NUR 2050 EXAM 2 STUDY GUIDE

Prior to being transported to the surgery suite, the nurse asks the client whether the client has any allergies. The client responds, "Does anyone communicate with anyone? I've been asked that question over and over!" What is the nurse's best response?

"This question is asked for verification and safety with each new phase of treatment."

A nurse is caring for a client with acute kidney injury who is receiving a protein-restricted diet. The client asks why this diet is necessary. Which information should the nurse include in a response to the client's questions?

"This supplies only essential amino acids, reducing the amount of metabolic waste products, thus decreasing stress on the kidneys."

EGD

(Esophagogastroduodenoscopy) goes through the mouth to look at esophagus and stomach Pre procedure: -Use of anesthetic agent -Monitor for perforation Post-procedure: -Vital signs -Observe for complications -Return of gag reflex, when appropriate

Bulk forming agents

(Fibercon, Metamucil, Citrucel) - attract water into the stool

Normal fasting blood glucose

(No food or drink for 8 hours) Should be under 126

SBAR Communication

(Situation, Background, Assessment, Recommendation) - framework for communication between members of the healthcare team about a patient's condition.

Remember often times you repeat back what the patient says in question format

(non-judgemental, validate feelings, do not give advice, do not brush off their feelings, do not pass it on to another profession immediately- think what can nurses do first)

Neutropenic precautions

*PATIENT IS AT RISK FOR INFECTION* -No sick visitors, a private room -Avoid invasive procedures -If invasive procedure is necessary than use strict aseptic or steril technique -A low bacteria diet (no fresh fruits, vegetables) -No fresh flowers

Aplastic anemia

*Patients with leukemia or bone marrow issues* -Immature RBCs -Non-differentiated

What are nursing considerations when administrating parenteral nutrition? Think in terms of how to care for the IV insertion site, the tubing changes, assessment protocols.

- Monitor for cellulitis - Use 10-20% dextrose solution after bag is empty while waiting for new bag to avoid hypoglycemia - Use infusion pumps - Start and stop gradually - Monitor weight - Monitor vital signs every 4 hours for developing infection - Monitor I&O - Blood glucose monitoring every 6 hours - Monitor glucose, CBC, albumin, and other lab values - TPN needs its own line - Handle TPN using strict aseptic technique

Primary use of NG tube

- instillation of medications and feeding (short term) •decompress or drain stomach fluid •absent peristalsis - paralytic lieu's •allows GI rest and healing •attached to suction

Hypertonic solution

-5% dextrose in 0.45% NaCl - used to treat hypovolemia and maintain fluid intake -10% dextrose in water -5% dextrose in 0.9% NaCl - temporarily used to replace nutrients and lytes and treat hypovolemia

Isotonic solution

-5% dextrose in water: do not use in excess; no sodium -0.9% NaCl (normal saline): may be used to expand temporarily the ECF -Lactated ringer's solution: multiple lytes in about the same concentration found in plasma

Diabetes Nutrition Recommendations

-A consistent carbohydrate intake at meals and snacks -Appropriate fat modifications -Consistent timing of meals

What is albumin's role in fluid balance in the body?

-A protein that is responsible for keeping fluid within the vasculature. -It keeps the osmotic/colloidal pressure -Responsible for permeability

What are the signs and symptoms of fecal impaction?

-Abdominal pain/discomfort and distention -Anorexia, n/v -Nonproductive defecation -Seepage of liquid stool with staining of clothes/linens -May be misdiagnosed as diarrhea -Digital rectal exam - fecal mass

Regular/house diet

-All foods permitted -Nutritionally adequate

Dietary consideration when someone has an ostomy

-Avoid high fiber foods the first 6-8 weeks -Likely will be put on clear liquid diet initially post-op -Make sure ileostomy patients consume a lot of fluids -Limit foods that cause blockages- popcorn, mushrooms, stringy vegetables, seeds, food with skin -Cabbage family foods→ causes gas

Renal Disease Allowances

-Carbohydrates ~ consider other diagnoses -Fats ~ consider other diagnoses -Vitamins and trace elements

What are the manifestations of hyperkalemia?

-Cardiac arrhythmias -Bradycardia/cardiac arrest

How often should the colostomy appliance be changed?

-Change pouch or colostomy appliance 1-2 times per week -Be sure to check the site surrounding stoma to ensure stool isn't irritating the skin

Colostomy

-Created with loop of the large intestine -Solid waste and bacteria are the contents of colostomy bag -Can have descending, ascending, or transverse colostomy

S/s of dehydration

-Dry, sticky, cracked mucous membrane -Eyes sunken -Eye balls soft from decreased intraocular tension

What is a normal stoma appearance immediately after surgery and after recovery?

-Edematous and big (swollen) after surgery -Bleeds easily at first

When should a colostomy bag be emptied?

-Empty bag when ⅓ or half full -Empty it frequently in a day; especially after meals

Liver Disease Diet

-Enough protein for regeneration of liver tissue -Prevention of dangerously high levels of ammonia -Maintain fluid and electrolyte balance

Diabetes Mellitus Diet

-Healthy eating plan that is naturally rich in nutrients and low in fat and calories -Variations dependent upon the patient's need • Exchange system • Carbohydrate counting •No concentrated sweets

When is SBAR communication used?

-In conversations with physicians, physical therapists, or other professionals. -Shift changes -When escalating a concern -When resolving a patient issue -When calling an emergency response time -In person discussions and phone calls -Daily safety debriefings

What is a rectal tube?

-Indwelling rectal tube -Insert in rectum Insert 30-45 mL of sterile saline to expand ring -Expands rectum and let stool seep through Similar to indwelling catheter

What is the function of ADH?

-It acts to decrease urine output at the distal convoluted tubules of the kidneys; water conserved -ADH is increased in stress or surgery -ADH is decreased with alcohol use

Ammonia Toxicity

-Loss of muscle coordination -Irritability -Asterixis (flapping tremor of the hands) -Hepatic encephalopathy •Restlessness •Euphoria •Day-night reversal of sleep •Change in respect for personal appearance

Ileostomy

-Made with last part of small intestine (ileum) -Contents include liquid and small amounts of undigested food -Standard brook ileostomy is often seen in Crohn's disease or ulcerative colitis

What is fecal impaction?

-Mass or collection of hardened or putty like feces in the rectum or sigmoid colon or higher -Cannot pass the anal canal

The nurse is caring for a client with cancer who is neutropenic. Which plan would be appropriate?

-Notify the doctor of any temperature over 100° F. -Use sterile technique when performing invasive procedures. -Avoid client exposure to anyone who is ill.

Know about enema and how to administer it? What position should the patient be in?

-Patient should lay in SIMs position -On left side lateral with right knee upward -Ensure patient is comfortable -Elevate bag so gravity aids in administration

Who is at risk for C. diff?

-People over the age of 65 People who have had recent: -Antibiotic therapy -Chemotherapy -GI surgery -Tube feeding/NG tube -Hospitilization

Goals of diabetic diet

-Prevent excessive postprandial hyperglycemia -Prevent hypoglycemia -Achieve and maintain ideal body weight -Achieve normal growth and development -Maintain/return triglycerides and cholesterol to normal -Prevent/delay complications of diabetes mellitus

Which pressure injury can manifest as a serum filled blister and which one manifests as a blood-filled blister?

-Serum - stage 2 -Blood - DTPI

What lab values are used to measure nutritional status?

-Serum Albumin -Prealbumin -Serum Transferrin -Total Lymphocytes Count -Red Blood Cell Count -Serum Iron Studies

What is shear and friction? What are ways to prevent injury from shear and friction forces?

-Skin displacement, pulling/sliding -Lifting devices -Proper devices -Transparent films

Renal Disease Diet Restrictions

-Sodium -Fluids -Proteins - to reduce urea production •may be below adult RDA 0.8 gm/kg/d -Potassium - may reach toxic levels Examples: Apricots, avocados, cantaloupe, chocolate, dried fruits, pumpkin, nuts, potatoes, bananas, oranges tomatoes, carrots

Abnormal appearance of stoma

-Swelling doesn't go down weeks after surgery -Stoma is dry and not moist -Coloration is either black, blue, pale→ necrosis or hypoxia -Pain from stoma Retracts or protrudes far out -The appliance won't fit properly, has to be changed more frequently than expected, or is irritating your skin.

What is bowel training?

-The purpose is to help patient have regular bowel movements without the use of a laxative by manipulating factors within the patient's control such as food/fluid intake, exercise and time of defecation. -First you need to assess what their regular bowel pattern and lifestyle is like. Then help them control/establish ways to help have regular BMs. -This may include keeping a bowel movement diary, teaching patient about specific foods, fluids and activity that help with BMs. Ensure privacy and patience.

How is C. diff treated?

-Treated with broad spectrum antibiotic (vancomycin or flagyl IV or PO) - 10 day course -Fecal microbiota transplantation: stool obtained from a healthy person -Is fresh or frozen -Given through a nasoduodenal tube or colonoscopy -Resolved in 3 hours -80% success rate -Adverse events: diarrhea, cramping, belching

What are the cons of a rectal tube?

-leakage, -perirectal skin damage -rectal mucosa injury -skin damage -injury of the anal sphincter

Normal creatinine levels

0.9-1.3 mg/dL

What is the therapeutic PT for coumadin therapy?

1.5 to 2 times normal value

What is the therapeutic PTT goal for a patient on heparin therapy?

1.5 to 2 times the normal value

Normal magnesium electrolyte levels

1.5-2.5 mEq/L

Normal sodium electrolyte value

135-145 mEq/L

Normal Hgb

14-17 g/L

Normal platelet count

140,000-400,000 mm3

What is the therapeutic INR for coumadin therapy?

2-3

Normal bicarbonate (HCO3) leveles

22-26 mEq/L

Normal pCO2 levels

24-46 mmHg

Normal potassium electrolyte values

3.5-5 mEq/L

Normal WBC

5,000-10,000 cells/mm3

Prediabetes A1C

5.7-6.4%

Normal Blood Urea Nitrogen (BUN)

6-20 mg/dL

Diabetes A1C

6.5% or higher

Normal fasting

60-100

Normal pH levels

7.34-7.45

Normal calcium electrolyte levels

9-11 mg/100 mL

Hypoglycemia

<70 mg/dL Signs and symptoms: irregular or fast heartbeat, fatigue, pale skin, shakiness, anxiety, sweating, hunger, irritability

An outpatient care nurse is providing instructions to a patient who is scheduled for a colonoscopy to remove a polyp. Which instructions are appropriate for client preparation for this procedure?

A bowel preparation will be required in preparation for the procedure.

Anemia

A reduction in the number of RBC, hematocrit and or hemoglobin.

What tests can be used to identify diabetes?

A1C test

Increased BUN

Above 20 mg/dL Signs/symptoms: dehydration, renal failure

What is the treatment for hypokalemia?

Administer oral K as prescribed

Clarifying question or comment

Allows the nurse to gain an understanding of a patient's comment. Example: Patient: I have never needed to take medicine before in my life. Nurse: Is this the first health problem you have had? Patient: Yes, I've always been healthy.

Decreased

Anemia and various diseases

What is ADH?

Antidiuretic hormone is formed in the hypothalamus and stored in the posterior pituitary gland

Vitamin K

Antidote for Coumadin

Protamine sulfate

Antidote for Heparin

Patients requiring clear or full liquid diets should receive

Approximately 200 g of carbohydrates per day, evenly spaced

NG tube complications

Aspiration, discomfort, trauma, wrong placement

A Muslim female client has been stabilized after an assault in the parking lot of a local restaurant. The nurse manager is making assignments for the oncoming shift. Which action by the nurse manager is the most appropriate to ensure the client's comfort?

Assign the client to a female nurse for every shift.

The nurse is caring for a child with neutropenia. Which beverage is unsuitable for the client with a low neutrophil count? A. 2% milk B. Fresh squeezed lemonade C. Kool-aid C. Coffee

B. Fresh squeezed lemonade

Imposition

Belief that everyone should conform to the majority belief system

Melena

Black tarry stool containing digested blood from the UGI tract

Hemolytic anemia

Blood cells being destroyed faster than they are being produced: -Sickle cell -Hereditary

Cholesterol screening

Blood test Patient education: Do not eat or drink anything except water for 9 to 12 hours before the test

What is the the treatment for hyperkalemia?

Calcium gluconate (immediate onset) -Decreases chance of immediate cardiac arrest

What happens when sodium levels are greater than 155 mEq/L?

Cardiovascular and renal symptoms

Palamar Flexion: Trousseau's sign

Carpopedal spasm induced by pressure applied to the arm by an inflated BP cuff.

What happens when magnesium levels are between 5-10 mg/dl?

Central nervous system depression, N/V, fatigue

A nurse is caring for a client scheduled for a CT scan with contrast. Which action is most appropriate?

Checking the client's creatinine level

What is negative pressure wound therapy?

Collection chamber that collects drainage § Reduces local edema § Increase regional blood flow § Enhanced epithelial migration § Preserve moist wound healing § Reduce bacterial colonization § Promote granulation tissue § Mechanically enhanced wound closure § Used on acute and chronic wounds

What happens when magnesium levels are between 10-15 mg/dl?

Coma ECG changes, respiratory paralysis

What happens when magnesium levels reach 30 mg/dl?

Complete heart block

The nurse is caring for a postoperative client who refuses a blood transfusion due to religious beliefs. The nurse is demonstrating trustworthiness when taking which action in response to the client's treatment wishes?

Contacting the interprofessional care team to discuss alternative treatment options

C. diff nursing considerations

DO NOT GIVE ANTI-DIARRHEAL MEDICATION

Leukopenia

Decrease in WBC (less than 5,000 cells/mm3) Signs/symptoms: fever, chills, sweating, sore throat, cough, shortness of breath Causes: hematopoietic diseases, medications, radiation therapy, unknown Nursing goals: monitor for infection, protect the patient against pathogens, respond aggressively to infection

Liver Disease Diet Considerations

Decrease protein -Dependent upon blood ammonia level and hepatic encephalopathy More carbohydrates -Decrease protein catabolism -Give energy -Maintain and replete liver glycogen stores Sodium restrictions -Due to elevated aldosterone levels -Retention of fluids Fluid restrictions depending on extent of disease -Amount posted to included amount allowed for nursing meals, and IVS -Nursing fluid amount is used for medications -No water pitcher or cups at bedside

Thrombocytopenia

Decreased platelet count Signs/symptoms: easy or excessive bruising, prolonged bleeding, blood in urine or stools Causes: idiopathic, leukemias, chemo/radiation therapy Nursing goals: safety measures, monitor for bleeding, teaching

A client is receiving TPN. The nurse notices that the bag of TPN solution has been infusing for 24 hours but has 300 mL of solution left. What should the nurse do?

Discontinue the current solution, change the tubing, and hang a new bag of TPN solution.

Stool softeners

Doesn't increase peristalsis; essentially they only make the stool mushier or softer, doesn't push the stool. Only allow water to penetrate the stool. i.e. Colace For example, If a patient is already constipated and they just haven't haven't pooped in 3 days, giving them colace won't make a difference. It's only going to make it mushier and this patient needs peristalsis. Therefore we would look to giving them a laxative.

A client brought to the emergency department states that he has accidentally been taking two times his prescribed dose of warfarin (Coumadin) for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to take which action?

Draw a sample for prothrombin time (PT) and international normalized ratio (INR).

Hypotonic solutions

Each provides water, Na, and Cl -0.33% NaCl (1/3 strength) - 0.45% NaCl (1/2 strength

S/s of fluid overload

Edema, HTN, ascites, anasarca (overal body edema), pleural effusion

pH in respiratory alkalosis

Elevated (greater than 7.45)

How often should you check blood sugar for someone receiving enteral or parenteral feeding?

Every 6 hours

What are the signs and symptoms of Anemia?

Fatigue, exertional dypnea, tachycardia, headache, dizziness, pallor

Enteral

Functional GI tract Example: NG Tube, PEG tube

Colonoscopy

Going through the rectum Pre-procedure: -Bowel prep (miralax or golightly) -Clear liquid diet -Day of procedure NPO -Enema if needed Post-procedure: -Check for bleeding

TPN is prescribed for a patient who has recently had a small and large bowel resection and who is currently not taking anything by mouth. What should the nurse do to safely administer the TPN?

Handle TPN using strict aseptic technique

What happens when sodium levels are greater than 160 mEq/L?

Heart failure

A patient with diabetes mellitus self monitors blood sugar at home. Now the primary care provider wants to assess the client's average blood sugar over a 3-month period. The best test for this would be:

Hemoglobin A1C

A client who is weak, dyspneic, and jaundiced has an elevated bilirubin level. With which problem are these clinical findings consistent?

Hemolytic anemia

What is considered high residual volume? What should you do if it is high?

High residual volume = 200-250 mL or greater If volume residual is high: -hold the feeding and report to the practitioner -may delay feeding 30-60 min -return fluid to body

increased creatinine

Higher than 1.3 mg/dL Causes: kidney function disorder reduces excretion Signs/symptoms: n/v, fatigue, changes in urination, HTN, chest pains, muscle cramps

A patient with atrial fibrillation is receiving warfarin (Coumadin) 5 mg each day. His INR today is 2.4 (N= 0.8-1.2). What is the expected change in medication dosage?

His INR is within desired range. No change in warfarin dose is needed.

insulin lispro

Humalog Rapid-Acting Insulin Onset: within 15 minutes Peak: 35-40 minutes

What are nursing considerations when administering parenteral nutrition?

IV insertion site care: sterile dressing change, change every 72 hours or according to agency Infusion set tubing should be changed every 24 hours and unused solution discarded within 24 hours of start. Catheter should be checked by X-ray

Blindness

Ignores differences and proceeds as if they did not exist

Leukocytosis

Increase in WBC Signs/symptoms: fever, bleeding, bruising, feeling weak and tired, pain, tingling, trouble breathing Causes: acute infection, leukemia Nursing goals: monitor for manifestations, of infection such as UTI, pneumonia, IV lines and wound

A nurse is caring for a client with a diagnosis of polycythemia vera. The client asks, "Why do I have an increased tendency to develop blood clots?" Which effect of the polycythemia vera should the nurse explain increases the risk of these thromboses?

Increased blood viscosity

Thrombocytosis

Increased platelet count Causes: after splenectomy, inflammatory diseases, hemorrhages, response to exercise Signs/symptoms: blood clots in arteries and veins, bruising easily, bleeding, bloody stools

What are the contributing factors of hyperkalemia?

Increased potassium intake -Excess or too rapid infusion of old blood -Excess IV K infusion -Increased oral intake only if accompanied by decreased excretion Movement of K into extracellular fluid -acidosis -insulin deficiency -tissue injury Decreased urinary excretion of K -Oliguric renal failure -Volume depletion -K sparing diuretics -Decreased effects of aldosterone

What are the contributing factors to hypokalemia?

Increased potassium loss -GI loss -Vomiting -NG suction -Diarrhea -Laxative abuse -Excessive sweating without K replacement Increased urinary excretion of K -Most diuretics -Steroids -Renal salt wasting -Hypomagnesemia -Poor intake

C. diff

Inflammation of the colon caused by the bacteria Clostridium difficile. Diarrhea is a major symptom. It is a nosocomial infection.

What are some pressure injury preventative strategies?

Inspect skin daily and document o Assess and treat incontinence o Prevent and treat dry skin o No vigorous massages o Use proper positioning transferring and turning techniques § Use pillows or wedges to separate bony prominences § Totally relieve heel pressure § Side-lying 30 degree lateral inclined position § Head of bed at 30 degree § Prevent shear § Use lifting devices § Use pressure redistribution surfaces § Poor sensation § Take into consideration involved body locations, length of use, patients' level of function, ability of patient to reposition, cost and financial feasibility § Egg crate foam § High quality foam mattress § Static air overlay § Air overlay with pump § Low air loss critical bed with rotation o Position carefully when seated § Limited time person spends sitting in chair without reposition or pressure relief o Complete nutritional assessment an intervention o Improve mobility and activity status o Monitor and document interventions and outcomes

Reflective question or comment

Involves repeating what the person has said or describing the person's feelings. Example: Patient: I've been really upset about my blood pressure and have to take these pills. Nurse: You've been upset... Patient: I guess I'm worried about what could happen if my blood pressure gets too bad.

What is the role of magnesium at the neuromuscular junction?

It affects release of acetylcholine at the neuromuscular junction Excess: decreases the release of acetylcholine and decreases neuromuscular excitability Deficit: increases the release of acetylcholine and increases neuromuscular excitability

PT/INR

Lab value monitoring for Coumadin therapy

PTT

Lab value monitoring for Heparin Therapy

Normal glucose levels

Less than 140 mg/dL

What are some factors that can give a false positive fecal occult test result?

Licorice, beets, medication certain food can lead to a false positive

Decreased creatine

Lower than 0.9 mg/dL Signs/symptoms: low muscle mass

Decreased BUN

Lower than 6 mg/dL Signs/symptoms: overhydration; loss of 80% hepatic function

Vitamin B12 deficiency (Pernicious anemia)

MCV = macrocytic

Iron deficiency anemia

MCV = microcytic MCHC = hypochromic

Anemia of chronic disease

MCV = normocytic MCHC = normochromic

What happens when calcium levels are greater than 13 mg/dL?

May cause cardiotoxicity, arrhythmias, and coma

What happens when calcium levels are less than 6 mg/dL?

May produce tetany and convulsions

Cultural assimilation

Minorities living within a dominant group lose the characteristics that made them different. Values replaced by those of dominant culture (First gen usually has a harder time assimilating)

Descending stool appearance

More formed darker brown stool

What happens when the potassium level is greater than 7.0?

Muscle irritability, including myocardial irritability.

Normal INR

N = 0.8-1.2 sec

Prothrombin time (PT)

N = 11-13 seconds

Normal PTT

N = 25-35 sec

Parenteral

Nonfunctional GI tract

What precautions must be done to prevent aspiration during feeding tube instillation?

Patient's head of bed should be positioned no lower than a 30 degree angle during continuous feeding. You should keep head of bed elevated for 1 hour after bonus feeding. Regular tube checks Stop feeding when turning patient or providing hygiene care (remember to turn it back on when patient positioned correctly)

Where is the bone marrow taken from in a bone marrow biopsy?

Pelvic bone, or larger bone

Softener-Irritant

Pericolace, Doxidan

PPN

Peripheral Parenteral Nutrition = less concentrated short term nutrition not as widely used Inserted into smaller veins through a peripheral intravenous line

Deep tissue pressure injury (DTPI)

Persistent, non-blanchable deep red, maroon, or purple discoloration of intact or non-intact skin, epidermal separation revealing a dark wound bed or blood-filled blister, pain and temperature changes often proceed skin color changes, results from intense and/or prolonged pressure and shear forces on bon-muscle undersurface.

Increased hgb

Polycythemia, congestive heart failure, COPD

NG tube nursing considerations

Provide oral and skin care, verify NG tube placement, wear gloves, face and eye protection

Pureed and Dental Soft

Pureed -Ground and pureed meats, fruits, vegetables, etc. Mechanical or Dental Soft -Patients with limited chewing ability -Included easily chewed foods

Open-ended questions

Questions a person is to answer in his or her own words. Example: "Tell me more about why you came in."

Close-ended questions

Questions that can be answered in short or single word responses. Example: "When did this pain start?"

Hyperglycemia

Random blood glucose test of 200 mg/dL Signs/symptoms: fruity smelling breath, n/v, shortness of breath, dry mouth, weakness, confusion, coma, abdominal pain

Renal Diet

Renal diet restriction depends upon: - Extensiveness of renal disease -Age -Growth and development -Concurrent diagnoses -Treatment of renal disease

What is nursing role in caring for a Jehovah witness patient refusing blood transfusion?

Respect the values, beliefs and cultural backgrounds of all patients. Jehovah's Witnesses decline transfusion of specific blood products, usually whole blood and primary blood components. Individuals vary in their choice and it is important to clearly establish the preference of each patient.

For patients undergoing MRI, what are some safety concerns and interventions?

Safety concerns: -May require a non iodinated contrast media which may be contraindicated in persons with renal disease -Not advised for pregnant women or pt with epilepsy -Pt with implanted devices (cochlear implant, pacemaker, IUD, infusion pumps) Nursing interventions: -Screen for presence of metal objects -Tattoos may burn or swell -Monitor for claustrophobia -Person w/ metal fillings may feel tingling

For patients undergoing CT scan, what are some safety concerns and interventions?

Safety concerns: -Pts over 300 lbs -Pregnant women -Confusion/agitation -Monitoring equipment that cannot be removed -Pt with implanted metal objects (pacemaker, infusion pump) Nursing interventions: -Assess for allergy to iodine -Obtain written consent -May be NPO for 4 hours if contrast is used -Remove all jewelry

Transverse stool appearance

Semi liquid, more mushy → due to some fluid absorption

While a client is receiving TPN it is most important for the nurse to monitor?

Serum glucose and electrolytes

What happens when sodium levels are 95-105 mEq/L?

Severe neurologic symptoms

What are the signs and symptoms of hypoglycemia?

Shakiness, anxiety, nervousness, diaphoresis (abnormal sweating), palpitations, coldness, and a headache - late signs include seizures, loss of consciousness, and death.

Normal random blood glucose test

Should be less than 200

Which type of ostomy can be irrigated for bowel training?

Sigmoid or descending colostomy

What are risk factors for pressure injury development?

Sustained pressure § Prolonged sitting § Prolonged laying in same position o Obesity o Low body weight o Immobility o Poor nutrition/maluni on o Incontinence o Low Braden scale rating o Dehydration o Age o Medications o Temperature elevations o Moisture o Diminished mental status o Anemia o Ischemia o Low diastolic BP o Medical diagnosis o Poor sensation o Friction/shear o Infection

What happens when magnesium levels are less than 1.0 mg/dl?

Tetany occurs

Culture shock

The feelings a person experiences when placed in a different culture. May result in psychological discomfort or disturbances.

What is the relationship between parathyroid hormone and calcium?

The goal of the parathyroid hormone is to keep the serum calcium level elevated

What happens if you abruptly discontinue TPN?

The patient could experience severe hypoglycemia.

The nurse assesses the daily lab reports for a patient with a long history of cirrhosis with acute hepatic encephalopathy. Which of the following findings would indicate to the nurse that the patient is improving?

The patient's ammonia level decreased from 160 to 120 mg/dL.

Residual volume

The volume of fluid remaining in the stomach at a point in time during enteral nutrition feeding

Diabetes Insipidus (DI)

There is not enough ADH, so fluid is lost.

SIADH

There is too much ADH, so more fluid is held onto, or retained.

What are Trousseau's and Chvostek's sign?

They are neuromuscular manifestations of HYPOCALCEMIA

What is the purpose of a bone marrow biopsy?

To take a look at bone marrow to see if it is differentiating appropriately. If person is suspected to have leukemia, meaning they have s/s of thrombocytopenia, leukopenia and anemia simultaneously

TPN

Total Parenteral Nutrition = Highly concentrated hypertonic solution administered via a central line into a large central vein (subclavian, jugular) Administered through a PICC (peripherally inserted central catheter)

A patient has had colon surgery as a result of an intestinal obstruction. Which is a method of delivering nutrition that avoids the gut?

Total parenteral nutrition (TPN)

What should you do if TPN has been has to be abruptly stopped?

Turn TPN down gradually

Positive Chvostek's sign

Twitching of the facial muscles in response to tapping over the area of the facial nerve.

Hematochezia

Undigested fresh blood usually coming from the lower GI tract; appears bright red (might have sigmoid colon or rectal bleed, or hemorrhoids)

Full Liquid Diet

Use -Little energy to chew -Food particles are small and east to digest -Nutritionally adequate Foods that pour or are liquid at body temperature -Milk -Ice cream -Gelatin -Custards -Pudding -Refined cooked cereal -Pureed or strained soup -Eggnog -Pop -Tea, coffee

Clear Liquid Diet

Use -To maintain fluid and electrolyte balance -To spare body protein -To stimulate GI function -Without residue, non-gas forming, nonirritating -Not nutritionally adequate •Used for a short time ~ 1 or 2 days Examples: Fat free broth, bouillon, tea, coffee, flavored gelatin (plain), fruit ices, strained fruit juices, carbonated beverages

Which of following interventions would a nurse utilize for a patient with thrombocytopenia?

Use an electric razor when shaving and avoid taking rectal temperature

Soft diet

Use with patients: -Problems chewing or digesting food -Without teeth (edentulous) -Transition between liquid and regular diet Foods -Moderately low in fiber - exclude raw fruits and vegetables -Exclude fried and highly seasoned foods -Usually bland in flavor -Soft and tender in texture

Directing question or comment

Used to obtain more information about a topic brought up earlier in the interview or to introduce a new aspect of a current topic. Example: Nurse: You mentioned your dad earlier. Did he develop complications related to high blood pressure? Patient: Yes. Nurse: What sort of complications? Patient: Kidney failure. He was on dialysis for years before getting a transplant. Nurse: Are you afraid this might happen to you?

Sequencing question or comment

Used to place events in a chronological order or to investigate a possible cause and effect relationship. Example: Patient: I don't feel like myself anymore since I've been taking my blood pressure medicine. I'm tired and don't have any energy. Nurse: Your tiredness began after you started taking your medicine?

What is the purpose of TPN and PPN?

Uses: -when feeding by way of the gut is not possible for more than 10 days -presence of debilitating illness lasting more than two weeks -loss of 10% or more of pre-illness weight -serum albumin less than 3.5 g/dL -wound infection fistula or abscess -renal or hepatic failure -Nonfunction of the GI tract for 5 to 7 days

Validating question or comment

Validates what the nurse believes he or she has heard or observed Example: At home, you have been taking both a water pill and a blood pressure pill every day. Did you take them today?

What happens when the potassium level is less than 2.5 mEq/L?

Ventricular fibrillation

Pernicious anemia

Vitamin B12 deficiency MCV = macrocytic *Prominent in vegans and vegetarians* -Lack of intrinsic factors BIG BEEFY TONGUE

What happens when sodium levels are less than 120 mEq/L?

Weakness, dehydration

NG Tube

What is it? Nasogastric tube Insertion: tube passed through the nasopharynx to the stomach Uses: - removal of gastric secretions - instillation of medications and feeding (short term) - radiographic test - pH and color

PEG tube

What is it? Per cutaneous endoscopic gastrostomy Insertion: Pull method, push method Uses: if you cannot eat, digest or absorb food Used long term

How does the body compensate during respiratory alkalosis?

Will decrease as kidneys compensate by excreting bicarbonate (compensation)

How does the body compensate during metabolic acidosis?

Will decrease as lungs attempt to compensate by blowing off CO2

How does the body compensate during respiratory acidosis?

Will increase as kidneys retain bicarbonate in an attempt to compensate

How does the body compensate during metabolic alkalosis?

Will increase as the lungs attempt to compensate by retaining CO2

How do you check for correct NG tube placement?

X-ray, acidic results of pH test

HS

before bedtime

AC

before meals

Bulk laxatives

bulk up the stool as well and increase peristalsis; contain cellulose (Cologel) or psyllium (Metamucil, Effersyllium)

Neutropenia

decrease in neutrophils

HCO3 in metabolic acidosis

decreased (less than 22 mEq/L)

pCO2 in respiratory alkalosis

decreased (less than 24 mmHg)

pH in metabolic acidosis

decreased (less than 7.34)

pH in respiratory acidosis

decreased (less than 7.34)

Stage 3

full-thickness loss of skin in which adipose is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present, slough and/or eschar may be visible, undermining and tunneling may occur

Stage 4

full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer, slough, and or/ eschar may be visible, epibole (rolled edges), undermining and/or tunneling often occur

Fecal occult test

hidden blood in stool- enzymatic detection of hemoglobin

HCO3 in metabolic alkalosis

increased (greater than 26 mEq/L)

pCO2 in respiratory acidosis

increased (greater than 46 mmHg)

pH in metabolic alkalosis

increased (greater than 7.45)

Normal A1C

less than 5.7%

Stage 1

non-blanchable erythema of intact skin

HCO3 in respiratory acidosis

normal (22-26 mEq/L)

pCO2 in metabolic acidosis

normal (24-46 mmHg)

pCO2 in metabolic alkalosis

normal (24-46 mmHg)

HCO3 in respiratory alkalosis

normal initially (22-26 mEq/L)

What is the purpose of honey in wound care?

o Facilitates debridement o Anti-inflammatory o Broad spectrum bactericidal and bacteriostatic o Control odor § May sting

Be able to distinguish the different wound care dressings based on their absorptive property

o Gauze- non-absorbent (for packing) o Hydrogels or wound gels- non-absorbent (rehydrates wound) o Transparent films- non-absorbent o Hydrocolloids- absorbs small to moderate amount of drainage o Foams- absorbs moderate to heavy drainage oCalcium alginates- absorbs heavy drainage

Stoma

opening into abdominal wall where there's a small outpouching of intestine Stoma is normally pink, red, and moist

Stage 2

partial thickness loss of skin with exposed epidermis, wound bed is visible pink or red and moist, moisture associated skin damage, serum filled blister

Laxatives promote

peristalsis

Unstageable

slough or eschar obscures the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar, if removed stage 3 or 4 pressure injury will be revealed, stable eschar on the heel or ischemic limb should not be softened or removed (risk of infection)

Ascending stool appearance

some liquid appearance

Chemical laxatives

stimulate colonic peristalsis selective to the colon (Senekot, Dulcolax, Correctol, Ex-lax)

Ethnicity

• Sense of identification with a collective cultural group • Largely based on group's common heritage • One can belong to an ethnic group through birth or adoption of characteristics of that group. • Groups share unique cultural and social beliefs and behavior patterns. • Largely develops through day-to-day life with family and friends within the community

Race

• Typically based on specific characteristics • Skin pigmentation, body stature, facial features, hair texture • Five major categories: • American Indian or Alaska Native • Asian • Black or African American • Native Hawaiian or Other Pacific Islander • White

Ammonia

•Ammonia formed: -End product of protein metabolism -Action of intestinal bacteria -Break down of nitrogenous components of blood •Ammonia converted to urea in liver •Urea excreted by the kidneys and GI tract

What are some risks associated with Low Serum Albumin?

•Increased risk of infection and sepsis •Increased morbidity and mortality -Post-operatively -Pressure ulcer/injury development •Edematous tissue, possible •Edematous bowel -Loses ability to passively absorb water = diarrhea -Does not hold suture