NURSING4060 MED- SURG FINAL EXAM STUDY GUIDE.

NURSING4060 MED- SURG FINAL EXAM STUDY GUIDE.  Med Math  NG tube – Placement and verification  Review the prescription & purpose of the procedure, understand the need for placement. Identify client, explain the procedure.  Review history of nasal problems, anticoagulants, previous trauma, & past history of aspiration.  Evaluate the clients ability to cooperate & make a hand signal w/ the client.  Perform hand hygiene, tape or use commercial fixation device to secure the dressing.  Use clean gloves, water soluble lube, topical anesthetic, cup of water & straw, catheter & syringe (30-60 mL), basin, pH strip (4), clamp or plug to close the tubing after insertion.  Steps: ATI i. Auscultate bowel sounds, palpate abdomen for distention, pain & rigidity. ii. Raise head of bed (high fowlers if possible). iii. Assess nares, look for deviation/obstruction. iv. Measure tube from tip of the nose to the earlobe, down to the xiphoid process. v. Give client water & when they swallow continue to insert tubbing. 1. If client vomits clear the airway & provide comfort before continuing care. vi. Check for placement w/ pH strip (4) & assess color, odor, consistency & amount. vii. Verify placement w/ X-RAY. 1. If the tube is not in the stomach, advance it 5 cm (2 in.) & repeat placement check. 2 MED- SURG FINAL EXAM STUDY GUIDE  Wound Evisceration – Nursing actions – what to do if you see evisceration?  Call for help, ask the surgeon to be notified & that needed supplies be brought to the room of the client.  Stay with the client.  While waiting for supplies, place the client in low fowlers w/ the knees bent.  Cover the wound with sterile wet normal saline dressing & keep the dressing moist. Do not attempt to reinsert organs.  Take vital signs & monitor the client closely for signs of shock.  Prepare the client for surgery as necessary.  Document the occurrence, actions taken, and the clients response.  Preoperative teaching, informed consent  Preparing client for surgery: i. Assist the client to void before transfer to the operating room. ii. Check all surgeon's prescriptions to ensure they have been carried out. iii. Review the client's record for a history & physical report & laboratory reports  Informed consent: i. The surgeon is responsible for explaining the surgical procedure to the client & answering the clients questions. The nurse is responsible for obtaining the clients signature on the consent form & needs to make sure the client understood the surgeon’s explanation. ii. The nurse needs to document the witnessing of the signing of the consent form after the client acknowledges the procedure. The nurse must also document any questions the client has, reinforce teaching, get an interpreter. iii. Minors younger than 18 need a parent or legal guardian. Some older adult clients may need a legal guardian to sign consent. iv. Psychiatric clients have the right to refuse a treatment until the court has legally determined that they are unable to make a decision for themselves. v. You only need 2 nurses if you’re getting consent over the phone, when the patient is unable to give it themselves. vi. Two witnesses are required if the client is 1. Able to only sign with an “X” 2. Blind, deaf vii. English is a second language.  Nutrition- NPO status pre-op. Withhold solid foods & liquids as prescribed to avoid aspiration, 6-8 hr. for general anesthesia, & 3 hr. for local anesthesia (as prescribed). i. Verify NPO status: (to avoid aspiration) for at least: 1. 6 hr. for solid foods. 2. 2 hr. (clear liquids) before general anesthesia. 3. 3 to 4 hr. (clear liquids) before local anesthesia 4. Chart the last time the client ate/drank. 3 MED- SURG FINAL EXAM STUDY GUIDE  Insert IV line & administer IV fluids as prescribed. The IV catheter should be large enough to administer blood products if needed. (a large-bore 18-gauge catheter)  Obtaining a detailed health history: i. Diagnosed medical conditions (previous & current) ii. Allergies: Banana or Kiwi – indicative of latex allergy iii. Eggs/Soybean – Don’t give propofol iv. Shellfish & Seafood = No Iodine v. Previous surgeries & problems, medication use, substance abuse. Reactions/problems to anesthesia (patient/family) vi. Assess anxiety level & support systems. vii. Lab results. Venous Thromboembolism risk. Head to toe assessment, Vital signs, & O2 sat. Pregnancy status, Chronic diseases etc.  Client comfort – post surgery  Prioritization and delegation – read prioritization guide in ATI – to access – start quiz fundamentals 1 – click on tools – resources.  Who can transfer a client from OR to PACU? o Anesthesia provider (anesthesiologist or CRNA)  Circulating nurse gives the verbal “hand-of” report to PACU nurse.  Postoperative care is provided initially in the PACU by a ACLS certified RN.  Initial postoperative care: assessments, administering medications, managing client’s pain, preventing complications, & determining when a client is ready to be discharged from the PACU.  PRIORITIES During the immediate postoperative stage: o airway patency o ventilation o circulatory status 4 MED- SURG FINAL EXAM STUDY GUIDE  Vital Signs: Until stable (every 15 min) and assess for trends.  Atropine- Decrease risk of Bradycardia during surgery & at times vagal slowing of the heart due to parasympathetic response to surgical manipulation. Block Muscarinic response to acetylcholine by  salivation, bowel movement & GI secretions. Slow mobility of GI system. •  salivation, Pancreatic juices & gastric juices •  risk of aspiration • A/E: Mad as a hatter, dry as a bone, red as a bee, can’t shit, can’t spit, can’t pee. • Urinary retention • Tachycardia • Dry mouth • Decreased levodopa effects • Contraindicated w/ glaucoma & urinary problems.  Ostomy care – differentiate between normal & abnormal stoma & appropriate nursing actions in both 1. Ileostomy- surgical opening from ileum to drain stool. When the entire colon must be drained due to crohn’s disease or ulcerative colitis. 2. Colostomy- Surgical opening into the large intestine to drain stool. When a portion of the bowel must be removed (cancer, ischemic injury) or requires rest for healing (diverticulitis, trauma). a. Ascending colon- liquid stool b. Transverse colon- more formed stool c. Sigmoid colon- near normal stool o Assess appearance of stoma, appliance fit, skin integrity o Stoma should be pink & moist o Apply skin barriers/creams (adhesive paste), allow to dry & then attach the bag o Evaluate output, empty when ¼ to ½ full. o Monitor fluid & electrolyte balance. o Refer to support group. o Dietary changes to manage flatus and odor. o Avoid foods that cause odor: fish, eggs, asparagus, garlic, beans, green leafy veggies o Avoid foods that cause gas: beer, carbonated beverages, dairy, corn,  Buttermilk, cranberry juice, parsley & yogurt helps to lower odor. 5 MED- SURG FINAL EXAM STUDY GUIDE o Stoma ischemia/necrosis: pale pink/bluish purple & dry appearance, Serious impairment of blood flow & requires immediate intervention.  Obtain vitals, O2 sat, current lab results. Notify the providers of findings.  Teach client to watch out for ischemia. o Intestinal obstruction- monitor & record output from the stoma, assess for manifestations of obstruction including abdominal pain, hypoactive bowel sounds, distention, nausea, & vomiting. Notify the surgeon  Client teachings in Crohns disease  Chronic relapsing disease that can develop discontinuously in any segment of the alimentary tract. Most common sites are terminal ileum & colon.  Involves all the bowel layers. Periods of remission & exacerbation. Fistula formation are common. Malabsorption & malnutrition can occur if ulcerations involve the small intestine.  Vitamin B12 deficiency – May need Vitamin B12 spray.  Each time episode of inflammation occurs – leads to scarring of intestine.  S/S: anemia (vitamin B-12 deficiency).  Risk factors: smoking & stress.  Educate pt. on s/s of bowel obstruction/perforation & to seek medical attention  Small, frequent meals, High calories, High protein, low fiber, low fat, lactosefree.  Identify trigger foods.  Avoid caffeine & alcohol  Monitor for electrolyte imbalances & dehydration.  If extreme exacerbation = NPO & TPN may be necessary to promote bowel rest + adequate nutrition.  Client comfort – pain management in phantom limbs – use of analgesics for phantom pain.  Frequent complication of amputation, client complains of pain at the site of the removed body part, most often shortly after surgery.  Pain is intense burning feeling, crushing sensation or cramping.