NUR 238 Final Exam Review PDF

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J. Fulton...

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NUR 238 Final Exam Review Acute Care/Medical-Surgical Trach Care If a patient has a trache in and they are talking or gurgling put more air in. Be careful not to put too much air in because you can cause ischemia. When suctioning traches, you have to preoxygenate before suctioning with an ambu bag and 910 liters of oxygen. You can only apply suctioning for 10-15 seconds at a time. Don’t suction with more than 80% pressure. When changing trache ties only undo one side at a time. A cloth trache tie is not changed for 72 hours. If you have a trache you must have a trache set and obturator at the head of the bed. Always perform trache suctioning before performing trache care because they can aspirate and mess up clean dressings. Perform a full respiratory assessment post trache care. The inner cannula has to be replaced every 8 hours and it is a sterile procedure.

Tube Feeding Enteral Feedings: 

Enteral feedings are instituted for a client who has a functioning GI tract but is unable to swallow or take in adequate calories and protein orally. It can be in addition to an oral diet, or it can be the only source of nutrition.

Potential Diagnoses:   

Inability to eat due to a medical condition (comatose, intubated). Pathologies that cause difficulty swallowing or increase risk of aspiration (stroke, advanced Parkinson’s disease, multiple sclerosis). Inability to maintain adequate oral nutritional intake and need for supplements due to increased metabolic demands (cancer therapy, burns, sepsis).

Client Presentation:  

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Malnutrition (decreased prealbumin, decreased transferrin or total-binding capacity). Aspiration pneumonia.

Complications: 

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Overfeeding: o Overfeeding results from infusion of a greater quantity of feeding than can be readily digested, resulting in abdominal distention, nausea, and vomiting.  Nursing Actions:  Check facility policy regarding residual check, which is usually every 4 to 6 hours, and take corrective actions as prescribed. Some facilities no longer require residual checks.  Follow protocol for slowing or withholding feedings for excess residual volumes. Many facilities hold for residual volumes of 100 to 200 mL and then restart at a lower rate after a period of rest.  Check pump for proper operation and ensure feeding infused at correct rate. Diarrhea: o Diarrhea occurs secondary to concentration of feeding or its constituents.  Nursing Actions:  Slow the rate of the feeding and notify the provider.  Confer with a dietitian.  Provide skin care and protection.  Recommend evaluation for Clostridium difficile (C-diff) if diarrhea continues, especially if it has a very foul odor. Aspiration pneumonia: o Pneumonia can occur secondary to aspiration of feeding and can be a lifethreatening complication. Tube displacement is the primary cause of aspiration of feeding.  Nursing Actions:  For prevention, confirm tube placement before feedings, and elevate the head of the bed at least 30 during feedings, and for a least 1 hour after.  Stop the feeding.  Turn the client to one side and suction the airway. Administer oxygen if indicated.  Monitor vital signs for an elevated temperature.  Auscultate breath sounds for increased congestion and diminishing breath sounds.  Notify the provider and obtain a chest x-ray if prescribed. Refeeding syndrome: o Refeeding syndrome is a potentially life-threatening condition that occurs when enteral feeding is started in a client who is in a starvation state and whose body has begun to catabolize protein and fat for energy.

 Nursing Actions:  Monitor for new onset of confusion or seizures.  Monitor for shallow respirations.  Monitor for increased muscular weakness.  Notify the health care provider and obtain blood electrolytes if needed. Total Parenteral Nutrition (TPN):   

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TPN is a hypertonic IV bolus solution. The purpose of TPN administration is to prevent or correct nutritional deficiencies and minimize the adverse effects of malnourishment. TPN administration is usually through a central line (a tunneled triple lumen catheter or a single or double lumen peripherally inserted central [PICC] line). TPN contains complete nutrition, including calories in a high concentration (10% to 50%) of dextrose, lipids/essential fatty acids, protein, electrolytes, vitamins, and trace elements. Standard IV bolus therapy is typically no more than 700 calories/day. Partial parenteral nutrition or peripheral parenteral nutrition (PPN) is less hypertonic, intended for short-term use, and administered in a large peripheral vein. Usual dextrose concentration is 10% or less. Risks include phlebitis.

Indications: 

Any condition that: o Affects the ability to absorb nutrition. o Has a prolonged recovery. o Creates a hypermetabolic state. o Created a chronic malnutrition.

Potential Diagnoses:     

Chronic pancreatitis. Diffuse peritonitis. Short bowel syndrome. Gastric paresis from diabetes mellitus. Severe burns.

Client Presentation:  

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Weight loss greater than 10% of body weight and NPO or unable to eat or drink for more than 5 days. Muscle wasting, poor tissue healing, burns, bowel disease disorders, and acute kidney failure.

Preparation of the Client:  

Determine the client’s readiness for TPN. Obtain daily laboratory values, including electrolytes. Solutions are customized for each client according to daily laboratory results.

Ongoing Care:    

The flow rate is gradually increased or decreased to allow body adjustment (usually no more than a 10% hourly increase in rate). Never abruptly stop TPN. Speeding up/slowing down the rate is contraindicated. An abrupt rate change can alter blood glucose levels significantly. Obtain vital signs every 4 to 8 hours and weights daily. Follow sterile procedures to minimize the risk of sepsis. o TPN solution is prepared by the pharmacy using aseptic technique with a laminar flow hood. o Change tubing and solution bag every 24 hours (even if not empty). o Do not use the line for other IV bolus solutions (prevents contamination and interruption of the flow rate). o Do not add anything to the solution due to risks of contamination and incompatibility. o Use sterile technique, including a mask, when changing the central line dressing (per facility procedure).

Nursing Interventions:   

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Check capillary refill glucose every 4 to 6 hours for at least the first 24 hours. Clients receiving TPN frequently need supplemental regular insulin until the pancreas can increase its endogenous production of insulin. Keep dextrose 10% in water at the bedside in case the solution is unexpectedly ruined, or the next bag is not available. This will minimize the risk of hypoglycemia with abrupt changes in dextrose concentrations. If a bag is unavailable and administered late, do not attempt to catch up by increasing the infusion rate because the client can develop hyperglycemia. OLDER ADULT CLIENTS have an increased incidence of glucose intolerance.

Complications: 

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Metabolic complications: o Metabolic complications include hyperglycemia, hypoglycemia, and vitamin deficiencies.  Nursing Actions:

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Review results of daily laboratory monitoring to ensure that the components prescribed in the client’s TPN match the client’s needs. Fluid needs are typically replaced with a separate IV bolus to prevent fluid volume excess. Monitor for hyperglycemia.

 Air embolism: o A pressure change during tubing changes can lead to an air embolism.  Nursing Actions:  Monitor for manifestations of an air embolism (sudden onset of dyspnea, chest pain, anxiety, hypoxia).  Clamp the catheter immediately and place the client on their left side in Trendelenburg position to trap air. Administer oxygen and notify the provider so trapped air can be aspirated. Infection: o Concentrated glucose is a medium for bacteria.  Nursing Actions:  Observe the central line insertion site for local infection (erythema, tenderness, exudate).  Change the sterile dressing on a central line per protocol (typically every 48 to 72 hours).  Change IV tubing per protocol (typically every 24 hours).  Monitor the client for manifestations of systemic infection (fever, increased WBC, chills, malaise).  Do not use TPN line for other IV bolus fluids and medications (repeated access increases the risk for infection). Fluid imbalance: o TPN is a hyperosmotic solution (three to six times the osmolarity of blood), which poses a risk for fluid shifts, placing a client at increased risk of fluid volume excess. o OLDER ADULT CLIENTS are more vulnerable to fluid and electrolyte imbalances.  Nursing Actions:  Auscultate the lungs for crackles and monitor for respiratory distress.  Monitor daily weight and intake and output.  Use a controlled infusion pump to administer TPN at the prescribed rate.  Do not speed up the infusion to catch up.  Gradually increase the flow rate until the prescribed infusion rate is achieved.

Chest Tubes Chest Tube Systems: A disposable three-chamber drainage system is most often used.   

First chamber: drainage collection. Second chamber: water seal. Third chamber: suction control (can be wet or dry).

Continuous bubbling in the water seal chamber indicates an air leak in the system. Potential Diagnoses:     

Pneumothorax. Hemothorax. Postoperative chest drainage. Pleural effusion. Pulmonary empyema.

Client Presentation         

Dyspnea. Distended neck veins. Hemodynamic instability. Pleuritic chest pain. Cough. Absent or reduced breath sounds on the affected side. Hyperresonance on percussion of affected side (pneumothorax). Dullness or flatness on percussion of the affected side (hemothorax, pleural effusion). Asymmetrical chest wall motion.

Client Tube Insertion 

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Preprocedure: o Verify that the consent form is signed. o Reinforce with the client that breathing will improve when the chest tube is in place. o Check for allergies to local anesthetics. o Assist the client into the desired position (supine or semi-fowler’s). o Prepare the chest drainage system per the facility’s protocol. (Fill the water seal chamber). o Administer pain and sedation medications as prescribed.

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Intraprocedure: o When the chest tube is inserted to drain fluid from the lung, the tip of the tube is inserted near the base of the lung on the side. When the chest tube is inserted to remove air from the pleural space, the tip of the tube will be near the apex of the lung. o Assist the provider with insertion of the chest tube, application of a dressing to the insertion site, and set up of the drainage system.  Place the chest tube drainage system below the client’s chest level with the tubing coiled on the bed. Ensure that the tubing from the bed to the drainage system is straight to promote drainage via gravity. o Continually monitor vital signs and response to the procedure. Postprocedure: o Check vital signs, breath sounds, O2 stat, color, and respiratory efforts as indicated by the status of the client and at least every 4 hours. o Encourage coughing and deep breathing every 2 hours. o Keep the drainage system below the client’s chest level, including during ambulation. o Monitor chest tube placement and function.  Check for the water seal level every 2 hours, and add fluid as needed. The fluid level should fluctuate with respiratory effort.  Document the amount and color of drainage hourly for the first 24 hours and then at least every 8 hours. Mark the date, hour, and drainage level on the container at the end of each shift. Report excessive drainage (greater than 70 mL/hr) or drainage that is cloudy or red to the provider. Drainage often increases with position changes or coughing.  Monitor the fluid in the suction control chamber and maintain the prescribed fluid level.  Ensure the regulator dial on the dry suction device is at the prescribed level.  Check for expected findings of tidaling in the water seal chamber and continuous bubbling only in the suction chamber. o Routinely monitor tubing for kinks, occlusions, or loose connections. o Monitor the chest tube insertion site for redness, pain, infection, and crepitus (air leakage in the subcutaneous tissue). o Tape all connections between the chest tube and chest tube drainage system. o Position the client in the semi-to-high-fowlers position to promote optimal lung expansion and drainage of fluid from the lungs. o Administer pain medications as prescribed. o Keep two enclosed hemostats, sterile water, and an occlusive dressing located at the bedside at all times.

o Due to the risk of causing a tension pneumothorax, chest tubes are clamped only when prescribed in specific circumstances, such as in the case of an air leak, during drainage system change, accidental disconnection of tubing, or damage to the drainage system. o Do not clamp, strip, or milk tubing; only perform this action when prescribed. Stripping creates a high negative pressure and can damage lung tissue. o Notify the provider immediately if the client’s O2 stat is less than 90%, if the eyelets of the chest tube become visible, if drainage is above the prescribed amount or stops in the first 24 hours, or complications occur. Complications 

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Air leaks: o Air leaks can result if a connection is not taped securely.  Nursing Actions:  Monitor the water seal chamber for continuous bubbling (air leak finding). If observed, locate the source of the air leak, and intervene accordingly (tighten the connection, replace drainage system).  Check all connections.  Notify the charge nurse if an air leak is noted. Accidental disconnection, system breakage, or removal: o These complications can occur at any time and require immediate notification of the provider or rapid response team.  Nursing Actions:  If the chest tube drainage system is compromised, immerse the end of the chest tube in sterile water to provide a temporary water seal.  If a chest tube is accidentally removed, dress the area with a dry, sterile gauze or occlusive dressing. Tension pneumothorax: o Sucking chest wounds, prolonged clamping of the tubing, kinks, or obstruction in the tubing, or mechanical ventilation with high levels of positive end expiratory pressure (PEEP) can cause a tension pneumothorax. o Data collection findings include tracheal deviation, absent breath sounds on one side, distended neck veins, respiratory distress, asymmetry of the chest, and cyanosis. o Notify the provider or rapid response team immediately.

Chest Tube Removal  8

Provide pain medication 30 minutes before removing chest tubes.

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Assist the provider with sutures and chest tube removal. Apply airtight sterile petroleum jelly gauze dressing. Secure in place with a heavyweight stretch tape. Obtain chest x-rays as prescribed. This is performed to verify continued resolution of the pneumothorax, hemothorax, or pleural effusion. Monitor for excessive wound drainage, findings of infection, or recurrent pneumothorax.

Blood Transfusion When giving a blood transfusion nothing else can go through that IV. If they have something else dripping, they need to have 2 IVs. You have 30 minutes to hang the blood. If the blood is not hanged in 30 minutes, it has to be returned to the blood bank. 4 hours is the maximum time for the blood to run. The first 20 minutes of hanging the blood are the most critical. Reactions tend to happen in the first 20 minutes. Start the infusion slower then speed up after 20 minutes. It’s possible but rare for patients to get infected from blood transfusions. LPNs cannot give blood products (albumin, RhoGAM, and other blood products).

Alzheimer’s Mild Alzheimer’s (early stage):        

Memory lapses. Losing or misplacing items. Difficulty concentrating and organizing. Unable to remember material just read. Still able to perform ADLs. Short-term memory loss noticeable to close relatives. Trouble remembering names when introduced to new people. Greater difficulty performing tasks in a worse setting.

Moderate Alzheimer’s (middle stage):        9

Forgetting events of one’s own history. Difficulty performing tasks that require planning and organizing (paying bills, managing money). Difficulty with complex mental arithmetic. Personality and behavioral changes: appearing withdrawn or subdued, especially in social or mentally challenging situations; compulsive; repetitive actions. Changes in sleep patterns. Can wander and get lost. Can be incontinent.

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Clinical findings that are noticeable to others.

Severe Alzheimer’s (late stage):        

Losing ability to converse with others. Assistance required for ADLs. Incontinence. Losing awareness of one’s own environment. Progressing difficulty with physical abilities. Eventually losses all ability to move; can develop stupor and coma. Death frequently related to chocking or infection. Vulnerable to infection, especially pneumonia, which may become lethal.

Risk Factors:        

Advanced age. Chemical imbalances. Family history of AD or down syndrome. Genetic predisposition, apolipoprotein E. Environmental agents. Previous head injury. Sex (female). Ethnicity/race (African American and Hispanic people are at increased risk for the development of AD than non-Hispanic white people due to the APOE and ABCA7 genes).

Nursing Care:    

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Check cognitive status, memory, judgement, and personality changes. Initiate bowel and bladder program based on a set schedule. Encourage the client and family to participate in an AD support group. Provide a safe environment. o Frequent monitoring/visual checks. o Keep client from stair, elevators, and exists. o Remove or secure dangerous items in the client’s environment. Provide frequent walks to reduce wandering. Maintain a sleeping schedule and monitor for irregular sleeping patterns. Provide verbal and nonverbal ways to communicate with the client. Offer snacks or finger foods if the client is unable to sit for long periods of times. Check skin weekly for breakdown. Provide cognitive stimulation. o Offer varied environmental stimulations. o Keep a structured environment and introduce change gradually. o Use a calendar to assist with orientation.

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o Use short directions when explaining an activity or care the clients needs, such as a bath. o Be consistent and repetitive. o Use therapeutic touch. Provide memory training. o Reminiscence with the client about the past. o Use memory techniques. o Stimulate memory by repeating the client’s last statement. Avoid overstimulation. Promote consistency by placing commonly used objects in the same location and using a routine schedule. o Reality orientation (early stages). o Easily viewed clock and single-day calendar. o Pictures of family and pets. o Frequent reorientation to time, place, and person. Validation therapy (later stages). o Acknowledge the client’s feelings. o Don’t argue with the client; this will lead to the client becoming upset. o Reinforce and use repetitive actions or ideas cautiously. Promote self-care as long as possible. Assist with activities of daily living as appropriate. Speak directly to the client in short, concise sentences. Reduce agitation. Provide a routine toileting schedule.

Patient Education:    

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Refer to social services and case managers for long-term/home management, Alzheimer’s Association, ...