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Condensed Cumulative Foundations II Final Exam Review

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NURS 1503U

Foundations II Final Exam Review There are 80 multiple choice questions: Oxygenation/CPR /9 questions Bowel Elimination/ostomy care /5 questions Sterile asepsis/catheterization/wound care and assessment /12 questions Tracheostomy care/NG tube care and insertion/Suctioning /15 questions IV Therapy including IV drug math - blood administration and TPN /39 questions /80 Oxygenation - Tachycardia is consistent with an infectious process. - ABC (Airway, Breathing, Circulation) priority: After obtaining vital signs, auscultate breath sounds (highest priority when pt. is showing respiratory distress). High temperature (fever) and rapid RR are vital sign findings of a problem, such as an infection. - Jugular vein distension gives information about fluid volume overload. Because of pt’s fever, warm skin, and inelastic skin tugor, pt. more likely experiencing fluid volume deficit - Increased anterioposterior (AP) diameter of the chest is a finding typical in clients with emphysema, but is not an indicator of pneumonia. - Clubbing of the fingernails is an indicator of chronic lung disease, such as chronic asthma or emphysema, but is not an indicator of acute infectious process such as pneumonia. - Nurse auscultates crackles bilaterally in lower posterior lung fields with diminished breath sounds noted throughout all lung fields. X-ray shows infiltrate in the lung bases bilaterally; COPD and pneumonia. - Metabolic acidosis: Low pH; caused by a low HCO3 - Metabolic alkalosis: Alkalosis reflected by high pH - Respiratory acidosis: Low pH indicates acidosis is present. Elevated pCO2 indicates a respiratory problem. Clients with conditions that depress respirations are prone to development of respiratory acidosis. Despite rapid RR, underlying COPD would cause retension of CO2. - Respiratory alkalosis: Alkalosis is reflected by high pH, although high CO2 indicates there is a respiratory problem - Left lung: 2 lobes; right lung: 3 lobes - Adequate oxygenation is affected by adequate circulation, ventilation, perfusion, and transport of gases to the tissues. Factors affecting oxygenation - Low Hg (respiratory rate will increase to accommodate) - Decreased O2 carrying capacity (anemia, CO2) - Decreased inspired oxygen concentration (room air 21% oxygen, high altitudes have lower O2 rate) - Hypovolemia (shallow breathing, decreased respirations, O2 saturation will decline, instruct patient to take deep breaths.) - Increased metabolic rate - Chest wall movement (kyphosis, broken ribs) - Increased oxygen demand - Hypoxic drive: Caution to be taken with COPD patients given high oxygen; administer 2-3L /min no more - Pharmacological agents (bronchodilators, steroids, mucolytics, and low dose anti- anxiety meds), oxygen, physical techniques (breathing techniques), and relaxation techniques are effective management for dyspnea - The normal ventilatory stimulus is CO2 - O2 therapy requires an MD order for type, amount and frequency; 8 rights, 3 checks - - The right client (name, birth date, - The right dose (litres/min) ID#) - The right frequency - The right medication (oxygen) - The right route (nasal prongs, mask, - The right reason (ordered, or needs etc) it) - The right site - The right time - - O2 does not burn, but supports combustion; is a drug - Do not use O2 in presence of open flame/heat sources - Smoking within 3 meters is prohibited - Do not lubricate O2 equipment (Vaseline, petroleum jelly, lotion, hair spray, etc. ignite easily) - Assessment: At start of shift and at least q4h in between, assess equipment – care if portable, flow rate (ordered? meets pt. needs? O2 sat good?), humidifier (pt. needs moist air), connections (check frequently, easy to become dislodged especially if using extension tubing or changing from prongs to mask after meals), tubing, client (comfort, RR, depth+quality, chest sounds, O2 sat, energy level, able to eat/sleep), O2 on RA if weaning off O2, observe for anxiety, improved LOC, fatigue, dizziness, decreased pulse, RR, return to BL VS, colour - O2 care: Must remove mask/prongs and clean skin underneath (moisture buildup), behind ears (breakdown from straps, tubing), change from mask to cannula for meals - Pulse oximetry: Measures O2 sat of arterial blood. Life-threatening is 70% or less - Arterial blood gas: A radial or femoral artery is punctured to obtain arterial blood (tests measure the oxygen concentration in the blood, the pH, partial pressure of CO2 (PaCO2) and the partial pressure of oxygen (PaO2). Normal values are blood pH: 7.35-7.45, PaO2 35-45 mmHg, PaO2 80-100 mmHg and O2 sat 95-100% - Pulmonary function tests measure lung volume (the amount of air moving into and out of lungs) and capacity (how much air lungs can hold). - Chest x-ray examination: A radiograph of the thorax is used to observe the lung fields for fluids, etc. - CT scan: Provides visualization of fine detail of the lungs and other structures in the thorax - Ventilation/perfusion lung scan: Used to detect pulmonary emboli. Results from two separate scans are compared; perfusion scan uses an injected radioactive tracer to measure pulmonary blood flow, and the ventilation scan shows the pulmonary distribution of a different inhaled tracer. Mismatches of the results indicate pulmonary emboli - Pt. with low Hb may still have good O2 sats, but not enough O2 for tissue needs - Oxygen saturation: amount of Hg that is fully saturated with oxygen expressed as percent of total available hemoglobin - If patient has low Hg, their RBCs could still be saturated with O2 therefore showing a high O2 sat, this is why you must know pt’s Hb; the 5 vital signh (should be 95-100%) - Don’t merely trust the equipment, always compare results with the rest of assessment - Face mask delivers O2 concentrations from 40-60% - The partial rebreathing mask and non-rebreathing mask are low-flow devices with a reservoir bag. The partial rebreathing mask provides an oxygen concentration of 40-70% with a minimum flow rate of 10L/min. The non-rebreather provides a high concentration of oxygen at 60-80% with a minimum flow rate of 10L/min. - The venturi mask (high flow device) can be used to deliver oxygen concentrations of 24-60% with oxygen flow rates of 4-12L/min depending on which flow control meter is selected. This mask is helpful for patients with COPD who require low, constant oxygen concentrations. Blood gas abnormalities Decreased P : O2 Collapsed alveoli (atelectasis) 1. Airway obstruction – by the tongue; by a foreign body 2. Failure to take deep breaths – pain (rib fracture, pleurisy), paralysis of respiratory muscles (spinal cord injury, polio), Depression of the respiratory centre (head injury, drug overdose) 3. Collapse of the whole lung (pneumothorax) Fluid in the alveoli 1. Pulmonary edema 2. Pneumonia 3. Near-drowning 4. Chest trauma Other gases in the alveoli 1. Smoke inhalation 2. Inhalation of toxic chemicals 3. CO2 poisoning Elevated P CO2 Decreased CO2 elimination (hypoventilation) 1. Decreased tidal volume – Pain (rib fractures, pleurisy), weakness (myasthenia gravis), paralysis (spinal cord injury, polio), 2. Decreased respiratory rate – head injury, depressant drugs, stroke Increased CO2 production 1. Fever 2. Muscular exertion 3. Anaerobic metabolism Diaphragmatic breathing – Flattening of diaphragm during inspiration, resulting in enlargement of upper abdomen; during expiration the abdominal muscles are contracted, along with the diaphragm. - Client should be in flat, semi-Fowler’s or side position with knees flexed and hands on abdomen, client takes deep breath through nose and mouth letting abdomen rise. Hold breath 3-5 seconds. Client exhales through nose and mouth, squeezing out all air by contracting the abdominal muscles. Repeat 10-15 times, with short rest inbetween. Exercise should be completed 5-10 times every hour postoperatively. Coughing – Helps clear chest of secretions and, although uncomfortable, will not harm incision site. - Client leans forward slightly from a sitting position, and places hands over incision site; this acts as a splint during coughing. Client inhales/exhales slowly several times. Client inhales deeply, holds breath for 3 seconds, and coughs sharply three times while exhaling – client’s mouth should be slightly open. Client inhales again to cough deeply once or twice. if client cannot cough deeply, may “huff” cough to simulate cough. Turning and leg exercises – Helps prevent circulatory stasis, which may lead to thrombus formation, and postoperative flatus or “gas pains” as well as respiratory problems. - Client turns on one side with upper-most leg flexed; uses side rails to facilitate movement. In supine position, client does 5 repititions each hour of: ankle pumps, quadriceps-setting exercises, gluteal tightenings, and straight-leg raises. Apply intermittent pulsatile compression device or sequential compression device to promote venous return. CPR Bowel elimination Small intestine: duodenum, jejunum, ileum Chyme mixes with digestive enzymes from pancreas (bile and amylase), moves slowly Nutrients are almost entirely absorbed in duodenum and jejunum The ileum absorbs certain vitamins, iron, and bile salts Large intestine: - Cecum (where appendix is at ileocecal valve) - Colon: ascending, transverse, and descending - Water, sodium and chloride are absorbed - If peristalsis is fast, liquid stool is the result. - If peristalsis is slow, water is absorbed resulting in a hard mass of stool (constipation) - Rectum: Fecal mass enters rectum for defecation - Valsalvar maneuver contraindicated in some clients experiencing heart problems; stool softeners Factors affecting bowel elimination Age: - Control of defecation at 2-3 years - Peristalsis decreases with age, esophageal emptying slows, older adults may have difficulty controlling bowel evacuation Infection: Can cause diarrhea and inflammatory or ulcerative changes in the small or large intestine. Most infections spread by oral-fecal route, through contaminated food or water. - Colitis (C. difficile) is a bacterial infection associated with antibiotic therapy. C. difficile is usually acquired in the hospital setting, where the organism is commonly found. Treatment includes immediate discontinuation of antibiotic and in cases where symptoms are severe; treatment is aimed at eradication of infection Diet - Fiber provides bulk absorbing fluids thereby increasing fecal mass, need lots of fluid - Insoluble fibre: in whole grains, wheat bran, and vegetables; does not dissolve in water; effective in preventing constipation - Soluble fibre: found in some beans, certain fruits and vegetables, and wheat bran; forms gel when mixed with water, is not as effective in preventing constipation Fluid intake: 1500-2000 mL of fluids /day - Physical activity: Usually increases peristalsis Psychological factors: Stress increases peristalsis to provide nutrients for defense, depression decreases peristalsis Personal habits: Gastro-colic reflex highest after meals, embarrassment-deny urge Position: Squatting is the normal position for defecation, toilets designed to facilitate this posture; whereas in a supine position it is impossible to contract the muscles used during defecation Pain: Hemorrhoids, rectal fistulas, abd. surgery (suppress urge to defecate), pt. may suppress urge to defecate to avoid pain; and result in constipation Pregnancy: As pregnancy progresses, the growing fetus exerts pressure on the rectum. a temporary obstruction created by the fetus impairs the passage of feces. - Slowing of peristalsis during the 3 trimester often leads to constipation - A pregnant woman’s frequent straining during defecation or delivery can result in the formation of permanent hemorrhoids. - Damage to the perineum extending to the anal sphincters during labour can also alter sphincter integrity. Surgery & anesthesia: Temporary cessation of peristalsis with manipulation of the bowel (paralytic ileus) lasts 24-48 hours. Early ambulation facilitates return Medications- narcotics, anticholinergics slow peristalsis, causing constipation - Antibiotics – produce diarrhea by disrupting normal bacterial flora in GI tract - NSAIDS irritate GI mucosa and lead to life-threatening hemorrage (Aspirin & gastritis) - Laxatives & cathartics promote peristalsis - Incontinence x2: incontinent of urination and defecation - Hemorrhoids: Dilated, engorged veins in the rectum ; external hemorrhoids are clearly visible as protrusions of skin, and internal hemorrhoids have an outer mucous membrane. - Hemorrhoids are frequently accompanied by fecal soiling of undergarnments and irritation of the distended veins by overly vigorous cleaning of the anus. - Two types of muscle contractions occur in the colon: slow-mixing contractions and mass peristalsis. Slow-mixing contractions  move contents through the colon and expose the chime to the mucosa, where active absorption of sodium and chloride causes water absorption and dries the chime to feces. Mass peristalsis movements  push the feces toward the rectum; Ingestion of food is the main stimulus for mass peristalsis, which is known as the gastrocolic reflex. In adults, mass movements occur only 3 or 4 times each day. - In cases of severe impaction, the mass can extend into the sigmoid colon. Patients who are debilitated, confused, or unconscious are most at risk for impaction  they are weal or are unaware of the need to defecate, or they may be so dehydrated that the stool is too hard and too dry to pass. - Flatulence: A common cause of abdominal fullness, pain, and cramping; in most healthy individuals, 100-200mL of gas is present in the GI tract - A person on a normal diet expels 50-500mL of gas a day (10-15 times passed/day) Ostomy care The location of the ostomy determines the consistency of the stool. Ileostomy: A stoma that has been constructed by bringing the end or loop of small intestine (the ileum) out onto the surface of the skin. Intestinal waste passes out the ileostomy, and is collected into an external pouch on the skin. Ileostomies are often above the groin to the right of the abdomen. Bypasses the entire large intestine. A transverse colostomy is an opening into the transverse colon (large bowel) and is usually above the waist. It can be on the right or left side. Ileoconduit: Loop colostomy: Usually performed in a medical emergency when closure of the colostomy is anticipated; usually temporary large stomas constructed in the transverse colon (the surgeoun pulls a loop of bowel onto the abdomen). The proximal end drains stool, whereas the distal portion drains mucus. End colostomy: Consists of one stoma formed from one end of the bowel with the distal portion of the GI tract either removed or sewn closed (a.k.a. Hartmann’s pouch) and left in the abdominal cavity. For many patients, end colostomies are a result of surgical treatment for colorectal cancer. Double-barrel colostomy: The bowel is surgically severed and the two ends are brought out onto the abdomen Assessment of bowel elimination: history - Usual bowel patterns (coffee in the morning?) - Routines around elimination - Characteristics of stool - Diet history - Fluid intake - Exercise, mobility, dexterity (can they perform self-hygiene?) - Any aids (elevated toilet seats, stool softeners and other meds as aids) - Ilnesses affecting GI tract (Crohn’s disease, IBS) - Meds - Emotional, social history (Hygiene in context of certain cultures) Physical assessment: - Inspect abdomen: contour, shape, symmetry, skin colour, scars, striae, stomas, lesions, distension - Auscultate - Palpate - Percuss - Squatting position - Elevated toilet seat if needed - Position with bedpan (call light/TP within reach, privacy, cultural aspects) Enemas - Cleansing enemas - Tap water enema: - Normal saline: - Soapsuds: - Oil retention: - Medicated (kayexulate): If too much potassium in body, kayexulate enema absorbs. - Order “enemas to clear”, caution to administer no more than 3, could result in fluid and electrolyte imbalance. Many things lead to constipation: (RNAO Fact Sheet) - Not being able to move around (being confined to a bed or wheelchair, or a general decrease in physical activity); - Inadequate amounts of fluids and dietary fiber; - Not responding to the urge to have a bowel movement; - Using laxatives over a long period of time; - Taking medications that cause constipation as a side effect; and - Increase in the hormone progesterone in women. - It is estimated that 30% -50% of older adults living in the community use laxatives regularly. - Constipation increases with age. - At one time or another almost everyone gets constipated. In most cases, constipation is temporary and not serious. - Drink sufficient fluids. Aim for 1½ -2 litres of fluids daily (6 to 8, eight ounce glasses). - Reduce caffeinated (coffee, tea, some soft drinks) and alcoholic beverages whenever possible as they actually cause you to lose fluids. - A high fiber diet is not recommended in persons who are immobile (bedridden) or persons who do not drink at least 1½ litres of fluids per day. - Adequate dietary fibre can be achieved by consuming about 2 to 3 servings of grains and about 5 servings of fruits and vegetables per day. Examples of dietary fiber include wheat bran, whole cereals such as wheat, rice, barley, rye, millets; fruits like mango and guava; and leafy vegetables such as cabbage, lettuce and celery. - Use routine consistent toileting each day based on your urge to have a bowel movement. Use a squat position to facilitate the bowel movement process. - Exercise such as walking (15 to 20 minutes once or twice a day) can stimulate the bowels. - If you are unable to walk or are bedridden, there are numerous exercises that you can do. Examples of such exercises include flattening the low back arch by tightening the abdominal muscles (pelvic tilt), rolling bent knees side to side twisting at the waist (low trunk rotation) and single leg lifts. Sterile asepsis - Area or object is considered contaminated if touched by an object that is not sterile - Procedures may include: wearing a mask, protective eyewear, gown, sterile gloves, “no touch” method, following principles of surgical asepsis for procedures - Used in OR, L&D, major diagnostic areas, and at bedside for IV insertion, catheter insertion, suctioning tracheobronchial airway, or reapplying sterile dressings, broken skin integrity cases (trauma, surgical incision, burns) 7 Principles of Surgical Asepsis 1. Sterile objects maintain sterility only when touched by other sterile objects 2. Only sterile objects are placed on a sterile field 3. Objects are considered contaminated if they are: below waist level, or out of sight 4. Contamination occurs with exposure to air 5. Capillary contamination occurs when a sterile field comes in contact with a wet unsterile field (absorption spreading) 6. Sterile objects are placed so that gravity does not cause fluid contamination 7. Sterile field borders of 1 inch are considered contaminated - Most nosocomial infections are the result of the transfer of microorganisms from staff member’s hands - Good aseptic technique can: reduce a patient’s length of stay, speed healing, reduce patient discomfort STEPS FOR STERILE DRESSINGS 1. Check doctors’ orders 2. Ask client if he/she requires any pain medication 3. Explain to client the procedure you are going to perform 4. Gather all supplies you will need for the dressing change 5. Wash hands 6. Choose a flat surface-have lots of room 7. Open the flap away from you 8. Open the flap to the left 9. Open the flap to the right 10. Lift the forceps out, tips down 11. Open the flap towards you 12. Place forceps down on the edge of the outer wrapper with the contaminated end on the flat surface and the sterile tips on the wrapper inside the 1” margin 13. Set up tray arranging gauze and forceps 14. Add any extra gauze you may need 15. Allow gauze to drop onto the middle of the try/field 16. Pour the ordered solution into the required section of the tray 17. If solution is already open, check date and time it was open: pour some of the solution out and then proceed to pour into your tray Catheterization - Provides continuous flow of urine when micturition is not possible - Provides means of assessing hourly urine outputs - Carries risk of UTI and trauma - Provides means of incontinence management - Performed when only absolutely necessary - Intermittent (straight catheters): Single-use catheter introduced long enough to drain bladder (5-10 mins), immediately withdrawn once bladder is empty, performed PRN (repeated use increases risk of trauma, infection), Coude catheter is a variation (more rigid and tapered). o Reflief of discomfort of bladder distension, obtaining sterile specimen, assessment of residual urine after urination, long-term management of clients with spinal-cord injuries, neuromuscular degeneration, or incompetent bladders - Indwelling (Foley catheter/retention catheter): Remains in place for a longer period (until client able to void voluntarily or hourly measurements are required), may have 2-3 lumens (irrigation), balloons inflated by 5mL, 10mL, or 30mL, connected to closed gravity drainage system - Closed gravity drainage system: Used for retention/indwelling catheters, consists of catheter, drainage tubing and collection bag, should not be opened anywhere along system, reduces risk of microorganisms entering system and infecting urinary tract, depends on force of gravity to drain urine from bladder to collecting bag - Short-term indwelling: Obstruction to outflow, surgical repair, prevention of obstruction, measurement of output for critically ill clients, continuous or intermittent bladder irrigations - Long-term indwelling: Severe urinary retention with recurrent episodes of UTI, skin rashes, ulcers, or wounds irrigated by contact with urine, terminal illness when bed linen changes painful for client - Acidifying urine of clients with retention catheter may reduce risk of urinary tract infection and calculus formation (cranberry juice increases acidity of urine). - Watch for collection of sediment in catheter or tubing or impaired urine drainage as indicators for need to change, ongoing assessment is high priority - Perineal care: should be performed by swabbing down tubing tray away from meatus (4”) - Client teaching: Teach principles of gravity drainage system, prevention of tension on catheter tubing, looping and kinks, how to manipulate system when ambulating, instructions for fluid intake and perineal care - Male catheter placement: 7-9” (20 cm), once urine flows, 1-2” extra - Female catheter placement: 4-6.5cm (2-3”?), once urine flows, 2.5cm extra (1”) - Removing indwelling/retention catheter: Usually on order of physician - If in place for long duration, client may require bladder retraining to regain bladder muscle tone (clamped few days prior to removal for specified periods of time [2- 4hrs] then released to allow bladder to empty Bladder irrigation: Flushing or washing out with a specified solution, carried out on MD order, may involve use of med for bladder lining, may be performed to maintain or restore patency of catheter (remove pus, blood clots) - Closed method is preferred technique o Associated with lower risk of infection, strict precautions ot maintain sterility, performed with two-way lumen - Document: catheter size, results, client teaching if appropriate, indicate if specimen obtained, if discontinued- record findings, report significant deviations from the norm - Female cleansing: distal  proximal  centre; male: circular motion Wound care and assessment - Wound: a disruption of normal anatomical structure and function that results from pathological processes either internally or externally. - Classified in 5 different ways: o Skin integrity (chronic, acute) o Cause (intentional; surgery, or unintentional; gun shot) o Severity of injury o Cleanliness of wound o Descriptive qualities TABLE 46­4  Wound Classification Description Involves Causes Implications for Healing Onset and Duration ACUTE Trauma, a Wounds are usually easily A wound that proceeds surgical incision. cleaned and repaired. through an orderly and Wound edges are clean and timely reparative process intact. that results in sustained restoration of anatomical and functional integrity. CHRONIC Vascular Continued exposure to Wound that fails to compromise, insult impedes wound healing. proceed through an chronic orderly and timely process inflammation, or to produce anatomical and repetitive insults functional integrity. to the tissue. Healing Process PRIMARY INTENTION Little tissue loss w quick healing Surgical incision, Healing occurs wound that is (surgical wounds) Edges approximate, low infection sutured or by stapled. Wound that is closed. risk epithelialization; Drainage lasts ~3 days heals quickly Epithelial cells evident by ~ day 4 with minimal Inflammation lasts ~ 5 days scar formation. Healing ridge obvious by ~ day 9 SECONDARY Longer healing time Pressure ulcers, Wound heals by INTENTION Increased fluid loss/drainage surgical wounds Wound edges are not Chronic inflammation that have tissue granulation Developing granulation tissue loss. approximated. Increased scarring tissue formation, Wound edges not approximate Possible loss of tissue function wound contraction, and epithelialization. TERTIARY INTENTION Wounds that are Closure of contaminated and Wound is left open for require wound is observation for several days, then wound signs of delayed until inflammation. edges are approximated. risk of infection is resolved - Types of wounds: Wounds with loss of tissue; wounds without loss of tissue - Granulation: Connective tissue, very vascular, develop from the edges to the centre of the wound, gradually fill I n wounds with tissue loss - Wound drainage: o Serous: Clear, watery, plasma-like, may be slightly pinkish o Purulent: Thick, yellow, green, tan, or brown , may have distinct odor o Sero-sanguineous: Pale, reddish, watery, mixture of serous and sanguineous o Sanguineous: Bright red, active bleeding - Peripheral vascular disease: Ankle/brachial pulse index often demonstrates false negative, toe pressure may be diagnostic, vascular studies - Local wound treatment: If perfusion is sufficient: provide prophylactic anti- microbial coverage, debride necrotic areas (to bone if necessary), provide a moist, healing wound environment, protect peri-wound skin Simple dressings - Protect wounds from microorganisms and reduce infection risks - Aid hemostasis and reduce risk of hemorrhage (pressure dressings) - Absorb drainage and promote healing - Splint/support wound and promote comfort
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