Exam 3: NSG 430/ NSG430 (2026/ 2027 Updated) Adult Health Nursing II Complete Guide| Verified Questions & Answers| Grade A| 100% Correct (Accurate Solutions)- GCU

Exam 3: NSG 430/ NSG430 (2026/ 2027 Updated) Adult Health Nursing II Complete Guide| Verified Questions & Answers| Grade A| 100% Correct (Accurate Solutions)- GCU Q. Charge nurse Kim social media posts are unbecoming of her profession. Which of the below social media posting most likely support behavior unbecoming of her profession? A. negative workplace comments B. patient photos C. details that identify the patient D. pictures of her family at the hospital ANSWER A. negative workplace comments Q. Inappropriate electronic and social media disciplinary actions are publicized in which of the below published reports? A. joint commission quarterly reports B. national social media reports C. health care quarterly reports D. nurse professional liability exposures claim report ANSWER D. nurse professional liability exposures claim report Q. Manager Jones must intervene appropriately with problem employees. What is the most important priority to maintain? A. provide specific guidelines B. address each situation based on the severity C. limit stressors in the environment D. patient safety ANSWER D. patient safety Q. Manager Kim has completed a termination conference with Nurse Smith. Which of the below strategies is most appropriate with this conference? A. discuss performance coaching B. support Nurse Smith in developing an action plan C. end the meeting and leave D. consult HR for employment resources ANSWER C. End the meeting and leave Q. Nurse Sills is a disgruntled nurse on the unit. Which of the below interventions will be the most effective action to implement? A. performance coaching B. be consistent and set standards C. transfer to another unit D. work around this behavior ANSWER B. be consistent and set standards Q. Social media high risk postings can lead to which of the below breaches? SATA A. media misfires B. patient privacy C. confidentiality D. HIPAA violations B. patient privacy C. confidentiality ANSWER D. HIPAA violations Q. Which of the below legal problems can occur from inappropriate use of social media by nurses? SATA A. unconstitutional claims B. disciplinary actions C. malpractice claims D. ethical dilemmas B. disciplinary actions ANSWER C. malpractice claims Q. A client with DM has been admitted to the unit and requires development of a teaching plan. Who should develop this teaching plan? A. UAP B. LPN C. RN D. RN or LPN ANSWER C. RN Q. The patient's NG tube needs to be checked for placement and patency. Who can perform this skill? SATA A. UAP B. LPN C. RN D. student nurse under the supervision of the instructor ANSWER B. LPN C. RN D. student nurse under the supervision of the instructor Q. An LPN can provide which of the below tasks? A. calculate IV flow rates B. mix IV solutions C. administer IV push meds D. initiate plasma expanders ANSWER A. calculate IV flow rates Q. Common delegation errors occur in delegation? SATA A. marginal delegating B. under delegating C. over delegating D. improper delegating ANSWER B. under delegating C. over delegating D. improper delegating Q. Which infection control activity should the charge nurse delegate to an UAP? A. screening clients for upper respiratory tract symptoms B. asking the client about the use of immunosuppressant meds C. demonstrating correct hand washing to the clients D. disinfecting blood pressure cuffs after clients are discharged ANSWER D. disinfecting blood pressure cuffs after clients are discharged Q. A patient with a diagnosis of sleep apnea has a problem with sleep deprivation r/t disrupted sleep cycle. Which action should the nurse delegate to the UAP? A. discuss weight loss strategies such as diet and exercise with the patient B. teaching the patient how to set up the BiPAP machine before sleeping C. reminding the patient to sleep on his side instead of his back D. administering modafinil to promote daytime wakefulness ANSWER C. reminding the patient to sleep on his side instead of his back Q. The nurse is caring for a patient after thoracentesis. Which actions can be delegated from the nurse to the UAP? SATA A. assess puncture site and dressing for leakage B. check vital signs every 15 minutes for 1 hour C. auscultate for absent or reduced lung sounds D. remind the patient to take a deep breath E. take specimens for the lab F. teach the patient symptoms of a pneumothorax ANSWER B. check vital signs every 15 minutes for 1 hour D. remind the patient to take a deep breath E. take specimens for the lab Q. In the care of clients with pain and discomfort, which task is most appropriate to delegate to UAP? A. assisting the client with preparation of a sitz bath B. monitoring the client for signs of discomfort while ambulating C. coaching the client to deep breathe during painful procedures D. evaluating relief after applying a cold compress ANSWER A. assisting the client with preparation of a sitz bath Q. The nurse is caring for a patient with esophageal cancer. Which task could be delegated to the UAP? A. assisting the patient with oral hygiene B. observing the patient's response to feedings C. facilitating expression of grief for anxiety D. initiating daily weights ANSWER A. assisting the patient with oral hygiene Q. The nurse is caring for a patient with chronic kidney disease after hemodialysis. Which patient care action should the nurse delegate to the experienced UAP? A. assess the patient's access site for a thrill and bruit B. monitor for signs and symptoms of post-dialysis bleeding C. check the patient's post-dialysis blood pressure and weight D. instruct the patient to report sign of dialysis disequilibrium syndrome immediately ANSWER C. check the patient's post-dialysis blood pressure and weight Q. When administering a blood transfusion to a patient, which action can the nurse delegate to the UAP? A. take the patient's vital signs before the transfusion is started B. assure that the blood is infused within no more than 4 hours C. ask the patient at frequent intervals about presence of chills of dyspnea D. assist with double-checking the patient's ID and blood bag number ANSWER A. take the patient's vital signs before the transfusion is started Q. The nurse manager in a public health department is implementing a plan to reduce the incidence of infection with HIV in the community. Which nursing action will be delegated to the UAP? A. supplying injection drug users with sterile injection equipment such as needles and syringes B. interviewing a patient about behaviors that indicate a need for annual HIV testing C. teaching high-risk community members about the use of condoms in preventing HIV infection D. assessing the community to determine which population groups to target for education ANSWER A. supplying injection drug users with sterile injection equipment such as needles and syringes Q. The nurse is caring for a patient with osteoporosis is at increased for falls. Which intervention should the nurse delegate to the UAP? A. identify environmental factors that increase risk for falls B. monitoring gait, balance, fatigue level with ambulation C. collaboration with PT to provide the patient with a walker D. assisting the patient with ambulation to the bathroom and in the halls ANSWER D. assisting the patient with ambulation to the bathroom and in the halls Q. The nurse is preparing a patient for MRI. Which action can the nurse delegate to the experienced UAP? A. teach the patient what to expect during the test B. instruct the patient to remove metal objects including zippers C. witness the patient sign consent D. check and record pre-procedure vital signs ANSWER D. check and record pre-procedure vital signs Q. The nurse is working in a hospice facility for patients with AIDS. The facility is staffed with LPN/LVN and UAPs. Which action will the nurse assign to the LPN? A. assessing patient nutritional needs and individualizing diet plans to improve nutrition B. collecting data about the patient's responses to medications for pain and anorexia C. developing UAP training programs D. assisting patients with personal hygiene and other activities of daily living as needs ANSWER B. collecting data about the patient's responses to medications for pain and anorexia Q. A client in the emergency department who is being monitored with a portable cardiac monitor and develops this rhythm (V.fib). Which action will the nurse take first? A. defibrillate at 200 joules B. start CPR C. administer epi 1 mg IV D. intubate and manually ventilate ANSWER A. defibrillate at 200 joules Q. A client seen in the clinic with shortness of breath and fatigue is being elevated for a possible diagnosis of heart failure. Which lab result will be most useful to monitor? A. serum K+ B. B-type natriuretic peptide C. BUN D. hematocrit ANSWER B. B-type natriuretic peptide A patient has urolithiasis and is passing the stones into the lower urinary tract. What is the priority nursing concern for the patient at this time? A. pain B. infection C. injury D. anxiety A. pain The nurse is caring for 25 year old patient admitted to the acute care unit with an extra strong thirst, and dilute, excessive straw colored urine output. What does the nurse suspect? A. DM type 2 B. DI C. Cushings disease D. Addison disease B. DI A client involved in a one car rollover comes in with multiple injuries. List in order of priority the interventions that must be initiated for this client A. secure two large bore IV lines and infuse NS B. use the chin lift or jaw thrust maneuver to open the airway C. assess for spontaneous respirations D. give supplemental oxygen via mask E. obtain a full set of vitals F. remover or cut away the clients clothing C, B, D, A, E, F A 56 year old client comes to the triage area with left sided chest pain, diaphoresis, and dizziness. What is the priority action? A. initiate continous ECG monitoring B. notify the emergency department health care provider C. administer oxygen via nasal cannula D. draw blood and established IV access C. administer oxygen via nasal cannula The nurse assesses a newly admitted patient with a diagnosis of hyperthyroidism. How would nurse best document the findings in this patient? A. bilateral exophthalmos B. large visible goiter C. myxedema D. moon face B. large visible goiter The nurse is caring for the following patients with endocrine disorders. Which patient must the nurse assess first? A. a 21 year old patient with DI whose urine output overnight was 2000 mls B. a 55 year old patient with SIADH who is demanding that the UAP refill his water C. a 65 year old patient with Addison disease who AM potassium was 6.2 D. a 48 year old patient with Cushing disease with a weight gain of 1.5 lb over the past 4 days C. a 65 year old patient with Addison disease who AM potassium was 6.2 Maslow hierarchy of basic level needs include which of the below? A. social B. safety C. physiologic D. self-actualization C. physiologic The nurse is caring for a patient who has just undergone a hypophysectomy for hyperpituitarism. Which post op findings requires immediate intervention? A. presence of glucose in nasal drainage B. presence of nasal packing in the nares C. urine output of 40-50 ml/hr D. patient reports thirds A. presence of glucose in nasal drainage The nurse is providing care for a patient who underwent thyroidectomy 2 days ago. Which lab values requires close monitoring by the nurse? A. calcium B. sodium C. potassium D. WBC A. calcium The client has portal hypertension and hepatic encephalopathy secondary to liver disease and is being treated with lactulose. Which lab result does the nurse check first to see if the medication is having the desired effect? A. WBC B. ammonia C. potassium D. platelet count B. ammonia The nurse just admitted a client with bacterial meningitis who reports a severe headache with photophobia and has a temp of 103.6. What do you do first? A. administer codeine 15 mg PO for the headache B. infuse ceftriaxone 2000 mg IV to treat the infection C. give tylenol 650 mg PO for the fever D. give furosemide 40 mg IV to decrease ICP B. infuse ceftriaxone 2000 mg IV to treat the infection A nurse focus for prioritizing care with emergency first D=disability includes which of the below interventions? A. assess pain level B. act to slow down development of disability C. 3-5 minute window for oxygenation D. reverse circulatory problem B. act to slow down development of disability A registered nurse is assigned the following clients: A-patient with MRSA who needs a dressing change B-patient with S/P bone marrow transplant needing her central line dressing change C-patient with DM needing his morning insulin D-patient with bronchitis, a low grade fever who is due for his albuterol Prioritize these clients A. ABCD B. DABC C. BCDA D. DCBA D. DCBA Charge Nurse Jones is making assignments for an unexperienced RN and a 10 year experienced RN. Which of the below patients should not be assigned to the unexperienced RN? A. a patient receiving NGT feedings and bladder irrigations B. a transfer patient from CCU with a BP of 88/50 C. a post-op wound debridement patient D. a patient with chest tubes B. a transfer patient from CCU with a BP of 88/50 (don't give new RN unstable patient!) Nurse Cox has received her handoff report. Which of the below patients should she assess first? A. Mrs. Tree, admitted for HBP, has a BP of 168/94 B. Mr. Hill is requesting pain meds C. Mrs. Dill is scheduled for dialysis this AM D. Mr. Lopez O2 sat was 98% and now is 90% D. Mr. Lopez O2 sat was 98% and now is 90% Abdominal Trauma: Injuries to the abdominal region, often caused by blunt force or penetrating trauma, potentially affecting organs like the liver or spleen. Can cause internal bleeding or organ damage Treatment: Surgery may be necessary for severe injuries. Stabilization, pain management, and monitoring for internal bleeding are essential. Assessment: Assess for signs of internal bleeding (e.g., abdominal pain, tenderness, distension) and signs of shock. Acetaminophen Overdose: Excessive ingestion of acetaminophen (Tylenol) leading to liver damage. Can be accidental or intentional. Treatment: Administer activated charcoal, N-acetylcysteine (NAC), and supportive care. Assessment: Assess the patient's level of consciousness, liver function, and potential symptoms of overdose (nausea, vomiting, abdominal pain). ALS (Amyotrophic Lateral Sclerosis): ALS is a progressive neurodegenerative disease that affects nerve cells in the brain and spinal cord, leading to muscle weakness and eventually paralysis. Treatment: There is no cure, but supportive care and management of symptoms are essential. Assessment: Monitor for progressive muscle weakness, respiratory function, and nutritional needs. Amputations: Treatment: Surgical intervention to control bleeding and amputation site closure, followed by wound care and rehabilitation. Assessment: Assess for hemorrhage, infection risk, and the need for psychological support. Back Pain: Back pain can result from various causes, such as muscle strains, disc herniations, or degenerative conditions, and it can range from mild to severe. Treatment: Pain management, physical therapy, and in some cases, surgery. Assessment: Evaluate the location and intensity of pain and any neurological deficits. Bee Stings: Bee stings can cause pain, swelling, and allergic reactions in some individuals. Treatment: Remove the stinger, apply cold compresses, and consider antihistamines or epinephrine for severe allergic reactions. Assessment: Monitor for allergic reactions, swelling, and anaphylaxis. Buck's Traction: Buck's traction is a method of immobilizing and aligning a fractured or dislocated limb by applying continuous pulling force using weights and pulleys. Treatment: Maintain traction, ensure proper alignment, and manage pain. Assessment: Assess skin integrity, alignment, and patient comfort. Carbon Monoxide Poisoning: Carbon monoxide is a toxic gas produced by incomplete combustion; poisoning can occur when individuals are exposed to high levels of this gas, leading to symptoms such as headache, dizziness, and even death. Treatment: Administer 100% oxygen, remove from the source, and consider hyperbaric oxygen therapy for severe cases. Assessment: Monitor for symptoms like headache, confusion, and unconsciousness. Cervical Spine Precautions: These are safety measures taken to protect the cervical spine (neck) from further injury, typically used in cases of suspected neck trauma. Treatment: Immobilize the cervical spine to prevent further injury. Assessment: Assess for signs of neurological deficit and maintain spinal precautions. Chemical Exposure: This involves contact with harmful chemicals that can lead to various health issues, from skin irritation to systemic toxicity. Treatment: Remove contaminated clothing, irrigate exposed areas, and administer antidotes or supportive care. Assessment: Identify the chemical, assess for exposure symptoms, and provide decontamination. Compartment Syndrome: Compartment syndrome is a condition where pressure within muscle compartments increases, potentially cutting off blood supply to the muscles and nerves within them. Treatment: Immediate surgical fasciotomy to relieve pressure. Assessment: Assess for the 5 Ps (pain, pallor, pulselessness, paresthesia, and paralysis) in the affected limb. Cushing's Triad: Cushing's triad is a set of clinical signs that can indicate increased intracranial pressure and includes systolic hypertension with narrowing pulse pressure, bradycardia, and irregular respirations. Treatment: Address the underlying cause of increased intracranial pressure (ICP). Assessment: Monitor for signs of elevated ICP, such as hypertension, bradycardia, and irregular respirations. Fat Embolism: Fat embolism occurs when fat particles from a fractured bone enter the bloodstream and can cause blockages in the lungs, brain, and other organs. Treatment: Supportive care, oxygen therapy, and addressing the underlying fracture. Assessment: Monitor for respiratory distress and neurological changes. Femur/Leg Fractures: Treatment: Immobilization, alignment, pain management, and surgical intervention if necessary. Assessment: Assess for deformity, swelling, and neurovascular compromise. Glasgow Coma Scale: A tool used to assess a patient's level of consciousness and neurological status after a head injury. Treatment: None (used for assessment). Assessment: Evaluate a patient's eye, verbal, and motor responses to assess their level of consciousness. Guillain-Barre Syndrome: A rare autoimmune disorder that affects the peripheral nervous system, leading to muscle weakness and sometimes paralysis. Treatment: Supportive care, immunoglobulin therapy, or plasmapheresis. Assessment: Monitor for muscle weakness, respiratory function, and autonomic dysfunction. Heat-Related Emergencies: These include heat exhaustion and heatstroke, conditions caused by prolonged exposure to high temperatures that can result in a range of symptoms, from dehydration to organ failure. Treatment: Cooling measures, rehydration, and addressing electrolyte imbalances. Assessment: Assess for signs of heat exhaustion or heatstroke, including core body temperature and mental status. Hemorrhage: Treatment: Control bleeding, restore blood volume, monitor VS and address the underlying cause. Assessment: Assess the type, location, and severity of bleeding and vital signs. Assess for signs of hypovolemic shock: tachycardia, hypotension, and pale skin. Human Bite: Human bites can lead to infections and complications, and they are often treated as wounds. Treatment: Wound cleaning, antibiotics, and tetanus prophylaxis. Assessment: Evaluate the wound for infection risk and consider X-ray for fractures. Assess for signs of infection, such as redness, swelling, and purulent discharge. Hypothermia: Treatment: Rewarming, gradual and gentle rewarming for severe cases. Assessment: Monitor core body temperature, vital signs, and mental status (confusion). ICP (Intracranial Pressure): Increased pressure within the skull, typically due to brain injury or swelling. Treatment: Reduce pressure, maintaining cerebral perfusion, and monitoring neurologic status, address the underlying cause and reduce ICP using medications or surgical intervention. Assessment: Monitor for signs of increased ICP, including altered consciousness and changes in vital signs. Interpersonal Violence: Refers to acts of violence between individuals, including domestic violence and assault. Treatment: Ensure safety, provide psychological support, and legal intervention if necessary. Assessment: Assess for injuries and signs of abuse, and consider social services or counseling. Laminectomy: A surgical procedure to remove part of the vertebral bone to relieve pressure on the spinal cord or nerves. Treatment: Surgical decompression of the spinal cord or nerves. Assessment: Evaluate neurological function, post-operative wound care to prevent infections, and pain management. Facial/Mandible Fracture: Treatment: Surgical repair, pain management, and soft diet. Assessment: Assess for deformity, pain, and potential airway compromise. Medications for Muscle Spasms and Cramping (fill out): Assessment: Evaluate the patient's response to the medication and monitor for side effects. Methods to Facilitate Movement in Patients with MS Trauma: Techniques and strategies to aid mobility and rehabilitation in patients with multiple sclerosis (MS) who have experienced trauma. Treatment: Physical therapy, adaptive equipment, and lifestyle modifications. Assessment: Assess the patient's mobility, functional limitations, and rehabilitation needs. Muscular Dystrophy: A group of genetic disorders characterized by progressive muscle weakening and loss. Treatment: Supportive care, physical therapy, orthopedic interventions, and genetic counseling. Assessment: Monitor for progressive muscle weakness and functional impairments. Neuro Assessment: A comprehensive evaluation of a patient's neurological status, including assessment of mental status, cranial nerves, motor and sensory function, and reflexes. Treatment: None (used for assessment). Assessment: Evaluate mental status, cranial nerves, motor and sensory function, and reflexes. Neurogenic Shock vs. Spinal Shock: Neurogenic shock is a type of distributive shock that occurs after a spinal cord injury, while spinal shock refers to a temporary loss of sensory and motor function below the level of spinal cord injury. Treatment: Differentiate between the two conditions and provide appropriate care. Assessment: Assess for signs of shock and spinal cord injury, including loss of sensation and motor function. ORIF (Open Reduction and Internal Fixation): A surgical procedure used to repair fractures by aligning bone fragments and securing them with internal hardware. Treatment: Surgical repair to stabilize fractures. Assessment: Evaluate the surgical site, wound healing, and pain management. Pelvic Fracture: Treatment: Immobilization, pain management, and surgical intervention in severe cases. Assessment: Assess for signs of shock, potential bleeding, and neurovascular compromise. Primary Trauma Survey: A systematic assessment of a trauma patient's condition to identify and address life-threatening injuries. Treatment: Immediate stabilization and prioritization of life-threatening injuries. Assessment: Evaluate airway, breathing, circulation, disability, and exposure (ABCDE) to identify and manage critical conditions. Skull Fracture: A break in one or more of the bones of the skull, which can be associated with head injuries. Treatment: Pain management, monitoring for intracranial bleeding, and possible surgical intervention. Assessment: Assess for signs of skull fracture, neurological deficits, and potential head injuries. SLE (Systemic Lupus Erythematosus): A chronic autoimmune disease that can affect various parts of the body, leading to a wide range of symptoms. Treatment: Medications to manage symptoms, control inflammation, and prevent flares. Assessment: Monitor for a wide range of symptoms affecting various body systems and manage disease activity. Tetanus Vaccine: A vaccine that provides immunity against tetanus, a potentially deadly bacterial infection. Treatment: Tetanus toxoid vaccine for prevention. Assessment: Evaluate the need for vaccination based on the patient's injury and vaccination history. Given for: Open fracture when immunization is unknown Open wounds Superficial and Deep Frostbite Snake, animal, and human bites Burn Patients If a pt has not had it for 10 years Thoracic Vertebrae Injuries: Injuries to the thoracic vertebrae, the mid-back region of the spine. Treatment: Immobilization, pain management, and potential surgical intervention. Assessment: Assess for signs of spinal cord injury, neurological deficits, and respiratory issues. Traumatic Brain Injury: Damage to the brain caused by an external force, often resulting in cognitive and physical impairments. Treatment: Management of intracranial pressure, surgery if necessary, and rehabilitation. Assessment: Assess for neurological deficits, level of consciousness, and changes in vital signs. Triage: The process of prioritizing and sorting patients in a medical emergency to ensure that the most critical cases receive immediate attention. Treatment: None (used for prioritizing care). Assessment: Assess and categorize patients based on the severity of their injuries or conditions to ensure efficient allocation of resources and care. Rheumatoid arthritis: medical/drug options, and nursing management/treatment/interventions. •Autoimmune disorder •Chronic, systemic disease •Recurrent inflammation of diarthrodial joints •Females more than males •Primary cause is unknown. -- Environmental factors - smoking -- Genetic factors Medical/ Drug options - Aggressive and early treatment - Disease-modifying anti-rheumatic drugs (DMARDs) methotrexate - Corticosteroids - Biologic Response Modifiers (etanercept, infliximab, adalimumab) TNF Inhibitors - NSAIDS - Which of these is first line therapy? And WHY? Nursing Management Goals: - Pain management - Manage fatigue - Prevent further limitation of mobility - Patient education on medication and adaptive devices - Modify activity pattern to control symptoms - Modify environment for safety and comfort Treatment: Interventions: - Energy Conservation - Splinting - Physical therapy - Cold and/or heat therapies - Relaxation - Nutrition - healthy diet with increased vitamins, protein and iron SLE: clinical presentations and nursing management/treatment/interventions/patient education •Multisystem inflammatory autoimmune disease -- Genetic, hormonal, environmental, immunologic -- Complex disorder affects skin, joints and serous membranes -- More women than men •Environmental factors include sun exposure and sunburns •Mild disorder to rapidly progressing •Diagnosis by presence of distinct criteria Clinical presentations: -- General -fever, malaise, weight loss, anorexia --Dermatologic - rash -- Musculoskeletal - polyarthralgia -- Cardiopulmonary -pericarditis -- Renal - nephritis -- Nervous System - neuropsychiatric -- Hematologic - anemia -- Infection - increased susceptibility Nursing management: Care during exacerbation •Assess, treat and monitor symptoms (fever, discomfort, fatigue, I&O, weight, s/s of bleeding) Treatment: -- Drug therapy -- Belimumab - monoclonal antibody -- NSAIDS -- Corticosteriods -- Hydroxychloroquine -- Immunosuppressive agents Interventions: Patient education - Fatigue management - Protection from sun and ultraviolet light - Nutrition - No smoking - Medication management - Risk for infection and osteoporosis SCI: Nursing interventions of the patient with spinal cord injury, Clinical manifestations of spinal shock, Autonomic dysreflexia: cause and nursing interventions Spine issues: Degenerative Disk Disease: •Spinal Stenosis •Herniated Disk Symptoms are similar: •Pain, radiculopathy , decreased reflex, weakness, bowel and bladder issues 1. Non-surgical, Pain control, exercise, education 2. Surgical (laminectomy, diskectomy, fusion, graft) Surgical Nursing Management: •Positioning and Movement •Monitor bowel and bladder •Orthotics (TLSO) •Pain control (opiods) •Neuro assessment Spinal Cord Injury -- 17000 new injuries per year -- Males,, average age 42 years old -- Higher risk behavior -- Upper Motor Neurons - nerves within the cord that carry messages between the brain and spinal nerves -- Lower Motor Neurons - spinal nerves from spinal cord to areas of body both motor and sensory portions -- Damage to spinal cord is caused by swelling which results in anoxia to spinal cord tissue Immediate Management/Concerns •Immobilization •CT Scan or MRI •Maintain airway, breathing, oxygenation, maintain BP, prevention of further damage •Cardiac issues/Pulmonary embolism -IV fluids, vasopressors and inotropes •Spinal shock - immediate but temporary loss of spinal reflexes •Neurogenic shock - sudden loss of ANS signals, serious complication vasodilation, bradycardia, hypotension due to loss of vasomotor tone and sympathetic innervation of the heart Medical Management •Surgery - Postop •Prevention of VTE, respiratory failure, pneumonia •Immobilization and reduction --- Skeletal traction - cervical injury --- Halo vest - cervical injury --- TLSO - thoracic and lumbar brace Nursing Interventions: •Respiratory issues •Orthostatic hypotension •Bowel •Bladder •Skin - pressure injury as well as pin care •Infection •Mobility •Pain - trauma and neuropathic •Autonomic dysreflexia (MORE HERE) •Spasticity •Motor and Sensory Changes •Sexual expression •Poikilothermia •Depression •Patient and family education GI about 7 questions Identify priority nursing diagnosis and assessment for the patient situation Nursing care and interventions in the management of enteral nutrition Feeding tubes and functions: •Nasogastric (NG): med administration, lavage, deliver enteral nutrition -- Large tube, 14-16 French •Dobhoff: enteral feeding only -- Smaller, 4 mm in diameter -- Common brand name is Cortrak- can use for a longer term as it has post pyloric feeding capabilities that make eternal feeding safer. -- Also placed with a special magnetic sensor that verifies placement eliminating the need for an X-ray •Gastronomy tube (G-tube): surgically placed for long term eternal feeding and medication administration. •Gastronomy/jejunostomy tube G-J tube: surgically placed in stomach and jejunum -- Double port system with single tube externally but bifurcated internally where one tube sits in stomach and the other in jejunum. -- Meds/flushes in G-port -- Feeds into jejunum (J-port) -- Better for long term feeds as less gastric residuals when feed directly into jejunum. Assessment and nursing care of NG, G, and GJ tubes: •Assess site including skin: s/sx of infection, breakdown, placement •Assessing placement: X-ray initially, auscultation, review chart for location and length, charting your assessment •Assess patency •Securement: tape (must be replaced daily or as needed), commercial securing device •Recording of daily intake- includes medication administration •Depending on institution but typically requires q4h assessments and flushes •Monitor and record tube feed rate •Monitor and record residual amount- big deal especially in certain patient populations •Components of abdominal assessment- what are they and in what order? •Patient position: HOB 30 degrees or higher during feedings if continuous, semi to high fowlers if intermittent bolus feedings, limiting amount of time flat for patient care when having high residuals and bolus feedings. •Psychological affects of being NPO. Care of the patient with complications of acute gastritis/peptic ulcer disease. Acute Gastritis: inflammation of stomach lining. -Assessment: -- Anorexia -- Epigastric pain (rapid onset) -- Hematemesis -- Hiccups -- Melena or hematochezia -- Nausea & Vomiting -- Possible signs of shock Peptic Ulcer Disease: ulcers that occur in the gastroduodenal mucosa. -Assessment: -- Epigastric tenderness/pain -- Abdominal distension -- EGD to assess for inflammation, ulcers, and/or lesions -- Can use EGD to test tissue for H. Pylori -- Possible GI bleeding -- And the same symptoms of gastritis Nursing Care: Nursing Diagnosis -- Acute/chronic pain -- Anxiety -- Imbalanced nutrition -- Fluid volume deficit -- Others? Other Potential Problems -- Hemorrhage -- Perforation -- Penetration -- Gastric outlet obstruction Common Interventions •Pain management •Reduce anxiety •Medication administration •Blood administration •VS- what are the s/sx of hemorrhage? What do we do when when someone has a GI bleed? •Collect psychosocial hx- ETOH use, diet, smoking, caffeine intake, medications reconciliation (what common meds would we be considered about?) •Maintain optimal nutrition •Surgical management- open or laparoscopic (see table 46-4, p1300) Goals/Evaluation Depends on acuity and current needs •Pain management •Anxiety reduction •Hemorrhage control •Hemodynamic stability •Lifestyle modifications •Post surgical needs Post op complications - prevention, cause and treatment. General nursing care of the post-surgical gi patient -- Site assessment- infection, closure, wound healing, exudate, draining tubes, dressings. -- Education- depends on the surgery and restrictions but includes diet, positioning, and activity. -- With laparoscopic surgery walking is very affective in relieving "gas pain." -- Concerns with administering narcotics post surgery due to risks for constipation and other SE such as lethargy. -- Supplemental therapies for SE of narcotics and surgery- stool softeners, fluid intake, and bulky/high fiber diet (if ordered). Enhanced Recovery After Surgery protocols •Improve patient outcomes by reducing post-operative complications, accelerated recoveries, and early discharge. •Big take away- trying to use less narcotics during and after surgery. For Post- Op -- NSAIDS -- Acetaminophen -- Gabapentin -- opioids only for breakthrough pain -- regular diet within 24 hrs -- discontinue IV fluids within 24 hrs -- ambulate within 24 hrs Assessment and management of Bowel Obstructions. -- Accumulation of intestinal contents, fluid, and gas that can lead to distension and perforation. -- Can be a medical emergency due to the amount of vasculature in the large intestine. If blood supply is cut off, necrosis can occur. -- S/sx: progresses slowly, weakness, weight loss, anorexia, constipation, distended abdomen, pain/cramping. -- Diagnosed with s/sx and radiology- X-ray or CT scan. -- Nursing management: oIV fluids, possibly with electrolytes- What are those types of fluids? (Isotonic IV fluids include normal saline, 5% dextrose solutions dissolved in water, and Lactated Ringer's solutions.) oPrep for surgery and post surgical care. Nursing care and interventions for patients post neck surgery -- Reason can vary from tumor and gland removal to fixation of deformity related to growth or trauma. -- Major concerns after surgery: oAirway management oEdema oHemorrhage oJP drain care if present oSwallowing ability oNerve injury- How will we know this? can they talk? --Assessment of superior laryngeal nerve damage- can cause dysphagia. oPain -- Nursing interventions: oSafe environment- suction, ambu bag, elevated HOB, oxygen delivery (facemask vs nasal cannula) oPain relief: IV vs PO, pharmacologic vs non-pharmacologic (ICE!!!!) oWound care oMonitoring bleeding and recording output oNutrition afterward oPromoting communication oMaintain mobility- Why when were focusing on upper GI? Assessment and management of patients with absorption disorders. Assessment: •EGD and colonoscopy •Labs: CBC w/ Diff & BMP •S/x of FVD •Telemetry •EKG •S/sx of infection •Pain •Intake & output •Diet •Skin integrity- why? What are some concerns? Treatment/Management: •Very similar to treatment of dehydration •Treat secondary causes- i.e. diarrhea, N/V, correct electrolyte imbalances •Closely monitor VS and telemetry •Education- both treatment and prevention •Medication regime and education •Care giver support **Common diseases/disorders that cause malabsorption in the GI tract: •Celiac Disease •Peritonitis •Chron's Disease •Ulcerative colitis •Diverticulitis •Pancreatic disease- pancreatitis (acute/chronic) •Trauma •Food/lactose intolerance •Major problems of malabsorption: oInability to absorb vitamins A & B12 oInability to absorb iron and calcium oInability to absorb carbohydrates, fats, and proteins oInability to to absorb water/fluid Care for patient under ERAS protocol (based upon slide info only). •ERAS for short •Depends on surgical specialty but very common with GI surgery. •Emphasis is to optimize physiologic function and facilitate recovery through specific pathways: pre-op, intra-op, and post-op. •Improve patient outcomes by reducing post-operative complications, accelerated recoveries, and early discharge. •Big take away- trying to use less narcotics during and after surgery. Preop -- patient counseling and expectations -- avoid mechanical bowel preparation -- solids up to 6 hours prior to surgery -- clear liquids up to 2 hrs prior to surgery -- consider acetaminophen, celecoxib, pregabalin, or gabapentin prior to surgery Intraop -- minimally invasive surgical approach -- local anesthetic or longacting local (liposomal bupivacaine) -- keep pt warm -- IV fluid maintenance -- Prophylaxis for nausea and vomiting (at least two classes of medications) -- Toradol (if appropriate) Postop info in slides above Liver - Biliary - AWS 5 questions Assessment and management of complications due to hepatic dysfunction (Jaundice, ascites, portal hypertension, esophageal varices, hepatic encephalopathy) Jaundice Assessment: -- Caused by impairment of hepatic uptake, conjugation of bilirubin or excretion of bilirubin -- Increase in serum bilirubin -- Yellow tinge to sclerae and skin -- Urine deep orange and foamy -- Clay colored or light-colored stools -- Fatigue, decreased appetite, weight loss, pruritis Management: Ascites Assessment: --Accumulation of fluid in peritoneal cavity Management: -- Low sodium diet -- Diuretics - (Spironolactone) -- No alcohol consumption -- Paracentesis - diagnostic ---- Large volume paracentesis 5-6 liters combined with IV infusion of albumin -- Indwelling peritoneal catheter -- Shunt Portal Hypertension: Assessment: -- A persistent increase in pressure within the portal vein -- Meets resistance or obstruction -creates collateral venous circulation around the high pressure area -- Splenomegaly -- Ascites -- Esophageal varices -- Hemorrhoids -- Caput medusae Management: Esophageal varices Assessment: -- Dilated veins common in the lower esophagus -- Hematemesis, melena, decrease in mental and physical status -- Bleeding esophageal varices are life-threatening --- Treat hemorrhagic shock - fluids --- Octreotide, Vasopressin, Propranolol --- Balloon Tamponade, Ligation, Banding -- High risk surgical procedures Nursing Management: -- Vital signs - blood pressure -- Assessment - physical, cognitive and emotional (rebleeding) -- TPN -- Gastric suction -- Oral care -- Blood transfusions -- Calm quiet environment, promote rest Hepatic encephalopathy: Assessment: Life threatening complication - neuropsychiatric manifestation due to increased ammonia levels Nursing Management: -- Monitor VS -- Assessment - LOC, agitation, asterixis, DTR's -- Lactulose - monitor stool output -- High protein diet - enteral feeding -- No sedatives or analgesics -- Safe environment Signs, symptoms, transmission and treatment of hepatitis A, B, C Viral Hepatitis: -- Systemic viral infection, necrosis and inflammation of liver cells -- Clinical signs: malaise, headache, anorexia, n/v, dark urine, light stools, pruritis, jaundice, -- Most will recover completely with rest and healthy diet, liver cells will regenerate. Avoid ETOH and liver toxic drugs -- Complications: Acute hepatic failure, chronic hepatitis, cirrhosis of the liver and hepatocellular cancer Hep A: Signs&Symptoms: -- May have no symptoms -- Symptoms: fatigue, anorexia, malaise, headache, low-grade fever, nausea and vomiting -- Highly contagious usually 2 wks before onset of jaundice -- Late symptoms: jaundice, tea-colored urine, clay-colored stools and RUQ tenderness -- Adults are more likely to have severe symptoms Transmission: fecal-oral route and outbreaks are common in areas of overcrowding and poor sanitation. -- Infected food handler can spread the disease and people can contract it by consuming water or shellfish from contaminated waters. -- Commonly spread by person to person contact -- Incubation period 2-6 weeks Treatment: -- Vaccinations -- Bed rest, nutritional therapy, hydration, avoid alcohol, hygiene measures -- Gradual increase with activity based on lab results -- Recover at home - patient and family education Hep B: Signs&Symptoms: -- Symptom onset usually more insidious & prolonged compared with HAV -- Symptoms: loss of appetite, abdominal pain, rash, arthralgia, malaise and weakness -- Jaundice, light colored stools and dark urine -- Liver and spleen tenderness & enlargement Transmission: -- A virus transmitted by blood, saliva, semen, vaginal secretions. -- Modes of transmission oBlood - exposure to blood products, body fluids oSexual contact oPerinatal transmission -- Incubation 1-6 months Treatment: -- Vaccinations -- IM administration of immune globulin within hours - days after exposure and start of vaccinations -- Management: Acute oAlpha-interferon injections oBalance nutrition - 6 small meals/day, hydration oVitamin supplements oRest oAvoid alcohol and drugs metabolized by liver -- Chronic - antiviral agents in combination with peginterferon Hep C: Signs&Symptoms: similar to HBV Transmission: -- Mode of transmission in most cases is though blood or blood transfusion oIV drug users oSexual intercourse oPiercing and tattooing tools -- Incubation period 15-160 days -- Risk chronic liver disease, cirrhosis, liver cancer Treatment (Chronic) - avoid alcohol, Sofosbuvir, daclatasvir or sofosbuvir/velpatasvir combination are preferred regimen (WHO, 2018). Assessment treatment and nursing management of the patient with cirrhosis -- Chronic progressive -- Permanent degeneration/injury of liver cells and disorganized regenerative capabilities leads to fibrous connective tissue 3 types -- Alcoholic Cirrhosis - most common -- Post necrotic Cirrhosis - complication of hepatitis, scar tissue -- Biliary Cirrhosis- chronic obstruction and infection, less common Diagnostic Test: -- Albumin - decreased -- Prolonged PT -- Liver Function Tests increased --- AST --- ALT --- GGT --- Alk phos -- Bilirubin - increased -- Ultrasound scar tissue -- CT, MRI - size and blood flow -- Liver Biopsy - confirms Cirrhosis S&S --Compensated- Fatigue, GI disturbances, RUQ pain (dull heavy feeling), enlarged liver and/or spleen, ankle edema, palmar erythema, angiomas -- Decompensated-jaundice, ascites, weight loss, hypotension, purpura, weakness, sparse body hair Nursing Management: -- Activity intolerance -- Imbalanced Nutrition: Less than body requirements -- Impaired skin integrity -- Risk for Injury -- Chronic pain -- Excess fluid volume -- Confusion -- Dysfunctional family process: alcoholism -- Rest -- Assessment - at risk for pneumonia, VTE, pressure injury, mental status changes, bleeding, increased edema -- Diet - small meals, high carb and protein, vitamin supplements -- Vital Signs, Intake and Output -- Skin care -- Safety measures - assist with ambulation, electric razor, soft toothbrush -- Medication management for symptoms Cirrhosis Treatment at home: - Stop or delay the progress, minimize damage to liver cells , and reduce complications ---Stop ETOH and cautious use of any drugs ---Continue Medications to control symptoms ---Appropriate healthy nutrition ---AA meetings, counseling ---Family education Assessment and management of the patient with acute pancreatitis -- Inflammation of the pancreas, either acute or chronic, range from mild edema to severe hemorrhagic necrosis. -- Most common cause is gallstones -- Diagnosis: Elevated amylase and lipase, WBC's -- Abdominal ultrasound, CECT (contrast enhanced), MRI Clinical Manifestations: -- Abdominal Pain (midepigastrium) -- Persistent vomiting -- Abdominal distention -- Tachycardia -- Low grade fever -- Cold clammy skin -- Cullen's sign (bluish periumbilical discoloration)or Turner's spots or signs (bluish flank discoloration) -- Restlessness -- Respiratory distress and hypoxia Management: -- Pain Management (opioids) -- Assess respiratory system -- NPO with possible NG tube to suction -- Enteral or parenteral nutrition -- Albumin -- Balance fluid and electrolytes -- Histamine-2 antagonists or PPI's -- Consider prep for surgery if indicated -- Bedrest Assessment and treatment of AWS (includes use of CIWA-AR) you do not need to memorize the scoring. Alcohol Withdrawal Syndrome: Abrupt cessation of alcohol exposure (heavy or prolonged) resulting in brain hyperexcitability, manifested clinically as anxiety, irritability, agitation, and tremors, or in severe cases, ETOH withdrawal seizures and delirium tremens AWS - Symptoms -- Tremors -- Anxiety -- Tachycardia -- Fear -- Nausea -- Agitation -- Insomnia -- Irritability -- Hallucinations Assessment: - Initial Risk Assessment on admission ---Hx of ETOH consumption --- Time of last drink ---Other Substance Abuse ---Hx of ETOH related seizures ---Communication with care providers ---Confidentiality Medication Management -- Benzodiazepines - sedation, decreases agitation, prevents seizure and promotes sleep -- Haloperidol or midazolam for severe withdrawal AWS Supportive Care -- Quiet, evenly lit room -- Monitoring and maintenance of fluids and electrolytes and medications -- Monitoring of vital signs, glucose -- Good Nutrition - MVI, protein -- Observation and Treatment of concurrent conditions (CAD, HTN, post surgical) -- Treatment of dependence after withdrawal Use of CIWA- Ar? Agitation (0-7). Anxiety (0-7). Auditory disturbances (0-7). Clouding of sensorium (0-7). Headache (0-7). Nausea/vomiting (0-7). Paroxysmal sweats (0-7). Tactile disturbances (0-7). Tremor (0-7). Visual disturbances (0-7). Renal - about 8 questions Identify priority nursing diagnosis and assessment for the patient situation CKD Assessment: Laboratory data: •BMP or RFP: creatinine, BUN, GFR, electrolytes Physical assessment: •BP •Skin condition •Edema •Peripheral vascular- sensation, color, temperature •JVD Psychosocial history •Medical history •Genetics •Medications and compliance CKD Diagnosis: •Fluid volume overload •Electrolyte imbalance- actual or risk for •Activity intolerance •Knowledge deficit •Fatigue •Hopelessness •Impaired urinary elimination •Ineffective coping •Noncompliance AKI PREVENTION: look at slide 19 in ppt Hyperkalemia: •Is a very high risk for patient's with AKI and needs to be treated immediately. •Without having labs readily available, a nurse must rely on their assessment skills to identify at risk patients. EKG and telemetry is one way, but T wave abnormalities may not always be present, and understanding risk factors that can cause hyperkalemic are imperative. S&sx: Diarrhea, colic, nausea, irritability, muscle weakness, ECG changes •Urgent Treatment, C BIG K Drop: C = calcium gluconate B = bicarbonate I = insulin (regular/short acting IV) G = glucose (D50 IV) K= kayexalate D = diuretics (Lasix IV) Rop = renal unit for dialysis Nursing care and interventions in the management of patients with AKI and ESKD AKI: -- AKI: rapid loss of renal function due to damage to the kidneys. -- Depending on duration and severity, life-threatening metabolic complications and electrolyte imbalances can occur. -- Diagnosed by a 50% or greater increase in serum creatinine above baseline. -- Oliguria and anuria is common but necessarily immediately present. Nursing Interventions and Management of AKI: -- Assessment: labs, mental status, LS, heart sounds, urine output, edema -- Stop the primary cause if possible (i.e. if caused from hemorrhage, stop the bleed!) -- Aggressive laboratory monitoring- prevent hyperkalemia! -- EKG monitoring- peaked T-waves, tachycardia, PAC & PVC -- Establish IV access for fluid (2 large bore IVs) -- Identify and correct shock if present. ---- Think renal perfusion- does your patient need fluid (tank is dry), vasopressors (squeeze arterioles), or inotropics to improve the pump (increase CO & SV). CKD Interventions: •Assess urine output color, consistency, odor •Physical assessment •Assess vital signs- regulate BP •Document, document, document- intake and output can be very influential on what medical interventions are ordered! •Collect labs •Monitor labs •Patient education- diet, medication compliance, weight reduction, activity, symptoms of complications from CKD (i.e. fluid volume overload) •EKG monitoring- electrolyte imbalances •Treating electrolyte imbalances •Assess skin- hypoalbuminemia is secondary to long term kidney disease, protein affects tissue generation/wound healing Causes of/patients at risk for renal failure both AKI and ESKD CKD = an umbrella term, that describes kidney damage or a decrease in the glomerular filtration rate (GFR) lasting for 3 or more mo. -- CKD is associated with decreased quality of life, increased health care expenditures, and premature death. -- Untreated CKD can result in end-stage kidney disease (ESKD), which is the final stage of CKD ESKD results in retention of uremic waste products and the need for renal replacement therapies, dialysis, or kidney transplantation. CKD: -- Risk factors include cardiovascular disease, diabetes, hypertension, and obesity. -- Diabetes is the primary cause of CKD. More than 35% of the U.S. population aged 20 years and older with diabetes have CKD. ---- Diabetes is the leading cause of kidney disease in patients starting renal replacement therapy. -- The second leading cause is hypertension, followed by glomerulonephritis and pyelonephritis; polycystic, hereditary, or congenital disorders; and renal cancer. -- More than 20% of the U.S. population aged 20 years and older with hypertension have CKD **ESKD (stage 5 and final stage of CKD-- GFR 15ml/min/1.73 m^2 AKI: -- AKI may be caused by direct or indirect kidney damage 1. Reduced blood flow to kidneys (pre-renal) 2. Glomerulonephritis (Renal/Intrinsic) 3. UT obstruction (Post-renal) ** This all leads to: Increase in plasma creatinine and decrease in urine output Gerontological considerations of AKI -- Usually results from dehydration and can accompany UTIs. -- Medications (polypharmacy) can cause. -- Reduction in diet and fluid intake- consider psychological disorders -- Post surgical risks associated with dehydration or prolonged hypotension. Signs and symptoms of renal failure both AKI and ESKD AKI Prerenal: -- Etiology: hypo-perfusion -- Blood urea nitrogen value: Increase (out of normal 20:1 proportion to creatinine) -- Creatinine: Increase -- Urine Output: Decrease -- Urine Sodium: Decrease -- Urinary sediment: Normal, few hyaline casts -- Urine osmolality: Increase to 500 mOsm -- Urine specific gravity: Increase Intrarenal: -- Etiology: Parenchymal damage -- Blood urea nitrogen value: increase -- Creatinine: increase -- Urine Output: varies, often decreased -- Urine Sodium: increase to 40 mEq/L -- Urinary sediment: abnormal casts and debris -- Urine osmolality: ~350 mOsm, similar to serum -- Urine specific gravity: Low normal Postrenal: -- Etiology: obstruction -- Blood urea nitrogen value: increase -- Creatinine: increase -- Urine Output: varies, may be decreased, or sudden anuria -- Urine Sodium: varies, often decreased to = 20 mEq/L -- Urinary sediment: usually normal -- Urine osmolality: varies, increased or equal to serum -- Urine specific gravity: varies CKD: - Clinical Manifestations -- Elevated serum creatinine levels indicate underlying kidney disease. ---- As the creatinine level increases, symptoms of CKD begin. -- Anemia, due to decreased erythropoietin production by the kidney, metabolic acidosis, and abnormalities in calcium and phosphorus herald the development of CKD. -- Fluid retention, evidenced by both edema and congestive heart failure, develops. -- As the disease progresses, abnormalities in electrolytes occur, heart failure worsens, and hypertension becomes more difficult to control. Signs/symptoms/treatment of electrolyte imbalances associated with renal failure. LEARN SLIDE 7 in ppt -- its a lot Care of the patient undergoing dialysis The artificial kidney: - Hemodialysis (HD): short term (1-2 hour) treatments. - Treatments occur several times a week, usually M, W, F or T, TH, SAT. - Occurs in a hospital or an outpatient center. - Essential components: oDialyzer: (machine) oUltrafiltration: executes the diffusion and osmosis- removes toxins, wastes, and extra fluid within blood. o**Dialysate: solution that circulates through the machine, and provides electrolytes (Ca, K).** o***Anticoagulant (usually heparin) to be instilled within the machine but may be calcium citrate- need to monitor electrolyte levels.** oEffluent (waste) bag- can be in closed system but depends on machine manufacturing. -Another version is continuous renal replacement therapy (CRRT): oOccurs within an ICU setting for people who can not tolerate HD hemodynamically. oRuns a at a much slower pace than HD (mostly the ultrafiltration) oRequires same components of HD. Access Devices •HD and CRRT both require vascular access to function. •VAS cath or Perm Cath: can be placed emergently or within interventional radiology/OR and provide venous access to access blood for dialyzer to function. oTypical veins are subclavian, internal jugular, or inferior vena cava. oIs a venous pull and venous return (no arteries involved). •Arteriovenous (AV) fistula: most common for long term HD and is placed in either arm. oBlood is pulled from the arterial system- dialyzed- returned to venous system. oCan use venous graft if veins are not compliant for fistula placement. Complications and Nursing Care of access devices •Most commonly clotting, infection, and total occlusion that requires surgical replacement. •Vein/limb preservation is very important- nurses responsible for limiting/avoiding access to a limb that has an AV fistula. -- No IVs, labs, or BPs on arm •Dressing changes •Accessing devices utilizing sterile technique •Patient and family education •Patient and family psychological support •Social work consults ESRD: Peritoneal Dialysis PD •Is a slower less irritating method of providing dialysis and can occur at home. •Utilizes a Tinkoff catheter that is surgically placed in the abdomen. •Method utilizes the peritoneal membrane within the abdominal organs as the semipermeable membrane. •Sterile dextrose solution is instilled into the peritoneal cavity through the Tinkoff cath at specific times. •Once the solution enters the peritoneal cavity, uremic toxins (urea and creatinine) are cleared from the blood stream. •Diffusion and osmosis occurs as waste products move from an area of high concentration to an area of lower concentration through the semipermeable membrane (peritoneum). •Ultrafiltration occurs through osmotic pressure gradient created by the dialysate fluid because of a high glucose concentration. Complications and Nursing Care JUST KNOW THIS SECTION •**Peritonitis** •Leaking •Bleeding •Infection (handle catheter accessing using sterile procedure) •Psychological needs and interruptions of routines/daily living •Can be a 24/7 operation •Intermittent runs for 8-9 hours and patients perform at night when sleeping •Patient and family education •Establishing support systems •May cause hernias- assess for and teach about assessing at home •Educate family about s/sx of infection Handling effluent Managing effects of ESRD (for both types) KNOW THIS •Monitor labs- especially electrolytes. •Hypotension is most common side effect of HD- some patients require medications (midodrine) before treatment to prevent. Nurse must plan timing correctly to ensure patient receives adequately. •Hypotension can occur hours after treatment, need to collaborate with medical team on treatment if symptomatic. •Adequate dietary intake- supplement lacking electrolytes and minimize the excessive. •Restrict liquid intake to 1500 ml/day. •Administer medications as ordered- phosphors binding meds must be given with meals. •Regulate protein intake- concern for the biproduct of protein synthesis or urea/uric acid. Remember kidneys act as the buffer here and would struggle to excrete the uric acid and may cause uremia. •Psychological support. •Infection prevention (sterile line care) •Assess and document AV fistula for bruit and thrill at least 1 x shift- report any changes immediately! Hospice and Palliative Care about 5 questions Understand the difference between hospice and palliative care Palliative care - a philosophy of care that is in conjunction with traditional medical care with a focus on quality of life, function and decision making. Patients can be in curative therapy when on palliative care. Hospice - interdisciplinary care for terminally ill patients having less than 6 months to live and their families. Patients are no longer receiving curative therapy with medications and treatments focusing on quality of life and comfort at end of life. Can be delivered in the home, inpatient facility or hospital ("comfort care") **All hospice care is palliative care but not all palliative care is hospice care Nursing management of end of life symptoms discussed in class (think pain, anxiety etc.) Pain •Effective pain control •Frequent assessment •Medication route •Opioids and increased regardless of respiratory rate and effort. •Scheduled and prn dosing •Treat constipation Dyspnea - uncomfortable awareness of breathing •assessment •oxygen therapy •nebulizer treatments •opioids •Anxiolytics (Ativan) •Environmental factors - ceiling fan, positioning Anxiety - often accompanies pain and dyspnea •anxiolytics, generally Ativan •therapeutic communication •environmental controls Agitation - "terminal agitation" •often most distressing for families and patients. •haloperidol (Haldol) or chlorpromazine (Thorazine) in severe cases. •Maintain patient safety Nutrition •Loss of appetite •Appetite stimulants •Patient preferences •EOL body unable to process food Hydration •May lose desire for fluid •Mouth care •Ice chips •IV fluids has risks •Do not force food or fluids •Daily medications for comorbidities may stop •Allow patient to eat and drink without restriction •Always inform patient of care regardless of LOC •Patient education •Family education Nursing care of the patient at end of life (think non pharmacological measures) •Symptom management through pharmacological and non-pharmacological measures •Turning and repositioning for comfort and secretions management •Mouth care •Eye care •Incontinence care •Skin care Communication: •Setting •Level of comfort •Promote patient autonomy •Patience, empathy and honesty •Patient and family barriers •Uninterrupted time •Interdisciplinary team approach •Provide time to process information •Provide support Hematology About 6 questions Nursing management and patient education of patient with thrombocytopenia Thrombocytopenia: decrease in the circulating platelets below 100,000mm3 A normal platelet count ranges from 150,000 to 450,000 Pt picture: •Assess for bleeding: WHERE? •Petechiae •Purpura •Stool, urine, excreta •Menstrual bleeding •Eyes, ears, and nose •Change in level of consciousness: what could this represent? •Other concerning s/s? Nursing Management: Assess •Lab values •Medications •Urine, stool, emesis •Thorough skin assessment •Thorough mental status assessment •Thorough pain assessment Implement Bleeding Precautions •Minimize sticks •Consider manual BP cuff •Avoid invasive procedures: examples? we don't want indwelling cath, anema, no sexual intercourse •Maintain a safe environment •Minimize use of razors, stiff toothbrushes, tourniquets •Provide foot protection •Implement falls precautions Administer •Stool softeners •Saline nasal spray •Aminocaproic acid-- helps decrease bleeding •Thrombin •Progestin for menstruating females •Hemostatic dressings as needed Administer •Platelet transfusions as ordered •Plasma, cryoprecipitate, factor, and desmopressin as ordered Patient Education: •Maintain safety •Minimize risk for injury •Avoid razors, flossing, firm toothbrushes •If you see something, say something (to your care team!) Nursing management and patient education of patients with anemia Anemia defined: •Males: Hgb less than 13g/dl; Hct less than 42% •Females: Hgb less than 12g/dl; Hct less than 36% Normal range: Hgb: For men, 13.5 to 17.5 grams per deciliter. For women, 12.0 to 15.5 grams per deciliter. Hct: Normal levels of hematocrit for men range from 41% to 50%. Normal level for women is 36% to 48%. Pt picture: •Fatigue •Dyspnea •Heart rate high •Dizziness/headaches •Chest pain •Irritability •Cold intolerance •Pallor Nursing Management: •Conserve energy •Cluster nursing care •Monitor lab values •Ensure informed consent for blood transfusions •Promote comfort •Monitor orthostatic BP's Administer as ordered: •Blood transfusions •Erythropoietin •Iron supplements--- SE is constipation so give stool softener & laxatives Patient Education: •Take frequent breaks, manage activities appropriately •Dress in layers to promote comfort •Maintain a healthy diet with iron-rich foods: examples? --- Spinach, tofu, sprouting broccoli, dark chocolate, dried apricot, pumpkin seed, lentil, molasses, quinoa •If taking iron supplements, manage side effects •If blood transfusions are given, process may take hours •Inform nursing staff of any s/s of hypersensitivity •Similar instructions for iron infusions Definition of neutropenia the presence of abnormally few neutrophils in the blood, leading to increased susceptibility to infection. It is an undesirable side effect of some cancer treatments. Defined: ANC (absolute neutrophil count) less than 1000/mm3 Pt picture: •Flu-like sx •Chills •Myalgia •Malaise •Fatigue Nursing management and patient education of neutropenic patients Nursing Management: Thoroughly assess: •Lung sounds •Oral cavity •Abdominal tenderness •Mental status •Perineum •Skin (including nails/nailbeds) •Monitor vital signs frequently •Assess for fever of 100.5 F or higher •Also assess for subnormal te