NURS 486 MOC III Exam #2: GI ATI Notes

A nurse is caring for a client who has acute pancreatitis. After the client's pain has been addressed, which of the following is the next intervention to include in the plan of care?

- NPO To rest the pancreas and reduce secretion of pancreatic enzymes, oral fluids and food are withheld during the acute phase of pancreatitis. This is the next intervention to be included in the plan of care.

Manifestations of acute pancreatitis

- Pain in Left upper quadrant that can radiate to the back. Abdominal tenderness - decreased bowel sounds -low-grade fever - hypotension and tachycardia - jaundice - N/V and fatty stools - Grey Turners spots (bluish flank discoloration) - Cullen's sign (a bluish periumbilical discoloration), hypotension, tachycardia

Acute pancreatitis management

*Pain is the priority* - Demerol or Dilaudid IV for pain - Decrease intestinal motility and pancreatic enzymes with Bentyl, H2 blockers like PPI/Protonic, Zantac, Prilosec - Crystalloid IVF is like lactated ringers. May need transfusion with albumin, plasma, dextran -BP support with dopamine or other vasopressors PRN - Antibiotics . *Position knee to chest, side-lying with HOB 45 degrees* - Lying on back/bending over increases pain *Prevent pancreatic stimulation (NPO)* 3. Manage hypovolemia with *aggressive fluid resuscitation* (200-300 mL/hr of maintenance fluid) - *Crystalloids (NS or LR) with colloids (albumin, hespan)* - *Manage shock/hypotension with vasoactive agent (dopamine)* - IV calcium or mag if Chvostek's Sign or Trousseau's sign. NG low suction, no smoking, limit stress - Hypomagnesemia: at risk for torsades de pointes, prolonged QT interval, and v. tach

Diagnostics for Acute pancreatitis

- Elevated serum lipase and amylase - abdominal ultrasound - CT with contrast - Endoscopy -Chest x-ray - Can have increased liver enzymes, glucose, triglycerides, and bilirubin Ultrasound (to find gallstones)

Acute pancreatitis hallmark signs

- Gray Turner's Sign and Cullen's Sign from bleeding - severe abdominal pain and distention - board-like abdomen - N/V - increased serum amylase

A nurse is providing discharge teaching to a client who will be receiving total parenteral nutrition (TPN) at home. Which of the following instructions should the nurse include? (Select all that apply.)

- Keep the TPN refrigerated when not in use - Infuse 10 percent dextrose and water if the solution runs out to maintain blood glucose levels and prevent hypoglycemia. - If precipitate is present, such as white crystals, it should not be used and should be returned to the pharmacy - gently rock the TPN bag back and forth, up and down. This action gently blends the solution in the bag prior to administration - "Maintain TPN infusion rate when behind schedule

A nurse is caring for a client who has bleeding esophageal varices treated with a Sengstaken-Blakemore tube. Which of the following nursing actions is appropriate for the nurse to perform

- Maintain constant observation while the balloons are inflated. - balloons are to remain inflated at all times that the therapy is in place. - While the balloons are inflated, the client must be observed constantly - There are three ports seen at the end of the tube, one of which is maintained at constant suction in order to aspirate fluid and air out of the stomach - Head of the bed must be elevated at all times

A client is preparing to receive a blood transfusion. What should the nurse expect to document?

- Pre-transfusion vital signs - 20-gauge IV catheter patent and primed with 0.9% sodium chloride - RN should remain at the bedside for the first 15 to 30 min, which is the time when a reaction is most likely to occur - verified by two licensed practical nurses - Client denies chills and low back pain is correct

A serious complication associated with enteral feedings is aspiration. To reduce the risk of aspiration, the gastric residual volume should be checked ________. If the client is receiving continuous feedings, the residual should be checked every ________ hr and should be less than _______ mL. . Assessing the residual prior to feeding helps determine if the client is absorbing the established amount of the feeding. If aspiration occurs, the feedings should be stopped immediately.

- prior to each bolus feeding. - 4 to 6 - 200 mL; Withhold the feeding and reassess the client's tolerance to feedings if the gastric residual volume is over 200 mL for two successive measurements

How long should the RN remain at the bedside after administering blood products?

15 - 30 min

The client with a new stoma should expect fecal output from the colostomy stoma in _____ days.

2 to 3 (raw vegetables, such as onions, cucumbers, mushrooms, broccoli, cabbage, and cauliflower, increase gas and odor)

lood products have a maximum administration time of ____ hr.

4 because room temperature can destroy red blood cells, causing release of potassium, which can result in hyperkalemia in the client. There is also increased risk of bacterial growth with increased risk for sepsis associated with the blood transfusion.

A nurse is caring for a client with decreased liver function due to cirrhosis. When selecting a snack, which of the following selections indicates the client understands dietary requirements?

A banana is an appropriate snack selection for a client with decreased liver function. Carbohydrates are an important component of the client's diet due to the fact that the liver can only metabolize small amounts of protein at a time.

A client is about to undergo an abdominal paracentesis. In which of the following positions should the nurse place the client?

After having the client void, the nurse should place the client sitting upright in a chair with feet elevated to allow peritoneal fluid to pool and drain optimally. The nurse can use Fowler's position if the client is unable to get out of bed.

Chvostek's Sign

Cheek, facial spasm when Cheek is tapped associates with hypocalcemia can be r/t pancreatitis

A nurse is caring for a client who has an active upper gastrointestinal bleed. After inserting a NG tube into the client, which of the following findings should the nurse anticipate?

Coffee-ground drainage or emesis

A nurse is caring for a client who requires total parenteral nutrition (TPN). Which of the following actions should the nurse take when finding that the TPN solution is infusing too rapidly?

Fluid overload can cause dyspnea. The nurse should slow the infusion rate and sit the client upright to help prevent or treat dyspnea. The nurse should also administer oxygen if necessary.

A nurse is responding to a client who has esophageal varices from portal hypertension. The client has IV fluids infusing and has a blood pressure of 68/48 after vomiting up 500 mL of blood. Which of the following actions may the nurse plan to do first?

Increase IV fluid rate then Trendelenburg

Acute pancreatitis management medications

Pain: - IV Demerol or Dilaudid Diarrhea: anticholinergics - Bentyl; decreases motility and pancreatic enzymes H2 Blocker / PPI - Zantac, Prilosec Hydration to prevent shock: -Crystalloids like Lactated Ringers - Blood products like albumin, plasma, dextran - IV calcium if Chvostek's Sign or if Trousseau's Sign - Mag BP: Vasopressors like dopamine Infection; antibiotics NPO Enteral feedings via nasojejunal tube; high carb

A nurse on the day shift is preparing to change a client's total parenteral nutrition (TPN) solution, but the new TPN solution has not arrived from the pharmacy. The client receives additional IV fat emulsion during the night shift. Which of the following actions should the nurse take?

The nurse should hang D10W if the TPN runs out or is not available to hang. D10W is a hypertonic solution that will maintain glucose level and prevent rebound hypoglycemia.

Trousseau's sign

arm/carpal spasm associated with hypocalcemia arm/carpal spasm

Cullen's sign

ecchymosis in umbilical area, seen with pancreatitis

How long are feeding bags safe to use?

it should be changed every 24 hr to minimize the potential for bacterial colonization.

A nurse is caring for a client with cirrhosis who has a new prescription for cephulac (Lactulose). Following administration, the nurse will monitor the client for which adverse effect of this medication?

monitor for diarrhea. Lactulose is a synthetic disaccharide that the small intestine cannot utilize. It causes diarrhea by lowering the pH so that the bacterial flora are changed in the bowel.

Sengstaken-Blakemore tube is used to ___________

stop or slow bleeding from the esophagus and stomach. When the balloons are inflated, they put pressure on the areas that are hemorrhaging to tamponade the bleeding. While the balloons are inflated, the client must be observed constantly because displacement can cause airway obstruction.