NUR 280 Comprehensive Review (comp 1, comp 2, comp 3)
1. Cane- place on strong side, move with weak
Hand grip level at client’s greater trochanter
Elbows flexed at 15 to 30 degrees
Hold 4-6 inches from the side of the foot
Hold in the unaffected side and move together with the weaker side
a. Inspect the cane tips regularly for worn rubber
b. For client with 1 upper extremity, hemicanes or quadripod canes are
used
c. For walker, instruct client to put all 4 points of the walker on the floow
before putting weight on the hand pieces. Move the walker forward,
followed by the weaker foot and then the unaffected foot.
2. Tumor lysis syndrome- hyperkalemia; cloudy urine
a. Potassium and uric acid are released faster than the body can
eliminate
b. Hyperkalemia, Hyperphosphatemia, Hypocalcemia, and hyperuricemia
(leading to AKI)
c. Encourage oral hydration; IV rehydration may be prescribed; Monitor
renal function; I&O;
d. Renal diet – low in potassium; NO (banana, cantaloupe, avocado,
potato, spinach, orange, raisins, salmon, beans) and low in phosphate;
NO (dairy foods, beans, nuts, lentils, cola, oatmeal, bran, and some
bottled iced tea)
e. Low purine diet (spinach, seafood and shellfish, asparagus, sardines,
anchovies, tuna, mussels, red meat, duck, alcoholic drinks, preserved
meats (cold cuts), organ meats, sugar sweetened foods, and limit
consumption of naturally sweet fruit juices.
f. Good choices (fresh fruits and vegetables with the exception of the
above items, rice milk-unenriched, bread, pasta, rice, fish (except
salmon), corn and rice cereals
g. Diuretics as prescribed (HTCZ – releases K+ but holds Ca+) to increase
urine flow to the kidneys
h. Allopurinol to increase secretion of purines (increase water intake)
i. Insulin and glucose (for severe hyperkalemia)
3. Retinal detachment-dark floating spots (pay attention to the eye
they are asking)
a. Assessment: flashes of light, floaters or dark spots(sign of bleeding),
incre - asing blurred vision, sense of curtain drawn over the eye, loss of
portion of the visual field, painless loss of central or peripheral vision.
b. Intervention: Provide bed rest, cover both eyes with patches as
prescribed to prevent further detachment, speak to the client before
, approaching, position the clients head as prescribed, protect the client
from injury, avoid jerky head movements, minimize eye stress, prepare
client for surgical procedures
c. Postoperative: maintain eye patches as prescribed, monitor for
hemorrhage, prevent N/V and monitor for restlessness, can cause
hemorrhaging, monitor for Sudden sharp eye pain (notify HCP),
encourage deep breathing but avoid coughing, provide bed rest,
position as prescribed (depending on the location of the detachment),
administer eye medication as prescribed, assist client with ADLs, avoid
sudden movements or anything that increases IOP, limit reading for 3
to 5 weeks, avoid squinting, straining, and constipation, lifting heavy
objects, and bending from the waist, wear dark glasses during the day,
and patches during the night, encourage follow-up because it may
occur in the other eye.
4. Chest tube- bad if drainage is >100ml/hr
a. Gentle bubbling in the suction chamber
b. Water seal chamber tidaling is normal during inspiration and
expiration, small bubbling but not continuous
c. Needs to be placed lower than the patient
d. Occlusive sterile dressing at the insertion site
e. Do not strip or milk tubing unless instructed by HCP
f. Have a clamp and occlusive dressing at the bedside at all times
g. Encourage coughing and deep breathing
h. Never clamp tubes without HCP prescription
i. If drainage system cracks or break, place tube on sterile water, then
replace with new system
j. When removing tube instruct client to deep breath and hold it, or take
a deep breath and bear down (valsalva maneuver). Dry sterile or
petroleum gauze dressing is taped.
k. If the chest tube is pulled out, pinch the skin opening together (close
it), then apply an occlusive dressing then taped with overlapping
pieces of 2 inch tape and notify HCP.
5. Diverticulosis- high fiber diet/ Diverticulitis- low fiber diet
a. Outpouching or herniation occurring commonly in the sigmoid colon
b. Watch for rigid board like abdomen, rebound tenderness, guarding of
abdomen, increasing temp and chills, pallor, restlessness, tachycardia,
and tachypnea (Peritonitis)
c. Assesment: N/V, left lower quadrant pain that increases with coughing,
straining or lifting, elevated temp, flatulence, cramplike pain, blood in
stools, palpable tender rectal mass
d. Interventions: During acute phase – bed rest, maintain NPO or provide
clear liquids as prescribed. Introduce fiber containing diet gradually
when inflammation has resolved. Administer antibiotics, analgesics,
and anticholinergics to reduce bowel spasm as prescribed. Instruct
client to refrain from lifting, straining, coughing, bending that increases
intra-abdominal pressure.
6. 70/30- 70 NPH/30 regular insulin
a. When mixing NPH and regular
i. Roll NPH gently (do not shake)
1. Cane- place on strong side, move with weak
Hand grip level at client’s greater trochanter
Elbows flexed at 15 to 30 degrees
Hold 4-6 inches from the side of the foot
Hold in the unaffected side and move together with the weaker side
a. Inspect the cane tips regularly for worn rubber
b. For client with 1 upper extremity, hemicanes or quadripod canes are
used
c. For walker, instruct client to put all 4 points of the walker on the floow
before putting weight on the hand pieces. Move the walker forward,
followed by the weaker foot and then the unaffected foot.
2. Tumor lysis syndrome- hyperkalemia; cloudy urine
a. Potassium and uric acid are released faster than the body can
eliminate
b. Hyperkalemia, Hyperphosphatemia, Hypocalcemia, and hyperuricemia
(leading to AKI)
c. Encourage oral hydration; IV rehydration may be prescribed; Monitor
renal function; I&O;
d. Renal diet – low in potassium; NO (banana, cantaloupe, avocado,
potato, spinach, orange, raisins, salmon, beans) and low in phosphate;
NO (dairy foods, beans, nuts, lentils, cola, oatmeal, bran, and some
bottled iced tea)
e. Low purine diet (spinach, seafood and shellfish, asparagus, sardines,
anchovies, tuna, mussels, red meat, duck, alcoholic drinks, preserved
meats (cold cuts), organ meats, sugar sweetened foods, and limit
consumption of naturally sweet fruit juices.
f. Good choices (fresh fruits and vegetables with the exception of the
above items, rice milk-unenriched, bread, pasta, rice, fish (except
salmon), corn and rice cereals
g. Diuretics as prescribed (HTCZ – releases K+ but holds Ca+) to increase
urine flow to the kidneys
h. Allopurinol to increase secretion of purines (increase water intake)
i. Insulin and glucose (for severe hyperkalemia)
3. Retinal detachment-dark floating spots (pay attention to the eye
they are asking)
a. Assessment: flashes of light, floaters or dark spots(sign of bleeding),
incre - asing blurred vision, sense of curtain drawn over the eye, loss of
portion of the visual field, painless loss of central or peripheral vision.
b. Intervention: Provide bed rest, cover both eyes with patches as
prescribed to prevent further detachment, speak to the client before
, approaching, position the clients head as prescribed, protect the client
from injury, avoid jerky head movements, minimize eye stress, prepare
client for surgical procedures
c. Postoperative: maintain eye patches as prescribed, monitor for
hemorrhage, prevent N/V and monitor for restlessness, can cause
hemorrhaging, monitor for Sudden sharp eye pain (notify HCP),
encourage deep breathing but avoid coughing, provide bed rest,
position as prescribed (depending on the location of the detachment),
administer eye medication as prescribed, assist client with ADLs, avoid
sudden movements or anything that increases IOP, limit reading for 3
to 5 weeks, avoid squinting, straining, and constipation, lifting heavy
objects, and bending from the waist, wear dark glasses during the day,
and patches during the night, encourage follow-up because it may
occur in the other eye.
4. Chest tube- bad if drainage is >100ml/hr
a. Gentle bubbling in the suction chamber
b. Water seal chamber tidaling is normal during inspiration and
expiration, small bubbling but not continuous
c. Needs to be placed lower than the patient
d. Occlusive sterile dressing at the insertion site
e. Do not strip or milk tubing unless instructed by HCP
f. Have a clamp and occlusive dressing at the bedside at all times
g. Encourage coughing and deep breathing
h. Never clamp tubes without HCP prescription
i. If drainage system cracks or break, place tube on sterile water, then
replace with new system
j. When removing tube instruct client to deep breath and hold it, or take
a deep breath and bear down (valsalva maneuver). Dry sterile or
petroleum gauze dressing is taped.
k. If the chest tube is pulled out, pinch the skin opening together (close
it), then apply an occlusive dressing then taped with overlapping
pieces of 2 inch tape and notify HCP.
5. Diverticulosis- high fiber diet/ Diverticulitis- low fiber diet
a. Outpouching or herniation occurring commonly in the sigmoid colon
b. Watch for rigid board like abdomen, rebound tenderness, guarding of
abdomen, increasing temp and chills, pallor, restlessness, tachycardia,
and tachypnea (Peritonitis)
c. Assesment: N/V, left lower quadrant pain that increases with coughing,
straining or lifting, elevated temp, flatulence, cramplike pain, blood in
stools, palpable tender rectal mass
d. Interventions: During acute phase – bed rest, maintain NPO or provide
clear liquids as prescribed. Introduce fiber containing diet gradually
when inflammation has resolved. Administer antibiotics, analgesics,
and anticholinergics to reduce bowel spasm as prescribed. Instruct
client to refrain from lifting, straining, coughing, bending that increases
intra-abdominal pressure.
6. 70/30- 70 NPH/30 regular insulin
a. When mixing NPH and regular
i. Roll NPH gently (do not shake)
