Pass Nclex Study Guide

PASS NCLEX STUDY GUIDE Realize that you must answer all questions in relation to what’s safe for the patient Realize that preventing the spread of disease is top priority CADIOVASCULAR Realize the following in regards to a plasma cholesterol screening (measures the amount of cholesterol that one has): • Realize that only sips of water are permitted for 12 hours before plasma cholesterol screening to achieve accurate results Realize that after the application of a cast on the arm, the arm should be elevated to minimize swelling; it should be elevated for the first 24 – 48 hours; it should be protected from pressure and flattening of the cast Realize that a Tredelenburg test is used with a client who may have varicose veins Realize that a heartburn that radiates to the jaw indicates chest pain Realize that when a patient is receiving thrombolytic therapy, IM injections may cause bleeding. Realize that roasted chicken have low cholesterol Realize that if the pulse increases, it indicates that the tissues are not being perfuse correctly Realize that the normal RBC in males is 4.3 – 5.9 million/mm3; females 3.5 – 5.5 million Realize that a low platelet count will give problems with no blood clotting, allowing blood to infuse joints, putting client at risk for injury Realize that the most common cause of mitral valve problems is a history of rheumatic fever with a subsequent complication of carditis, which affects the valve Realize that the BP should always be taken on the opposite arm from the graft Realize that a normal range for CVP is 3 – 12 cm water pressure; a reading of 8 cm indicates a desired response to fluid replacement, avoiding a hypovolemic state • Realize that a CVP readings measures the pressure in the right atrium • Realize that a Swan-Ganz catheter measures the pulmonary artery wedge pressure, which is an indirect reading of the pressure in the left ventricle • Realize that a pulmonary artery catheter is a multi-lumen apparatus that allows for the following measurements: o Pulmonary artery pressures o Myocardial filling pressures o Cardiac output o Pulmonary resistance o Systemic resistance o Cardiac index – the cardiac output divided by the body surface area Realize that a nitroglycerine patch should be removed before an MRI test Realize that Buerger’s disease (thromboangiitis obliterans) is a vascular occlusive disease of the extremities causing a decreased blood flow to the feet and legs • Nurse must check for ulcers formation and gangrene • Results in thrombus • Seen in men 20 – 35 year old • Smoking is a causative factor • Pain at rest and coldness is a major system • Pain control is a goal of treatment • Fluids are not restricted • Goal of medical management is to prevent progression of disease Realize that the keep-open rate is the lowest possible infusion rate; this rate should not be allowed for a patient with sickle cell, as they need more hydration • Realize that a child with sickle cell should not be given aspirin because of bleeding tendencies • Realize that the keep-vein-open (KVO) rate is (20 mL/h); this rate will keep access open • Realize that you just keep sickle cell clients away from people with infections Realize that postoperative open heart clients should be encourage to be out of bed and ambulating as soon as possible, frequently one or two days after surgery Realize that elderly patient usually have lower temperature due to a lower basic metabolic rate • Realize that an elderly client is usually intolerant to cold Realize that recognition of adult hypertension should be done after two readings taken at least five minutes apart Realize the following about a sequential compression device (SCD) • Apply antiembolism stocking prior to applying the sequential compression device sleeves o Realize that stocking should be worn the entire time that client is in the hospital; it should be removed before baths and replaced after the skin is dry and before the client gets out of bed (non-ambulatory) o Realize that stocking is worn to prevent discomfort and to increase blood flow • Realize that you need to be able to fit two fingers between the sleeve and the leg • Realize that the SCD is used to decrease venous stasis and reduce the risk of thrombus formation Realize that if a patient has obese leg and thighs, it is not good to put elastic stocking on because it may decrease venous return because of constriction around the thigh and legs Realize that talcum powder is a toilet powder composed of perfumed; if a nurse applies it to a client’s feet, it allow easier applications of the stocking Realize that elevating the client legs before applying the stocking prevent stagnation of blood in the lower extremities Realize that when you apply the stocking, make sure that there are not wrinkles because they can cause irritation to the skin Realize the following about DVT: • Realize that a patient with DVT should not be ambulating; patient should be on bedrest for 5 – 7 days to prevent pulmonary embolisms and legs should be elevated with warm moist packs • Realize that the affected calf is expected to be warm • Realize that extremity edema is expected because of venous congestion • Realize that client needs to be given anticoagulants Realize the following about IV sites: • Realize that if tenderness and redness at the IV insertion site is noted, the IV catheter should be removed to prevent further damage to the vein; and warm soaks should be applied to decrease inflammation, swelling and discomfort o Realize that reddened area with red streaks is indicative of phlebitis • Realize that IV that are infiltrated should be discontinued and restarted at a new site; elevating the extremity may increase the rate of reabsorption of the fluid • Realize that unused solution are always discarded; site of catheter changed every 4 weeks, change IV tubing and filers every 24 hours • Realize that a marking pen should not be used on an IV bag; ink can penetrate the plastic and get into the solution; labeling should be done on the bag label using a regular pen • Realize that hypertonic dextrose solution similar to TPN is used to wean patient off TPN • Realize that extravasation is when a vesicant has filtrated; realize that a vesicant is a medication or IV solution that causes blisters and tissue sloughing (burning) o Realize that the following are medications that can cause a burn if infiltrated: gentatmicin, penicillin, vancomycin, dilantin, any antineoplastic, calcium, potassium and epinephrine o Realize that all infiltrations needs cool compresses except for vancomycin, which needs warm compresses • Realize that if a hematoma occurs, cool compresses are needed. Realize that whenever bleeding is suspected, cool compresses is best to constrict vessels to slow down or stop the bleeding • Realize that if IV line is clotted, it is best to just pull it and not use it; sometimes you can just dissolve the clot but this is not always recommended • Realize that with a CVP, after administration of medication, flush with saline and then a heparinized solution afterwards; flush every 12 hours or after medication administration • Realize that it is smart to limit manipulation of the cannula at the IV insertion site to prevent dislodgement • Realize that IV sites should not be close to joints because movements could cause displacement Realize that the correct sequence for cardiac assessment is inspection, palpation and then auscultation Realize that polyarteritis nodosa is inflammation of the small arteries causing diminished blood Realize that these forms of vagal or Valsalva maneuvers can reverse SVT: • Having a child stick their thumb in the mouth, close it and the blow Realize that if a patient is undergoing a septic shock and there is blood at the venipuncture site around an IV catheter, this is an indicator of dissememinated intravascular coagulation (DIC), a life-threatening problem. • Realize that sepsis is the most frequent cause of DIC • Realize that the reason there maybe blood around the venipuncture site is that the septic shock causes an increase in capillary permeability • Realize that DIC is an acquired clotting disorder from overstimulation; prolonged oozing from sites of minor trauma first symptom • Realize that disseminated intravascular coagulation (DIC) is the hyperstimulation of coagulation pathways that eventually fails, resulting in bleeding o Realize that disseminated intravascular coagulation (DIC) is not a disease, but a sign of an underlying condition o Realize that disseminated intravascular coagulation (DIC) maybe triggered by (1) sepsis, (2) trauma, (3) cancer, (4) shock, (5) abruption placentae, (6) toxins or (7) allergic reactions o Realize that in DIC, (1) the PT and PTT are prolonged and (2) the platelet count are reduced o Realize that the laboratory test that are specific for DIC are fibrin-split product (FSP)/fibrin degradation product (FDP)  Realize that FDP is a group of soluble protein fragments that are produced by the proteolytic action of plasmin on fibrin or fibrinogen o Realize that clients with DIC should have oral swabs used in administering their oral care because it has the least potential cause of tissue injury in the oral cavity o Realize that clients with DIC should be protected from injury that will result in bleeding o Realize that patients with DIC may bleed from (1) mucous membrane, (2) veni-puncture sites and (3) the GI and urinary tract o Realize that during the initial process of DIC, the patients may have no new symptoms o Realize that the diagnosis of DIC is often established by (1) a drop in platelet count, (2) an increase in PT and aPTT, (3) an elevation in fibrin degradation product and (4) measurement of one or more clotting factor Realize that client diagnosed with anemia needs a diet high in protein, iron and vitamins Realize that the following foods have iron: • Beef • Brown rice • Raisins • Green beans • Carrots • Oatmeal-raisin Realize that hypothermia causes vasoconstriction and hypertension • Realize that hypothermia causes myocardial irritability, which disrupts conduction system of the heart and causes the heart to be near the fibrillation threshold, especially ventricular fibrillation • Realize that the external re-warming technique can cause re-warming shock and temperature afterdrop, which can lead to ventricular fibrillation Realize that during a paracentesis, shock may occur so a blood pressure cuff needs to be left on for monitoring • Realize that the following are complications of paracentesis: abdominal pain, rigidity and distention, nausea and vomiting • Realize that the nurse should make sure that the client voids just before a paracentesis to prevent a puncture of the bladder Realize that heat can facilitate hypotension Realize that isometric exercises such as heavy weight-lifting and rowing are contraindication in a hypertensive client Realize that a patient with a constant nose bleed needs to be told to pinch nose for 5 – 10 minutes with an ice-cold washcloth • Realize that silver nitrate applicator and gelfoam may be required to stop bleeding Realize that elevated blood glucose levels places a person at risk for heart disease Realize that defibrillation should be set to 200 joules, then 200 – 300 joules, and then 360 joules; these are emergency treatment for ventricular fibrillation; completely depolarizes myocardial cells so SA nodes can reestablish as pacemaker Realize that cardio-version is the restoration of normal sinus rhythm by chemical or electrical means • Realize that a sedative/hypnotic is used for sedation for the procedure • Realize that digitalis must be withheld for 48 hours before procedure to prevent ventricular fibrillation after cardioversion Realize that the sync button on the defibrillator is used for cardio-version to treat the following: • Atrial flutter • Atrial fibrillation • Supraventricular tachycardial synchronizes shock with R wave • Realize that it is important not to touch the bed when using the defibrillator; it is a priority to prevent accidental countershock Realize that following a total knee replacement, surgery may interrupt blood supply to the affect extremity • Realize that checking the incisional bleeding and recording the drainage is done every 4 hours Realize that after a heart attack, a male client can resume sexual activity when he can tolerate the physical activity of climbing two flights or stairs or walking one block without SOB or chest pain; patient should maintain a supine position and not have intercourse after a heavy meal Realize that a low fat and low cholesterol diet is recommended for a patient with hypertension; fried foods should be avoided; baking, roasting, boiling, or broiling are the only appropriate way of cooking for client with hypertension Realize that a patient with arteriosclerotic heart disease (ASHD) requires a diet that is low fat and low sodium. • Realize that baked chicken without the skin is low in fat and sodium • Realize that green vegetables low in fat and sodium • Realize that hotdogs and canned soup are high in sodium • Avocado is high in fat • Realize that ham is high in sodium • Realize that scrambled eggs, orange slices and milk have low sodium Realize that the following are risk factors of CVA: being black, being a male, substance abuse (cocaine especially), smoking, heavy alcohol use, diabetes, obesity, heart murmur, oral contraceptive use, sedentary lifestyle (job), migraines, history of myocardial infarction, elevated cholesterol Realize the following in regards to a migraine: • May have throbbing headache • May take ergotamines at the start of the migraine Realize that when a vascular sound or bruit (a swooshing sound) is heard over the abdominal aorta, it most often indicates aneurysm is present; physician should be notified immediately Realize that it is mandatory to check the pedal pulses after a cardiac catheterization immediately after the procedure and repeat it every 15 minutes for several hours to detect changes in circulation Realize that an appropriate diet for a client with hypertension is whole grains, and fresh fruits and vegatables Realize that sitting on the side of the bed enhances arterial supply of the leg Realize that elevating the leg does not increase circulation, it only promotes venous return Realize the following about Raynaud Syndrome: • Realize that yoga can decrease stress that can cause vasospasms; helps increase circulation • It is best to keep warm • Realize that the color of the finger changes from white to blue to red and is accompanied by tingling, numbness and burning pain Realize that many medications which are ordered as IV push or bolus need to be given slowly over several minutes; with the usage of a watch Realize that a nurse should expect that the emotional response of a client with a CVA of the left hemisphere to be most influenced by his/her personality and general health prior to the CVA Realize that clients with CVA will need the following nursing care: • The prevention of flexion of the affected extremities • Maintain adduction of the affected shoulder to prevent deformities • Client will be unable to perform active ROM, will need assistance from nurse • The nurse will need to prevent external rotation of the hip joint, prevent foot drop (plantar flexion) and place the hand in slight supination so that the fingers are barely flexed… all to prevent deformities Realize that the left hemisphere of the brain controls speech, math skills analytical thinking Realize that impulsive behavior is seen with right hemisphere CVA • Realize that a patient diagnosed with a CVA on the right hemisphere are often disoriented to time, place, person; has visual spatial defects; has proprioceptive (posture) difficulties, impulsive behavior, poor judgement, decreased attention span, lack of awareness or denial of neurological deficits increase risk of injury • Determine if client needs assistance with eating as difficulty in eating causes severe anxiety in CVA clients • Assist client in ambulating • Realize that you must speak to client using phrases and short sentences, as it will decrease tension and anxiety; client may understand some of the incoming communication if it is kept simple; speech may be re-learned with appropriate support and interventions Realize that disorientation to person, place and time is also seen with right hemisphere CVA Realize that the following may occur from a CVA: • Impaired motor skills • Lack of coordination • Mood change Realize the following about autologous blood donation: • Realize that the donor may give own blood up to 5 weeks before surgery • Realize that the donor will have to begin oral iron supplements, at least before the first transfusion • Realize that the donor can give 2 – 4 units of blood Realize the following in regards to blood transfusion: • Realize that a hemolytic reaction to blood transfusion may be a lower backache, hypotension, fever, vomiting, nausea, hematuria; transfusion must be stopped • Realize that a febrile reaction to blood transfusion is a fever, chills, nausea, headache; treatment is the stop blood and administer aspirin • Realize that an allergic reaction to blood transfusion is urticara (hives), pruritus, fever, wheezing, facial flushing, epiglottal edema ; treatment is to stop blood, give benadryl and administer oxygen • Realize that a circulatory overload to blood transfusion, the transfusion needs to stop, position client upright and administer oxygen Realize that normal serum albumin is 3.5 – 5.5 g/dL; albumin deficit decreases oncotic pressure and fluids shifts form vascular area to tissue • Realize that the albumin levels are the best indicators of long-term nutritional status Realize that a patient has an extremely low hemoglobin level; the nurse should do the following: • Provide oxygen • Draw a type and cross for 2 units packed red blood cells • Start IV • Place on cardiac monitor Realize that palpating the carotid pulses together can cause a vagal response and slow the client’s heart rate; it is a no no. Realize the following from right-sided heart failure: • Dependent edema, liver enlargement, congestion of the venous system resulting in peripheral edema, congestion of the gastric veins resulting in anorexia and eventual development of ascites enlargement of abdominal girth, anorexia, nausea, bloating, anxiety, fear, distended jugular vein, weight gain and depression • Realize that cor pulmonale is the hypertrophy or failure of the right ventricle resulting from disorders of the lungs, pulmonary vessels, chest walls or respiratory control center Realize that issues with left sided heart failure take priority over right sided-heart failure issues Realize the following from left sided heart failure: • Dyspnea, S3, dry non-productive cough • Realize that an S3 ventricular gallop is the earliest sign of heart failure Realize that pain in the chest after coughing indicate irritation of the parietal pleura or pericarditis Realize the following in regards to warfarin (Coumadin): • Warfarin (Coumadin) last for 2 – 5 days Realize the following about heparin: • Realize that heparin is an anticoagulant; lower limits of normal 20 – 25 seconds; upper limits of normal 32 – 39 second; therapeutic level is 1.5 – 2.5 times control • Realize that if the time is way over the time, protamine sulfate is needed (used to neutralize the anticoagulant action of heparin) • Realize that the time represents the time it takes for clotting • Realize that if a breast feeding client is receiving heparin, she will still be able to breastfeed; realize that heparin is not transmitted in breast milk Realize that the normal range of PT is 11-16 seconds and an INR of 0.8-1.2, meaning 80% to 120% range. Ideal INR is 100% or 1 • Realize that the lower the INR from 1, the quicker the blood clots. • Realize that the higher the INR from 1, the longer it takes for the blood to clot. • Realize that for people taking warafin, the normal INR is 2-3 range because their blood clots to easily. Realize that it is good to ensure accurate blood pressure cuffs to increase the accuracy of blood pressure readings Realize that patient with peripheral vascular disease (PVD), should sit with their feet flat on the floor or comparable surface and avoid crossing legs or wearing constrictive clothing • Realize that a moderate amount of walk promotes blood flow and the development of collateral circulation Realize that hearing aid battery may affect placement of permanent pacemaker • Realize that shortness of breath and dizziness is a symptom of decreased cardiac output with a pacemaker battery failure • Realize that a patient that is discharged with a pacemaker should be told to take their pulse everyday because a change in heart rate can signal a malfunction of the pacemaker; instruct client to take pulse for 1 full minute at the same time each day and record • Realize that anytime the pulse rate drops below the present rate on a pacemaker, the pacemaker is malfunctioning; realize that the pulse should be maintained at the minimal rate set on the pacemaker • Realize that the primary purpose of a pacemaker is increased cardiac output Realize the following in regards to a heat stroke: • Realize that anhydrosis (absence of sweating or diaphoresis) is usually present in heat stroke, so skin is hot and dry • Temperature is 105oF or above • May cause bizarre behavior, confusion, deliriousness or comatose • May cause hypotension • Realize that a headache may be the initial symptoms of hyperthermia Realize that when walking, if a client legs throbs, it may be indicative of a form of peripheral vascular disease Realize that fatigue is a useful guide in gauging activity tolerance in patient with decrease cardiac output; cardiomyopathy is subacute or chronic enlargement of heart Realize that with hemophilia, the most frequent site of bleeding are into muscles and joints; repeated bleeding episodes causes change in bone and muscles • Realize that it is a common misconception that one with hemophilia just constantly bleeds all the time; one needs to incur trauma first before bleeding can be an issue Realize the following in regards to platelet transfusion: • Realize that the standard transfusion sets are not used for platelet administration because the filter traps the platelets, and also there is an increased adherence of platelets to the lumen of the longer tubing; an administration set particularly designed for platelet must be used; it has a smaller filter and shorter tubing Realize that if a patient hematocrit increases by more than 4% in a span of two weeks, the likelihood of hypertension and seizure increases; thus the physician should be called to decrease dose of epoetin alpha (procrit) • Realize that epoetin alpha (procrit) may cause flu-like symptoms in the beginning of therapy and the following side effects: o Arthralgias (pain in joint), nausea, edema, reaction at injection site Realize the following in regards to CVC insertion: • Realize that the patient should not breath deep during insertion; patient should be instructed to perform valsalva maneuver to prevent air embolism • Realize that insertion occurs at the right side of the body, usually through the subclavian into the superior vena cava; turning the head away from the site makes the site more accessible and prevents contamination from airborne pathogens • Realize that if skin needs to be shaved, do it the night before to allow partial healing of minor skin irritations • Realize that patient will be placed in the Trendelenburg position to dilate veins and decrease risk of embolism Realize that the widening pulse pressure and bradycardia is a cardiac problem Realize that all processed foods have sodium Realize that abdominal pain is not associated with an MI Realize that ventricular dysthythmia is common after an MI Realize the following in regards to a myocardial infarction: • May have chest pain radiating to arms, jaw, and neck • Dyspnea • Indigestion • Apprehension • Low grade fever • Elevated WBC, ESR, CK-MB, LDH • Realize that the most common complication following a myocardial infarction is dysrhythmia, with ventricular types being the most serious Realize that a temporary pacemaker is an electronic device that is used for temporary cardiac pacing; in second degree blocks, only some of the impulses from the atria are conducted to ventricles; 2:1 or 3:1 Realize that after a coronary artery bypass graft (CABG), the client may see some swelling in the leg used for the donor graft; edema increases at home because the client is usually more active Realize that if during a PICC line removal that a piece of the catheter breaks off, a tourniquet needs to be tied to the upper arm to prevent the piece from moving into the right atrium Realize that morphine will do the following: • Decrease blood return to the right side of the heart (decrease preload and after-load pressure and cardiac workload) • Decrease peripheral resistance (causes vasodilation and pool of fluid in extremities) • Provides relief from anxiety • Realize that morphine would be administered prior to giving a client oxygen because it will decrease the heart’s oxygen consumption • Realize that morphine causes respiratory depression • Realize that morphine is contraindicated in head injury because it masks signs of increased intracranial pressure Realize that garlic capsules can be taken for hypertension Realize that nausea and being diaphoretic are potential signs for an MI Realize the following in regards to ambulatory electrocardiography: • Do not bathe or take shower during monitoring; sponge bath is fine • Client should record event in daily log • Realize that there is no reason to change a diet Realize that placing a client in the Trendelenbury position does not have full evidence that it increases oxygen perfusion to the brain… it is an unsubstantiated, but a common practice (don’t choose as an answer on the NCLEX) GI Realize that a Miller-Abbott tube is a tube that is used to relieve intestinal obstruction; it is inserted through a nostril; the tube is passed through the stomach and into the small intestine • Realize that intestinal tubes are often used for treatment of paralytic ileus Realize that women need 1,200 – 1,500 kcal/day; men need 1,500 – 1,800 kcal/day); women need 15 mg/day of iron; men need 10 mg/day of iron; pregnant women need 30 mg/day required Realize that there is an increase change of growth of organism after 4 hours with a formula bag for tube feedings… it should be changed every 4 hours Realize that legumes are an economical source rich in proteins Realize that oral hygiene with hydrogen peroxide destroys bacteria found in the mouth, reducing the chance of infection Realize that irritable bowel syndrome is a condition marked by abdominal pain (often relieved by the passage of stool or gas); disturbances of evacuation (constipation, diarrhea, or alternating episodes of both); bloating and abdominal distention; and the passage of mucus in stools. • Realize that irritable bowel syndrome is often called spastic bowel disease; no inflammation is present Realize the following in regards to an inguinal hernia: • Usually a bulge in the lower right quadrant • Usually pain at the umbilicus radiating down to the groin Realize that a classic symptom of hiatal hernia is associated with reflux; it is complaints of awakening at night with heartburns • Realize that clients with hiatal hernia should withhold food and fluids just before going to bed so food won’t slide (reflux) through the hernia, causing heart burn Realize that cystic fibrosis causes a deficiency in pancreatic enzymes that digest fats, carbohydrates and proteins • Realize that a client with cystic fibrosis requires a high protein diet • Realize that a client with cystic fibrosis requires a low fat diet; realize that fat needs to be decrease because it interferes with the absorption of other nutrients • Realize that a client with cystic fibrosis requires a high calorie diet • Realize that a client with cystic fibrosis has an impairment of intestinal absorption Realize that eructation is the production of gas from the stomach, usually with a characteristic sound; belching Realize that if a patient has a dry, parched (extreme dry) mouth and tongue, the mouth should be rinsed with room temperature tap water before and after meals Realize that an elderly client needs to increase protein intake to slow down the degeneration process Realize that a herniorrhaphy is a surgical procedure for repair of a hernia Realize that a guaiac test is a test for unseen flood in the stool Realize that alcohol increases the risk of GI bleeding Realize that when the bowel perforates as a result of increased intraluminal pressure within the gut, intestinal content are released into the peritoneum, leading to peritonitis; this client needs to prepare for emergency surgery Realize that pyorrhea is the discharge of purulent matter Realize that red, swollen gums can indicate pyorrhea, which is caused by improper cleaning and poor mouth hygiene Realize that polyethylene glycol-electrolyte (GoLYTELY) is an osmotic laxative • Realize that 4 liters of polyethylene glycol-electrolyte (GoLYTELY) needs to be ingested • Realize that once polyethylene glycol-electrolyte (GoLYTELY) is ingested, the client must only drink water • Realize that tap water can be used to reconstitute the polyethylene glycol-electrolyte (GoLYTELY) poweder • Realize that a client must not drink the polyethylene glycol-electrolyte (GoLYTELY) solution cold because it can cause hypothermia Realize that a colonoscopy is not a painful procedure Realize that bowel prep and NOP status puts a patient at high risk for imbalances Realize the following in regards to suppository insertion: • Client must breath through the insertion to relax the rectal muscles • The suppository should be positioned to touch the wall of the clients rectum • The suppository should be inserted to 3 to 4 inches into the patient rectum • Lubricant should be applied to the tip of the suppository before insertion Realize that charcoal, if given within two hours, will absorb particles of salicylate from an aspirin overdose; it is important to determine when client last took aspirin Realize that you should inform client to breath slowly when performing palpation techniques on the abdomen as it will enhance relaxation of the abdominal muscles Realize that bimanual palpitation is just the usage of both hands to palpate Realize the following about diverticulosis: • Realize that diverticula is an outpouching of the walls of a canal • Pain in the left lower quadrant (colicky pain) • Pain relieved by passage of stool or fart • Associated with dietary deficiency with fiber • Should be placed on high fiber diet • Should take bulk laxative • Must be NPO • Realize that foods that are indigestible may block the diverticula o Realize that the following foods should be avoid:  Seeds, nuts, corn, popcorn, cucumbers, tomatoes, figs, strawberries, and caraway seeds Realize that the use of the stethoscope to palpate the patient’s abdomen, with the fingers moving over the edge of the diaphragm is used to decrease ticklishness and the voluntary guarding that results; realize that when the fingers drifts over the diaphragm edge, the nurse can palpate without causing ticklishness Realize that contact precautions is always required for clostridium difficile, which causes pseudomenbranous colitis Realize that the fact that a patient that is diapered and incontinent makes them contact precaution requirement because of the fecal contamination potential Realize that eating onion, beans and cucumbers contributes to gas production (fart) • Realize that chewing gum, skipping meals and drinking beer contributes to the production of flatus (fart) Realize the following about a colostomy, sigmoid colostomy or ileostomy: • You can place a commercially prepared deodorizer inside the pouch to eliminate an odor • Realize that the colostomy should be irrigated at the same time every day to assist in establishing a normal pattern of elimination • Realize that drinking helps prevent odor • Realize that eating crackers, toast and yogurt actually helps prevent odor • Realize that anything that low residue prevent odor • Output from ileostomy needs to be measured because it is usually liquids and in copious mount • Realize that you must not use moisturizers (emollient) because it prevents a good seal around the stoma • Realize that drainage from ileostomy is very irritating to the skin • Realize that irrigation of sigmoid colostomy is not necessary more than once a day • Realize that the ostomy bag should be changed at least once a week; which is a good time for the stoma to be closely inspected o Realize that the ostomy bag needs to be change more frequently if the seal around the stoma is loose or leaking • Realize that all activities that the client participated in before the colostomy may be resumed after appropriate healing of the stoma or incision • Realize that if the stoma appears to be tight and there is a decrease amount of stool and this information needs to be reported to the physician because it may indicate an obstruction or stoma stricture Realize the following in regards to an ileal conduit: • Realize that an ileal conduit is a method of diverting the urinary flow by transplanting the ureter into a prepared and isolated segment of the ileum • Realize that soap and water should be use to clean skin, no an antiseptic solution • Realize that it is important to apply a close-fitting drainage bag to the stoma to avoid urine from contacting the skin • Realize that you must not use moisturizers (emollient) because it prevents a good seal around the stoma Realize that the contrast from GI studies can interfere with other examinations, thus, should be scheduled after those examinations Realize the following in peptic ulcer disease (PUD): • Diets rich in milk and cream needs to be avoid because they stimulate acid secretions • Symptoms are: o Dull pain o Gnawing pain o Burning in the midepigastrium • Avoid aspirin • Avoid motrin • Avoid meat extracts • Avoid alcohol • Avoid caffeinated beverages • If client taking a histamine blocker (cimetidine, tagamet) then small frequent feedings are not necessary Realize that clients with gastric ulcers may be malnourished because food may cause nausea or vomiting • Realize that pain related to gastric ulcer occurs about 0.5 to 1 hour after a meal and rarely at night and pain is not helped by ingestion of food Realize that client with duodenal ulcers experience pain after meals Realize that in acute appendicitis, the pain (lower right quadrant) usually comes prior to the nausea and vomiting (McBurney’s point) • No heating pads, enemas or laxatives should be used • Hold analgesics to avoid blunting pain because it will make it hard for diagnosis purposes • Client should be NPO • Place ice bag on abdomen • Place client in Fowler’s position in postop to decrease tension on the abodmen Realize that nausea and vomiting that comes before abdominal pain frequently indicate gastroenteritis Realize that frequent use of nasal sprays to relieve allergic symptoms can result in vasoconstriction that causes atrophy of nasal membranes, resulting in decreased integrity of blood vessels, resulting in nosebleeds Realize that clients need a slow, steady weight gain of no more than 2 lbs per week; rapid weight gain can put undue stress on the heart Realize that if the skin over the abdomen is taut and glistening, it indicates ascites Realize that small frequent amounts of watery diarrhea with abdominal pain and nausea may indicate possible bowel obstruction that can be life- threatening if the bowel perforates • Realize that a distended abdomen with complaints of pain is an indication of an obstruction • Realize that nausea and vomiting are also signs obstruction Realize that drinking contract for an abdominal CT scan and feeling nauseated is common Realize that sitting in a high Fowler’s position at 90 degrees will lessen aspiration risk by utilizing the pressure of gravity to pass food through the stomach and into the duodenum; sitting before a meal allows for a rest period before eating, which helps minimize fatigue and therefore helps the patient’s desire to eat and enhances swallowing efforts Realize that six small meals versus three large ones can increase swallowing-muscles strength and are easier to digest Realize that when one has a difficult time of swallowing, peanut butter is to be avoided because it is sticky in the mouth and the throat; most milk products are avoided because they produce mucus Realize that a Sengstaken-Blakemore esophagogastric tube provides balloon tamponade to stop bleeding of esophageal varices; inflated esophageal balloon can obstruct airway; in case of airway obstruction, use scissors to cut tube’s balloon port • Realize that with an esophagogastric tube, assess vital signs for decreased blood pressure and elevated pulse; ensure that balloon pressure and volume is maintained Realize that muscles spasms are associated with vomiting; these muscle spasms can cause severe pain and if an abdominal surgery is present, it can threaten the integrity of the wound Realize that the following in regards to colorectal cancer and it’s risk factor: • Being over 40 • History of ulcerative colitis • Diet for ulcerative colitis is high protein, high calorie and low residue (to rest bowel) • A diet high in fat, high in protein and low in fiber/ residue is a risk factor for colorectal cancer Realize the following about an NGT: • Realize that a Levin tube is an NGT • Realize that tube feedings should be given at room temperature to minimize intestinal cramping • Realize that clamping the tube between feedings prevent introduction of air and loss of liquid • Prevent aspiration • Prevent cramping (warming up the formula to room temperature) • Prevent air from entering the stomach by clamping the proximal end of the feeding tube • Realize that a Salem sump tube is an NGT o Realize that a Salem sump tube is working correctly if there is a hissing sound from the blue lumen tube; hissing sound is indicative of air that is freely exiting the airway, purpose is to provide continuous steady suction without pulling gastric mucosa • Realize that if the air vent of the Salem sump tube fills with stomach contact, the nurse can clear it by inserting 30 mL of air through it; realize that clearing the air vent will re-establish proper suction in the tube • Realize that the nurse should first assess if the tube is open and draining to determine if there is a problem with the nasogastric tube; if it is patent and draining, it does not need to be irrigated • Realize that medication can be administered thru the NGT only after properly placement has been checked • Realize that in order to check for proper placement, the nurse should check the pH (0 – 4) of the content aspirated from the NGT o Realize that the nurse should flush the NGT with 30 ml of air before aspirating fluids • Realize that with an NGT placement, a 60 – 90 degree fowler position best facilitates swallowing and the movement of the NGT through the GI tract • Realize that an Ewald tube is an OGT; insertion often causes gagging and vomiting so a suction equipment is needed to reduce the risk of aspiration Realize that the basic guidelines to teach a post-gastrectomy client are measures to prevent dumping syndrome, which include: lying down for 30 minutes after meals, drinking fluids between meals, and reducing intake of carbohydrates Realize that dumping syndrome is a syndrome marked by sweating and weakness after eating; occurs in patient who have had gastric resections • Realize that a desire to lie down is one of the early manifestations of dumping syndrome, which also includes vasomotor disturbances of syncope, symptoms manifestations (90 minutes to 3 hours after eating) • Realize that client should decrease intake of carbohydrates since they are the first food to be digested • Realize that undigested foods is dumped into the jejunum, resulting in distention, cramping, pain, diarrhea 15 – 30 minutes after eating; causes diaphoresis, diarrhea, and hypotension • Restrict fluids with meals • Eat smaller frequent meals • Low carbohydrate and fiber diet Realize the following about Billroth II (gastrojejunostomy): • Realize that after a Billroth II (gastrojejunostomy), dumping syndrome can occur • Realize that lying down after eating is recommended in order to delay the gastric emptying process • Realize that eating lying down or semirecubent is another measure that can be taken • Realize that a desire to lie down is one of the early manifestations of dumping syndrome, which also includes vasomotor disturbances of syncope, symptoms manifestations (90 minutes to 3 hours after eating) • Realize that it needs to be understood that patients with Billroth II (gastrojejunostomy) is an exception to the rule of not lying down after eating… as this patient must lie down after eating Realize that vomiting for 2 weeks can cause electrolyte imbalance and decrease cardiac output Realize that if weight is below 75% of ideal body weight, it is considered medically unstable Realize that progressive systemic sclerosis causes dysphagia and esophageal reflux; instruct the client to avoid spicy foods, caffeine, and alcohol because they stimulate gastric secretions Realize the following about bulk-forming laxative (psyllium hydrophilic mucilloid) (Metamucil): • Realize that bulk-forming laxatives is the category of laxative that is usually seen as the safest, even when taken on a routine basis • Realize that laxatives are to be used as a last resort • Realize that the following are bulk-forming foods: cereal, fresh fruits and vegetables Realize that docusate sodium (colace) could not be used regularly because of laxative dependency, bowel damage, electrolyte imbalance; Colase is an emollient (moisturizes) laxative of the fecal-softener type Realize that magnesium hydroxide (milk of magnesia) is a saline laxative that if use chronically can significantly alter the electrolyte balance, causing dehydration and lead to dependence Realize the following about ulcerative colitis: • It is an inflammation and ulceration of the colon and rectum; requires high-calories, high-protein, low-fat, low-residue diet • It is characterized by eroded areas of the mucous membrane and tissue beneath it • Need TPN to rest bowel • Maintain fluid/ electrolyte balance • Occurs in 30 – 50 year old • Fat is not present in the stool; blood, pus and mucus are present in stool • Rectal bleeding is common • Diarrhea occurs, often bloody o Chronic diarrhea stool occurring 10 to 12 times per day • Weight loss, anemia, dehydration occurs • Fistula formation is rare Realize that a pilonidal cyst is often in the sacrococcygeal region Realize that ecchymosis (superficial bleeding under the skin) around the umbilicus or in either flank indicates retroperitoneal bleeding Realize that anorexia nervosa has little to do with appetite and more to do with the fear of obesity and losing control over food intake • Realize that a client with anorexia nervosa would want to talk about and plan their meal; they display a marked preoccupation with food • Realize that clients with an eating disorder experience difficulty with self-identity and self-esteem Realize that menstruation is usually absent in anorexic women; it’s return is a measure of successful treatment. Realize that patients with GERD should not drink carbonated beverages because they caused increased pressure in the stomach • Realize that a patient with GERD should sleep on their left side with their head elevated 6 – 12 inches to prevent nighttime reflex Realize the following about acute epiglottis and its following symptoms: • Sitting upright to breathe better is a symptom • Tongue protrusion increases pharyngeal movement • Drooling caused by difficulty swallowing because of pain and excessive secretions Realize the following in regards to bowel sounds: • Realize that no sounds heard in 3 to 5 minutes indicates intestinal obstruction • Realize that 1 or 2 sounds heard in two minutes indicates a decrease motility of bowels • Realize that normal bowels sounds are 5 – 30 sounds per minute • Realize that greater than 30 sounds per minutes indicates increases motility due to gastroenteritis, diarrhea, and laxative use • Realize that client will have a high pitch bowel sound ABOVE the area of obstruction; client will have absent or decrease bowel sound below obstruction Realize the following in regards to a hemorrhoidectomy: • Realize that after a hemorrhoidectomy, client should be monitored for urinary retention; urinary retention occurs because of the closeness of the bladder to the surgical site and the occurrence of rectal spasms and anorectal tenderness; catheterize to empty bladder • Realize that sitz bath should be taken three or four times per day beginning after 12 hours postop to manage pain. Realize that if an evisceration occurs after abdominal surgery, the intestine should be kept moist and covered with a soaked sterile dressing soaked in sterile saline; patient should be placed in low fowler’s position; instruct patient not to cough • Realize that low fowler’s position (head elevated 15 degrees) reduces stress on the suture lines; client may also be placed supine with the hips and knees bent • Realize that elevating the head of the bed to 30 – 45 degrees would reduce stress on a suture line on a patient recovery from an appendectomy o Realize that following an appendectomy, the client should be encouraged to take a deep breath, hold their incision and then cough, as this is the most effective way to deep breath and cough… it dilates airway and expands the lung surface area Realize the following about abdominal incisions: • A slight swelling is expected during healing • A slight crusting of incision line is normal • Realize that the incision line should not be red, as it indicates an infection • Realize that the incision line should be pink Realize that kale is a cabbage Realize that a good source of folate is the following: • Green leafy vegetables • Legumes • Tomatoes • Various fruits such as oranges and cantaloupe Remember that milk is a good source of vitamin D Realize that in acute inflammatory bowel disease, red wine may exacerbate the inflammatory condition; should avoid whole-grain breads; diet should be low-residue, high protein and high calorie during the acute phase Realize that a low-residue diet is a diet in which fiber and other foods that are harder for your body to digest are restricted • Realize that the following foods are low-residue: o A cup of beef bouillon o Steam white rice o Strawberry gelatin o Clear chicken broth o Two slices of white toast o Apple sauce o Apple juice o Cottage cheese o Crackers Realize that small, frequent meals facilitate gastric emptying and decrease heartburns; take low-sodium antacids Realize that celiac disease is malabsorption, weight loss, and diarrhea resulting from immunological intolerance to dietary wheat products. • Realize that celiac disease is an inborn error in wheat and rye embolism • Realize that intestinal malabsorption occurs, resulting in malnutrition • May have diarrhea • Realize that a gluten free diet is needed, no wheats, oats, rye, and barley • Realize that a diet should only contain high calories, high protein Realize that performing an enema is a standard, unchanging procedure that can be delegated to the nursing assistant; responsibility and authority for performing the task (function, activity, decision) is transferred to another individual; it is the nurse’s responsibility to describe clear outcomes; observing returns is a part of the task delegated and should be performed by the nursing assistant • Realize that describing the returns from the enema is part of the responsibilities delegated; nurse should monitor performance and results according to established goals • Realize that enemas should be performed after breakfast to avoid potential nausea • Realize that patient should bath after an enema • Realize that with an enema, the irrigation bag should be 12 – 18 inches above the rectum Realize the following in regards to acute pancreatitis: • Records of daily weight should be obtained because of fluid and electrolyte imbalances; assess intake and output, skin turgor and mucus membranes • Realize that mereridine sulfate (Demerol) should be avoided due to potential toxicity • Realize that client should be NPO to decrease the secretion of secretin from the pancreas; nasogastric suctioning removes gastric secretions and decreases abdominal distention • Realize that bedrest decreases the metabolic rate and the secretion of pancreatic enzymes • May cause acute mid-abdominal pain • May cause acute vomiting • Associated with males between 40 – 45 with a history of heavy drinking • Associated with females between 50 – 55 diagnosed with biliary disease • Maintain fluid/electrolyte balance • Low-fat, bland diet • Small frequent feeding • Respiratory care, touch cough and deep breath every two hours Realize that vitamin B12 is used for patients with pernicious anemia Realize that liquid medication that contains sorbitol (sweetening agent) that is given thru a gastric tube may cause diarrhea if the client is allergic to sorbitol Realize that a disoriented, confused client who is unable to care for himself will require cues from the nurse to eat; the client will needs cues from the nurse to feed him/her self; goal is for the client to feed self Realize that the following are ways to prevent constipation: • Increase intake of soluble and insoluble dietary fibers; eat two to four serving of fruits per day as well as three to five servings of vegetables Realize that lying on the right side with the head of the bed elevate promotes gastric emptying while preventing aspiration Realize that in order to prevent complications with a client with an abdominal aortic aneurysm (AAA), the client needs to be encourage to increase fluid intake and dietary fibers to prevent constipation and the need for straining with bowel movements that may cause increased intra- abdominal pressure and risk of rupture • Realize that in regards to aortic aneurysm (AAA), it’s all about not increasing intra-abdominal pressure • Realize that intra-abdominal pressure while an aortic aneurysm (AAA) exist may lead to the rupture of the aneurysm • Realize that after an aortic aneurysm (AAA) repair, if the client vital signs show signs of shock still, maintain the client on bed-rest and evaluate for a decrease in CVP readings with previous readings o IV fluids rate will be increased Realize that when one has diarrhea, they should consume only low-residue diets when having diarrhea; white bread and refined cereals are well tolerated Realize that a mouth wash that is glycerin-based will cause dehydration and irritation of the tissues Realize that placing an heating pad to the abdomen once a day will cause a reflex vasodilation of the extremities, with is good for an elderly person with peripheral arterial insufficiency Realize that a stroke may occur up to 72 hours after the first one Realize that regular exercise helps to prevent constipation Realize that a food/feeling/thoughts action journal is good for assess a client’s eating habits Realize that a tonsillectomy may cause frequent swallowing, which indicates bleeding at the throat; should be observe when a child awakes and is asleep; other signs are increased pulse, pallor, and vomiting bright red blood Realize that hypokalemia can cause the following: • Hypertension • CHF • Digitalis toxicity with frequent premature ventricular complexes (PVCs) • May cause muscle weakness • May cause lethargy Realize the following in regards to a hiatal hernia: • Instruct client not to lie down for one hour after eating • Elevate head when sleeping Realize that the concept with gastritis is to rest the bowel: • Realize that if client is vomiting all the time, do not give food… realize that you must slowly put the client on a bland diet as client will need to be NPO Realize the following in regards to Crohn’s disease: • 20 to 30 and 50 to 80 year olds are victims of this disease • Steathorrhea is common • Colicky abdominal pain after meals • Diarrhea is rare • Weight loss, anemia and dehydration occurs • Fistula formation is common • Ileum and right colon are affected Realize that drinking too much fluids can over distend the stomach and ultimately increase a client’s nausea LIVER Realize that fatigue and dark urine are the initial indications of hepatic dysfunction Realize that a distended abdomen and splenomegaly indicates the possibility of internal bleeding… a life-threatening situation Realize the following in regards to cholecystitis: • May cause nausea • May cause frequent belching • May cause right upper abdominal pain Realize the following in regards to the T-tube: • It serves two purpose, (1) to allow drainage of bile and (2) to allow the introduction of media • Client should avoid strenuous exercise • Client should not immerse T-tube in water • Realize that the expected drainage is 500 – 1000 mL/day initially, will gradually decrease Realize that following a cholecystectomy, the client is usually discharged the day of surgery or the next day; ensure that the client has help at home for the first 24 – 48 hours • Realize that after an abdominal cholecystectomy, the client should place a pillow against the abdomen, take three deep breath, hold the breath and then cough 2 – 3 times; this should be done every two hours to prevent respiratory complications; splinting prevent abdominal jarring • Realize that if the client complains of severe abdominal pain in the right upper quadrant, it could indicate peritonitis or wound infection Realize that the following are the sources of vitamin K: • Green salad (most green vegetables), pork • Realize that if a client has vitamin K deficiency, it means that they can bleed easily; realize that the nurse should carefully check the client’s arm after taking the blood pressure for any bruises Realize that the normal ammonia range is 80 – 110 g/dL Realize that the normal AST liver enzyme range is 8 – 20 units Realize that the normal ALT liver enzyme range is 8 – 20 units Realize that the normal bilirubin range is 0.1 – 1.0 mg/dL Realize that a patient should be lying on his right side for several hours after a liver biopsy to promote hemostasis and thereby prevent hemorrhage and bile leakage • Realize that in preparation of a liver biopsy, the nurse should position the client supine with the arms raised above the head to allow access to the liver; realize that the needle is inserted between two of the lower ribs or below the right rib cage Realize that due to biocultural skin variations, signs of early jaundice are best observed on the posterior hard palate in Asians; involved with taking isoniazid Realize jaundice may signal metastatic disease Realize that jaundice indicates a possible stone in the bile duct causing obstruction Realize the following about alcohol withdrawal symptoms: • Realize that being hyper-alert, being easily started, and anorexia are early symptoms from alcohol • Increase in pulse, anxiety, tremors, insomnia, hallucinations, restless, agitated, irritable • Realize that alcohol withdrawal peaks 24 – 48 hours after last drink • Realize that an elevated pulse rate is a good indicator of a client’s progress through alcohol withdrawal • Realize that a steady increase in vital signs indicates that the client is approaching delirium tremens (the most severe expression of alcohol withdrawal syndrome), which can be avoided with additional sedation Realize that chronic alcohol use is the most common cause of hypomagnesemia (1.5 mEq/L); which may result in cardiac arrest; manifestations include increase neuromuscular irritability, tremors, tetany, seizures Realize that the best way to identify possible physical of alcohol depended is through a complete physical assessment Realize that hepatic toxicity is a serious complication resulting from an acute Tylenol overdose that manifests approximately 1 to 3 days after initial ingestion; there is an increase in ALT and AST Realize the following in regards to hepatitis A and its symptoms: • Fatigue • Anorexia o Realize that anorexia clients are unable to eat large meals • Intolerance to odors • Encourage client to eat all small meals and snacks; if client has nausea later, offer morning meals that are rich in nutrients • Should eat protein from milk, meat and eggs • Should increase calories to 2,000 to 3,000 calories per day to meet energy needs • Realize that hepatitis A is not infectious within a week or so after the onset on jaundice • Only requires standard precaution Realize that early signs of alcohol withdrawal are tremors, elevated pulse, anxiety, being startled easily; these signs begin a few hours after reduction of alcohol intake and peak in 24 – 48 hours Realize that patient with chronic alcoholism needs supplements with all B vitamins, especially thiamine (vitamin B1); thiamine deficiency is the primary cause of alcohol-related changes such as Wernicke’s encephalopathy and Korsakoff’s syndrome Realize the following in regards to disulfiram (antabuse) and its side effects: • Realize that taking disulfiram (antabuse) helps to minimize complications from the sedative effects of the drug • Realize that the longer a client take disulfiram (antabuse), the more sensitive he/she will be to alcohol • Realize that any contact with any amount or any form of alcohol, even a very small amount will cause an alcohol-disulfiram reaction, which is extremely uncomfortable and may even lead to shock and cardiac dysthythmia Realize that in the event of ascites, albumin (albuminar) is given to pull fluid back into the blood vessel; then a diuretic is given to remove the excess fluids Realize the following with cirrhosis: • May need shunt to relieve portal hypertension • Realize that early in the disease process, client will need a high protein, high carbohydrate diet • Realize that later in the disease process, client will need to be restricted on fiber, protein, fat and sodium • Avoid alcohol • Avoid sodium, fluid restrictions • Monitor for bleeding; administer blood • Measure abdominal girth; weight client daily • Assess for respiratory difficulties • Realize that an impaired thought process is an early symptom of chronic cirrhosis RESPIRATORY Realize that Kussmaul respirations (very deep breathing) are associated with diabetic ketoacidosis Realize that specimens should be obtain in the early morning because secretions develop during the night; the nurse should have the client cough deeply and expectorate into a container upon awakening Realize that the purpose of the cuff on the tracheostomy tube is to decrease the chance of aspiration into the trachea Realize that clients with full-thickness burns to the face, neck, chest or abdominal burns results in severe edema, causing airway restriction Realize that clients who abuse marijuana experience cravings for sweets and carbohydrates Realize that a nasal septum disruption is indicative of cocaine use; realize that chronic inhalation of cocaine creates sores, burns, disruption of mucous membranes and holes in the nasal septum Realize that the extension of the neck could obstruct airway because the tongue falls in back of the mouth Realize that every positive PPD (Mantoux) test should be verified with a chest x-ray Realize that pertusis is a contagious disease characterized by paroxysmal coughing; vomiting that follows that cough, and a whooping inspiration. • Realize that pertusis requires droplet precaution, a private room and a distance of 3 feet between patient is visitor Realize that the nurse should only use the finger tips (not palm of hand) when palpating the uterine contraction in active labor Realize that status asthmaticus (persistent and intractable asthma) is a life threatening condition that can last longer than 24 hours Realize that an increase in respiratory rate passed 20 actually decreases the oxygenation towards the tissues Realize the following in regards to a pneumonectomy (excision of an entire lung) postoperatively: • Realize that the position of the tracheal should be evaluated; a tracheal shift occurs because an increase in pressure occurs on the operative side and causes pressure against the mediastinal area Realize that ROME refers “Respiratory Opposite (ph