N2 study guide exam 1

Expected output for ostomies (SIGMOID COLOSTOMY)

Normal postoperative output Small to moderate amount of mucus with semi‑formed stool 4 to 5 days after surgery Postoperative changes in output After several days to weeks, output resembles semi‑formed stool Pattern of output Resumes a pattern similar to the preoperative pattern

Risk factors for peptic ulcers

The most common causative link to PUD is H. pylori. In the elderly, the prevalence of PUD is linked to the use of NSAIDs (e.g., aspirin, ibuprofen).

RED FLAG: Catheterizing a Patient with Urinary Retention

If the catheterization fails to drain a significant volume of urine, the diagnosis will be reconsidered. If there is difficulty in passing the catheter, do not use force, do not inflate the catheter balloon until urine is seen in the catheter, and do not use a catheter introducer unless adequately trained in its use. If you are unable to pass a urethral catheter, use of a suprapubic puncture may be indicated.

Hypotonic IV Solution

Draws water from the vasculature into the cells. 0.45% Normal Saline Cells swell and burst

Ulcerative Colitis nursing care/interventions

Medical management; Removal of precipitating factors, Decompression of gut to reduce colonic distention, Correct fluid and electrolyte imbalance, Surgical Removal of entire colon with indicated urgency, Proctocolectomy with ileostomy (large intestine and rectum removed), total colectomy with ileoanal anastomosis

Nursing care and teaching with GERD

PATIENT PLAYBOOK: PATIENT EDUCATION FOR GERD You should instruct the patient with GERD to: Eat small meals and avoid eating two to three hours before sleeping. Rinse the throat with water after each meal, as this neutralizes the esophagus and cleanses the esophagus from the gastric juices. Sit in a semifowler's position after eating. Avoid irritating food substances (caffeine, alcohol, or acidic foods). Cease smoking, as it increases gastric acidity and interferes with healing of the esophagus. GERD Meds--Antacids -neutralizes acid in the stomach-PRN, -H2-Receptor blockers (↓amount of acid [mild symptoms]), Zantac, Pepcid AC, Tagamet- DAILY, -PPI (MOST powerful!! Med to treat GERD), Omeprazole (Prilosec), prevacid, pantoprazole/protonix -DAILY GERD Treatments--Surgery; laparoscopic surgeries to fix LES, or Nissen fundoplication (much more invasive)

Jugular Vein Distention

Put patient at a 45% angle and have them turn head to the side to check for distention.

Education on UTI prevention

Void after intercourse, Women wipe from front to back, Drink plenty of fluids, Drink cranberry juice (maintain acidic pH)

Strangulated obstruction

is accompanied by vascular compromise of the segmental arterial supply and venous drainage. Strangulating obstruction is common in small bowel obstruction and can progress to gangrene in as little as six hours. Although strangulation of the large bowel is rare, cecal perforation due to massive distension, perforation of the bowel wall by tumor, or diverticulum may occur.

UTI Complications

**Pyelonephritis is an example of Upper UTI complication of lower UTI; ascending infection that spread from the bladder to the kidneys, Infection that spread to the blood stream (nephritis and sepsis)

Bowel Obstruction

-Decreased motility, leading to block -Illeus--> nothing moving -S/S: vomiting, nausea, no BM -Intervention: resection of bowel, NG tube, medication

Nursing care of a constipated patient

-Having 2 or less BM per week -Intervention: increase fluid intake, increase fruit and veggie intake

Serious Complications of Ulcerative Colitis:

-Toxic MEGACOLON; Severe episode of colitis with total DILATION of colon which is NOT compatible with life; *Treatment is removal of entire colon, -Colon Perforation; Associated with toxic megacolon, perforation occurs if colon dilation isn't reversed

Edema Pitting Scale

0+ No pitting 1+ Mild pitting. 2mm depression, disappears rapidly 2+ Moderate. 4mm, disappears in 10-15 sec 3+ Moderate/Severe. 6mm, lasts more than 1 min 4+ Severe. 8mm, can last more than 2 min

Isotonic IV Solution

0.9% Lactated ringers Is one that has the same osmotic pressure as the referent solution (e.g., plasma).

Normal specific gravity

1.010 - 1.025

BUN normal value

7-20mg/dl

normal GFR

90 to 120 mL/min/1.73 m2

Stoma

A stoma is the artificial opening created during the ostomy surgery

Ileostomy

A surgical opening into the ileum to drain stool, which is typically frequent and liquid since large intestine is bypassed

Colostomy

A surgical opening into the large intestine to drain stool, with the ascending colon producing more liquid stools, the transverse colon producing more formed stools, and the sigmoid colon producing near-normal stool

Nephrotoxic drugs to avoid with renal disease

Amikacin- Chemotherapeutic agents Gentamicin Contrast medium Amphotericin B Ethylene glycol Gentamicin Gold and other heavy metals Sulfonamides Nonsteroidal anti-inflammatory drugs

Bladder Cancer causes

Cancer-causing agents (carcinogens) in the urine Cigarette smoking contributes to more than 50% of cases, and smoking cigars or pipes also increases the risk. Other risk factors include the following: age, chronic bladder inflammation, diet high in saturated fat, external beam radiation, family history of bladder cancer, infection with Schistosoma haematobium (parasite found in many developing countries), and treatment with certain drugs (e.g., cyclophosphamide). Exposure to carcinogens in the workplace also increases the risk for bladder cancer

Nursing care of a cholecystectomy

Care of the drainage tube ◯ Clients can have a Jackson-Pratt drain or other drainage tube placed intraoperatively to prevent accumulation of fluid in the gallbladder bed. ◯ Monitor and record drainage (initially serosanguineous stained with green-brown bile). ◯ Antibiotics are often prescribed to decrease the risk for infection. Care of the T-tube ◯ Instruct client to report an absence of drainage with manifestations of nausea and pain (can indicate obstruction in the T-tube). ◯ Inspect the surrounding skin for evidence of infection or bile leakage. ◯ If prescribed, elevate the T-tube above the level of the abdomen to prevent the total loss of bile. ◯ Monitor and record the color and amount of drainage. ◯ Clamp the tube 1 hr before and after meals to provide the bile necessary for food digestion. ◯ Assess stools for color (stools clay-colored until biliary flow is reestablished). ◯ Monitor for bile peritonitis (pain, fever, jaundice). ◯ Monitor and document response to food. ◯ Expect removal of the tube in 1 to 3 weeks. (this came from ATI)

Ulcerative Colitis

Chronic inflammatory bowel disorder that affects both the mucosa and submucosa of the colon and rectum. Focus of care is "support"

Nursing actions for a patient with a GI bleed (postural hypotension issues)

Complications of GI Bleed ◯ Hemorrhage ■ Manifestations of hemorrhage include bleeding, cool and clammy skin, hypotension, tachycardia, dizziness, and tachypnea. ■ Nursing Actions ☐ Assess for hemorrhage from the site, monitor vital signs, and monitor diagnostic test results (particularly Hgb and Hct). ☐ Notify the provider immediately. ■ Client Education - Report fever, pain, and bleeding to the provider. ◯ Perforation of the gastrointestinal tract ■ Manifestations include chest or abdominal pain, fever, nausea, vomiting, and abdominal distention. ■ Nursing Actions - Monitor diagnostic tests for evidence of infection, including elevated WBC, and notify the provider of unexpected findings. ■ Client Education - Report fever, pain, and bleeding to the provider.

Hypertonic IV Solution

Draws water from inside the cells, and into the intravascular space to dilute the high concentration of solutes. Must be given with caution to patients with heart or liver failure and they must be monitored carefully for hypervolemia. Cells shrink D5 with normal saline 3% Normal Saline

Contraindications in care of the small bowel obstruction

Enteroclysis should be avoided if perforation or ischemia are suspected. Upper GI studies are contraindicated because they may transform partial to complete obstruction or further complicate total obstruction.

Ways to detect hypervolemia

Excess fluid in the intravascular space causes an elevation in blood pressure. The pulse may be bounding. Increased jugular venous pressure may be visible in distended neck veins. Increased volume circulating through the kidneys may result in increased urine output. Excess fluid in the interstitial space may produce edema, bulging fontanelles in infants, and pulmonary congestion as evidenced by dyspnea and crackles on auscultation. Potential complication is pulmonary congestion. You will see this in your CHF patients Hypertension(hint was a test question)

Red Flag: Hypertonic Solutions

Hypertonic solutions cause greater damage to blood vessels as their tonicity increases. All solutions with tonicity over 500 mEq/L must be infused through central venous catheter.

Correct insertion techniques for a foley catheter

I could not find this.....I guess look in ATI

Ulcerative Colitis Signs/Symptoms

Key symptom is: BLOODY diarrhea (ulcers on the intestines causes bleeding), rectal bleeding; Can be less than bloody 5 stools per day and as many as 10 - 20 bloody stools each day, Lower abdominal pain, weight loss, anemia, anorexia, fatigue, weakness, tachycardia, hypotension, pallor, blood loss.

Client education for cholecystectomy

Laparoscopic or NOTES approach ◯ Instruct the client to ambulate frequently to minimize free air pain, common following laparoscopic surgery (under the right clavicle, shoulder, scapula). ◯ Tell the client to monitor the incision for evidence of infection or wound dehiscence (laparoscopic approach). ◯ Educate the client regarding pain control. ◯ Teach the client to report indications of bile leak (pain, vomiting, abdominal distention) to the provider. ◯ Teach the client to resume activity gradually and as tolerated, and to resume the preoperative diet. ● Open approach(JP drain or T-tube) ◯ Instruct the client to resume activity gradually. Avoid heavy lifting for 4 to 6 weeks. ◯ Tell the client to begin with clear liquids and advance to solid foods as peristalsis returns. ◯ Remind the client to report sudden increase in drainage, foul odor, pain, fever, or jaundice. ◯ Teach the client to take showers instead of baths until drainage tube is removed. ◯ Instruct the client that the color of stools should return to brown in about a week, and diarrhea is common. ● Dietary counseling ◯ Encourage a low-fat diet (reduce dairy products and avoid fried foods, chocolate, nuts, gravies). The client can have increased tolerance of small, frequent meals. ◯ Tell the client to avoid gas-forming foods (beans, cabbage, cauliflower, broccoli). ◯ Promote weight reduction. ◯ Instruct the client to take fat-soluble vitamins or bile salts as prescribed to enhance absorption and aid with digestion. (This came from ATI)

Assessment finding for improvement in infection

Lower UTI; Painful urination [dysuria], Frequency, urgency, or hesitancy, Cloudy of foul smelling urine, Hematuria (bloody), Lower abdominal pain, Mild fever they have improved Upper UTI; High fever, Chills, Nausea/vomiting, Flank pain or pain around waist level improved

Difference from upper to lower UTIs

Lower includes: Bladder and urethra, Upper includes: Ureters, kidneys (MORE severe than lower)

Nursing care of a cholecystectomy Post op interventions

Monitor for respiratory complications caused by pain at the incisional site Encourage coughing and deep breathing Encourage early ambulation Instruct the client about splinting the abdomen to prevent discomfort during coughing Administer antiemetics as prescribed for N/V Administer pain meds as prescribed Maintain NPO status and NG tube suction as prescribed Advanced diet from clear liquids to solids when prescribed and as tolerated by the client Maintain and monitor drainage from the T-tube if present (This came from my saunders book could not find this in the text)

Care of the patient with an NG tube

NURSING ACTIONS ● Assess and maintain proper function of the NG tube and suction equipment. ● Maintain accurate I&O. ● Assess bowel sounds and abdominal girth; return of flatus. ● Encourage repositioning and ambulation to help increase peristalsis. ● Monitor tube for displacement (decrease in drainage, increased nausea, vomiting, distention). ● Assess pertinent lab results (electrolytes, hematocrit). ● Provide frequent oral and nares care.

Stoma/ colostomy care

NURSING ACTIONS ● Assess the type and fit of the ostomy appliance. Monitor for leakage (risk to skin integrity). Fit the ostomy appliance based on the following. ◯ Type and location of the ostomy ◯ Visual acuity and manual dexterity of the client ● Assess peristomal skin integrity and appearance of the stoma. The stoma should appear pink and moist. ● Apply skin barriers and creams (adhesive paste) to peristomal skin and allow to dry before applying a new appliance. ● Evaluate stoma output. Output should be more liquid and more acidic the closer the ostomy is to the proximal small intestine. ● Empty the ostomy bag when it is one-fourth to one-half full of drainage. ● Assess for fluid and electrolyte imbalances, particularly with a new ileostomy. ● Evaluate ability of the client or support person to perform ostomy care. CLIENT EDUCATION ● Educate the client regarding dietary changes and ostomy appliances that can help manage flatus and odor. ◯ Foods that can cause odor include fish, eggs, asparagus, garlic, beans, and dark green leafy vegetables. Buttermilk, cranberry juice, parsley and yogurt help to decrease odor. ◯ Foods that can cause gas include dark green leafy vegetables, beer, carbonated beverages, dairy products, and corn. Chewing gum, skipping meals, and smoking can also cause gas. Yogurt, crackers, and toast can be ingested to decrease gas. ◯ After an ostomy involving the small intestine is placed, instruct the client to avoid high-fiber foods for the first 2 months after surgery, chew food well, increase fluid intake, and evaluate for evidence of blockage when slowly adding high-fiber foods to the diet. ◯ Proper appliance fit and maintenance prevent odor when pouch is not open. Filters, deodorizers, or a breath mint can be placed in the pouch to minimize odor while the pouch is open. ● Provide opportunities for the client to discuss feelings about the ostomy and concerns about its effect on the client's life. Encourage the client to look at and touch the stoma. ● Refer the client to a local ostomy support group.

Red Flag Stoma Complications

Narrowing of the stoma that may indicate that the stoma is interfering with fecal elimination. Stoma separation from the abdominal wall may necessitate the need for surgical repair. A stoma that is bulging might indicate a hernia is developing in the stoma area. Contact dermatitis as evidenced by a rash or redness around the stomal region. This may be due to the type of tape being used or the specific ostomal appliance. Lack of outflow may reveal an obstructed or impacted ostomy, which could require surgical revision. Unusual drainage either in color, amount, or odor should be noted and reported as potential manifestations of infection and inflammation.

Expected output for ostomies (ILEOSTOMY)

Normal postoperative output More than 1,000 mL/day Can be bile‑colored and liquid Postoperative changes in output After several days to weeks, the output decreases to approximately 500 to 1,000 mL/day Becomes more paste‑like as the small intestine assumes the absorptive function of the large intestine Pattern of output Continuous output

Expected output for ostomies (TRANSVERSE COLOSTOMY)

Normal postoperative output Small semi‑liquid with some mucus 2 to 3 days after surgery Blood can be present in the first few days after surgery Postoperative changes in output After several days to weeks, output becomes more stool‑like, semi‑formed, or formed Pattern of output Resumes a pattern similar to the preoperative pattern

RED FLAG: Enema Administration

Patients with severe abdominal pain, ulcerative colitis, or a history of megacolon should have a written order before enemas are administered because these conditions would normally prohibit the use of standard bowel preparation procedures, such as administration of laxatives and cleansing enemas.

what does a normal stoma look like?

Stomal appearance should normally be pink or red and moist. ● Signs of stomal ischemia are pale pink or bluish purple color and dry appearance. ● If the stoma appears black or purple in color, this indicates a serious impairment of blood flow and requires immediate intervention

RED FLAG: Alarm Symptoms for Patients with GERD

The following are symptoms that are considered alarming when evaluating patients with GERD: Weight loss Recurrent vomiting or bleeding Dysphagia Anemia (iron deficiency) Abnormal masses Recent onset of progressive symptoms (less than 3 months) If older than 45 years of age and new symptoms: Dyspepsia Continuous epigastric pain Symptoms unrelieved by proton pump inhibitors (PPIs) If older than 45 years of age with long-standing symptoms Barrett's esophagus or severe esophagitis

Care of the patient with glomerulonephritis

The major goals of care are to control edema and blood pressure. To control edema, the patient should be prescribed a low sodium diet (2 g per day) and placed on a fluid restriction (1 L per day). In the hospitalized patient, it is important to maintain a careful record of intake and output. Penicillin is indicated in nonallergic patients. Oral penicillin G is usually prescribed as 250 mg four times a day for 7-10 days. Patients who are allergic to penicillin can be prescribed erythromycin, 250 mg four times a day for 7-10 days. Obtain throat cultures from family members and close personal contacts, and treat those who are infected. In patients with severe edema, loop diuretics, such as furosemide (Lasix), may be prescribed. Potassium-sparing diuretics are contraindicated because of an increased risk of hyperkalemia. Hypertension may be severe and may not be controlled by the diuretic. In this case, calcium channel blockers or angiotensin-converting enzyme (ACE) inhibitors may be prescribed. Amlodipine (Norvasc) is an example of the former and usually prescribed in a dose of 5-20 mg orally, twice a day. Captopril (Capoten) is an ACE inhibitor and is prescribed as 25 mg orally, two or three times per day. Total daily dose should not exceed 150 mg.

Rovensing's sign for appendicitis

The nurse can assess for appendicitis by first testing for McBurney's point (pain elicited in the RLQ when firm pressure is applied). Then, the nurse can further differentiate the diagnosis by assessing for Rovsing's sign (rebound tenderness) Press deeply and evenly in the LLQ for five seconds. Note the patient's response. Abdominal pain when felt in the RLQ is a positive Rovsing's sign. The Rovsing's sign is based on the concept that changes in the intraluminal pressure will be transmitted through the intestine when the ileocecal valve is competent. Pressing on the LLQ traps air within the large intestine and increases the pressure in the cecum. When the appendix is inflamed, this increase in pressure causes pain.

Treatment of UTI

Trimethoprim-sulfamethoxazole D.S. (TMP/SMZ, Bactrim) Fluoroquinolones Cephalosporins: First-Generation Penicillins

RED FLAG: Ureteral and Urethral Strictures

Ureteral strictures (a narrowing of the lumen of the ureter) can be caused by surgery as a result of scarring. These strictures can decrease the actual function of the kidney, you can access for strictures when renal pain increases if the patient drinks large amounts of fluids in a short period of time. Correction is made with stent placement. Urethral strictures (a narrowing of the lumen of the urethra) occur as a result of inflammation of the urethra from causes such as trauma, urethritis, congenital defects, and surgery. You can assess for strictures of the urethra by noticing a diminished force of the urine stream, a split urine stream, and spraying of urine. In addition, the patient may develop urethritis and potentially a UTI. Correction is made by a urethral dilation and potentially stent placement.

Cullen's sign

a bluish periumbilical discoloration, can occur with intra-abdominal bleeding

3) Nursing assessment for postural hypotension.

a. Dizziness, loss of consciousness when going from sitting to standing b. Sign of intravascular fluid loss c. Should be assessed in patients with a history of fluid losses, dizzy, lightheaded when sitting or standing d. A decrease in systolic BP of more than 20 mm Hg when going from lying to standing along with an increase in heart rate of 10 beats/min e. OR, a decrease in diastolic BP of more than 10 mm Hg along with an increase in heart rate of 10 beats/min

Nursing care for ulcerative colitis patient (especially when the pt is having diarrhea/constipation)

clear liquids to a low-fiber diet as tolerated high protein diet with vitamins and iron supplements as prescribed Meds: salicylate compounds, corticosteroids, immunosuppressants as prescribed Monitor stools: noting color, consistency, and the presence or absence of blood Give IV fluids as prescribed Monitor I&0 monitor for bowel perforation, peritonitis and hemorrhage

In the ICU ileus is common in

critically ill patients with sepsis, shock, respiratory pathology, and severe electrolyte abnormalities, especially hypokalemia.

Radiation to the right scapula should raise the suspicion of

gallbladder

Malignant bowel obstruction

is a common complication in patients with advanced abdominal or pelvic malignancies, notably colorectal, ovarian, and gastric cancers. Small bowel obstruction (SBO) is most commonly due to postoperative adhesions, fibrous bands within the peritoneum, which may compress the bowel and cause obstruction, or be a focus for a volvulus (a twisting of the bowel on itself that causes obstruction). Prior abdominal surgery or sepsis (e.g., pelvic inflammatory disease, appendicitis) may cause adhesions.

McBurney's Point

is the name given to the point over the right side of the abdomen that is one-third of the distance from the anterior superior iliac spine to the umbilicus (navel). This point roughly corresponds to the most common location of the base of the appendix where it is attached to the cecum.

Murphy sign

occurs when the patient guards the movement by an inspiratory arrest secondary to painful contact with the fingers, which confirms cholecystitis (inflamed gallbladder) right upper quadrant pain, tenderness or mass

Assessment findings for cholelithiasis (gallstones)

pain in the right upper of quadrant which can radiate to the right scapular region; anorexia; nausea; and vomiting. However, many people are asymptomatic, and the diagnosis of cholelithiasis is made incidentally when the patient has other tests performed. Fever, tachycardia, and hypotension can indicate the presence of infection

The presence of tachypnea, tachycardia, hypotension, cold and clammy skin, altered mentation, low urine output, and fever suggest complicated disease with

peritonitis and shock

Grey Turner (tenderness) or Fox signs

should be sought in the flank and inguinal area It's a bruising in that area

simple obstruction

there is an obstruction in one site; closed loop obstructions are characterized by two sites of blockage.

colostomy (potential dx)

when a portion of the bowel must be removed (cancer, ischemic injury) or requires rest for healing (diverticulitis, trauma)

Ileostomy (potential dx)

when the entire colon must be removed due to disease (Crohn's disease, ulcerative colitis)

Bladder cancer symptoms

with painless gross hematuria, which is the classic presentation. More common conditions (e.g., UTI, kidney disease, or renal calculi) also cause hematuria. dysuria, urgency, or frequency of urination). Patients with advanced disease can present with pelvic or bony pain, lower-extremity edema from iliac vessel compression, or flank pain from ureteral obstruction.