquids are better tolerated. Bouillon also contains some electrolytes that may prevent electrolyte imbalance. Ice cream is not a clear liquid.



12. The nurse is obtaining a client's medication history. Which of the following medications may cause gastrointestinal bleeding? (Select all that apply.)A) AspirinB) Cathartics

C) Antidiarrheal opiate agentsD) Nonsteroidal anti-inflammatory drugs (NSAIDs) Feedback: INCORRECT Aspirin and NSAIDs may cause gastrointestinal bleeding. Antidiarrheal opiate agents slow the motility in the gastrointestinal tract, and cathartics increase motility.



13. To prevent the client from performing a Valsalva maneuver, the nurse might request a stool softener for a client with which of the following conditions? (Select all that apply.)A) GlaucomaB) HypotensionC) Cardiovascular diseaseD) Risk for increased intracranial pressure Feedback: INCORRECT The Valsalva maneuver can increase intracranial pressure, which is undesirable. It can also increase intraocular pressure and thus increase the risk for optic nerve damage. Hypotension is not aggravated by the Valsalva maneuver, but the maneuver can increase blood pressure, which could place a strain on the heart.


Correct Answer(s): A, C, D

14. The nurse teaches clients with a new colostomy that they can eat whatever foods they like but that which of the following foods typically produce gas and should be consumed cautiously? (Select all that apply.)A) PastaB) BeansC) GarlicD) OnionsE) Cauliflower Feedback: INCORRECT Foods affect clients differently. However, some foods appear to produce more gas than others. Warning clients about these traditional gas producers will alert them to be aware of the possible problem and allow them to make informed choices. Garlic and pasta are not known to produce excessive gas.


Correct Answer(s): B, D, E

15. The nurse begins to suspect a fecal impaction in a client who has not had a stool in 10 days when which of the following occurs? (Select all that apply.)A) The client feels nauseated.B) The client oozes liquid stool.C) The client has a rounded abdomen.D) The client has continuous bowel sounds. Feedback: INCORRECT

Nausea, liquid stool, and continuous bowel sounds are all symptoms of an impaction. Liquid stool can seep around the impaction. If stool cannot exit, there is a backup of gastrointestinal contents, which often results in nausea. Bowel sounds may be increased as the body attempts to push the impaction forward. A rounded abdomen by itself may indicate obesity or even ascites. For a rounded abdomen to be a symptom of an impaction, distention must be present.


Correct Answer(s): A, B, D

16. The nurse instructs the client to avoid which of the following foods, which could give a false reading on the fecal occult blood test? (Select all that apply.)A) FishB) LasagnaC) Cranberry juiceD) Raw vegetables Feedback: INCORRECT Fish and some raw vegetables can produce false-positive results if consumed during the collection of stool for occult blood testing. Although lasagna and cranberry juice are red, they do not irritate the gastrointestinal tract so that bleeding occurs. The fecal occult blood test measures blood in the stool and is unaffected by foods that are red.



17. A client with a Salem sump tube begins to drain stomach contents from the blue "pigtail." Which nursing actions would be appropriate for the nurse to implement at this time? (Select all that apply.)A) Clamp the blue pigtail.B) Attach suction to the blue pigtail.C) Irrigate the large lumen with saline.D) Position the blue pigtail at the level of the client's ear. Feedback: INCORRECT Irrigation determines the patency of the main sump drain. If it is obstructed, stomach contents can and will exit via the blue pigtail. Positioning the blue pigtail above the level of the stomach minimizes its becoming a drain. One should never clamp or apply suction to the blue pigtail, because that would eliminate its function as an air vent that prevents the gastric mucosa from being sucked into the sump's eyelets.


Correct Answer(s): B, D

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Care Exam 2 Notes