Surgical Nursing test questions and answers 2024

List the sites for intramuscular injections (include name the muscles used). Ventrogluteal- 0-4mls Vastus lateratis- 5mls dorsogluteal- not used Deltoid- not over 4 mls The 3 principles of pain control are 3 principles of chronic pain management Give the client as much control as possible Use a preventative approach, give before pain is bad Titrate to effect, desired effect with as few side effects as possible Intramuscular sites are Intramuscular Sites Ventrogluteal site- preferred site- has fewer blood vessels, even fat distribution and remains relaxed even if patient is tense. Location: Right palm over left greater trochlear, index finger over anterior superior iliac spine, middle finger spread dorsally over iliac crest. Injection site is in the middle of triangle created. Vastus lateralis site- preferred site for infants and children. Located in middle two thirds of thigh. Dorsogluteal Deltoid Subcut sites are Abdomen, buttocks, front and side of thigh Out and upper arm Dysuria painful urination : Enteral Tubing Used when the patient is unable to ingest food but is still able to digest and absorb nutrients. Feeding tubes can be inserted through: Nose (nasogastric or nasointestinal) Nasogastric- stomach nasointestinal -jujunum Short term - less than 4 weeks Dyspnoea: shortness of breath or uncomfortable awareness of breathing Dysmenorrhoea: Pain during menstruation that limits normal activity Nursing Interventions for nutrition Nursing Intervention's Help stimulate appetite: minimise odours, oral hygiene, position, manage symptoms i.e. antiemetic, analgesia Adhere to preferences or restrictions Replace % fluid loss via oral, IVT, SCT Assist: meals/drinks, use special aids Provide alternatives/varieties, small versus large Identify or eliminate food intolerance, allergy Ensure adequate intake with activity Monitor weight, food/fluid intake and output (FBC), BGL for diabetes Health promotion with education Enteral Tube Complications Aspiration - displacement, regurgitation or lying flat Diarrhoea - change in diet, mal absorption, Constipation- lack of movement or fibre Tube occlusion, Tube displacement- blockage, kink Abdominal cramping/nausea/vomiting- delayed emptying, fast feeds, antibiotics or bacterial infection Care of Clients Stage 3 Students can give Oral care, Securing NGT, GT or PEG, Monitor bowel sounds Fluid Balance Chart (input/output) Monitor gastric drainage (colour, consistency, odour and amount) Skin integrity, Education and reassurance Peripheral IV Assessment Scale Pain, Redness, Swelling, Hardness, Discharge Haematoma- Localised collection of blood outside of a blood vessel Phlebitis inflammation of a vein Characterised by redness traveling along the vein, heat, pain, low grade fever Extravasation- leaking of medication into the surrounding tissues of a cannula site Pain, burning, stinging, heat, redness Infiltration accidental administration of IV fluid into the surrounding tissues Characterised by swelling, discomfort, tightness BODY FLUIDS (60 to 70%% body weight) (Average adult require 2.5 to 3L/day) Fluid Gains (mL) Fluid Losses(mL) Oral fluids Kidneys Solid foods 800-1000 Skin 500-600 Metabolism 300 Lungs 400 GIT 100-200 Total Gains Total Losses The Nursing Process Enables the nurse to organise and deliver individualised care successfully by identifying, diagnosing and treating human responses to health and illness. There are 5 steps: Assessment; Nursing diagnoses; Planning; Implementation; Evaluation Phases of Wound healing Inflammatory 0 to 6 days Proliferative 5 to 20 days Maturative 21 days - . Arterial Ulcers due to: Arteriosclerosis, diabetes, advanced age, hypertension, smoking. S&S: cool, thin, shiny, dry skin, absence of hair growth, thickened nails, pallor on elevation. Decreased/absent leg/pedal pulses, slow capillary refill, painful at rest relieved by lowering legs. Venous Ulcers due to h/o DVT, obesity, valvular incompetence in the veins r/t trauma, age, pregnancy, immobility S&S: oedema, red/brown pigmentation, evidence of healed ulcers, dilated veins, heat, mod to no pain relieved by elevation of leg, normal leg/pedal pulses Cellulitis- Inflammation of surrounding tissues Redness, swelling, tenderness What characteristics of a wound do you report Location Size: width, length, depth Appearance: granulating, epithelisation, sloughy, necrotic, hyper-granulation Exudate: serous, purulent (pus), sanguineous and sero sanguineous Types: black, yellow, red, mixed Wound edges: red, pink, purple, blue, yellow, green, black, raised, cavity. Odour: ? malodorou Faecal Characteristics that you would not -Colour - brown (alterations clay/white, pale, black or tarry, red) Pale- absence of bile, pale fatty, tarry blood in small intestine, red bleeding in large intestine -Odour- infection, malabsorption -Constituents- pus, mucous, blood, objects, undigested food -Frequency -Amount -Shape -Consistency Urination the Process Bladder: stretch receptors (150 - 200mL), send messages to the micturition centre in spinal cord (SC) Parasympathetic impulses cause detrusor muscle to contract Internal sphincter relaxes, urine to urethra As bladder contracts, impulses travel up SC to Pons and cerebral cortex Conscious decision to void, external muscle relaxes (voluntary control). Over Flow Incontinence voluntary or involuntary loss of small amounts (20-30mL) -underactive detrusor: faecal impaction, DM, spinal cord injury, enlarged prostate glands Rx: Intermittent catheterisation, surgery, IDC Functional Incontinence involuntary, unpredictable - change in environment (sensory, cognitive or mobility deficit) Rx: environmental alterations, scheduled toileting, skin and perineal care Urge Incontinence involuntary passage of urine after a sense of urgency - decreased bladder capacity, irritation, infection, increased fluid intake Rx: Anti-cholinergic drug therapy, biofeedback, bladder training Others: : referral to Continence Advisory Service Stress Incontinence Leakage of small amounts, caused by sudden increase in intra-abdominal pressure - incompetent bladder outlet, weak pelvic muscles Rx: Pelvic floor exercise, surgery, biofeedback Reflex Incontinence Involuntary loss (large or small amounts) - spinal cord dysfunction Rx: Anti-cholinergic drug therapy, intermittent catheterisation, surgery, IDC. Urgency need to void immediately Dysuria: painful or difficult urination Nocturia: excessive at night Oliguria: < 500mL/24 hr Anuria: inability to produce urine Polyuria: large amounts of urine Incontinence involuntary loss of urine Residuel urine: volume remain after voiding (>100 ml) Frequency: < 2 hr intervals Nursing Interventions re incontinence -Patient education -Promoting normal micturition -Promote complete bladder emptying -Prevent infections Nursing interventions urination in acute care Maintain elimination habits -Medications -Catheterisation -Alternatives to urethral catheterisation -Nursing practice Neurovascular Observations Colour- pink, pale, mottled, flushed Temperature- hot, warm, cool, cold Movement- present, decreased, absent, active & passive Sensation- present, numb, tingling, absent Pain- mild, moderate, severe, absent, present, passive movement Pulses- strong, faint, absent Comparison- with unaffected limb Remarks i.e. swelling or oedema Post operative Care =Preparation: patient's room for return from theatre, post op bed, nbm/fasting sign, other equipment etc. =Ensure receive full handover for client from recovery staff =Psychological support: active listening, explanation, reassurance etc =Observation/documentation: pain, vital signs, medications, TPR, IVT, FBC, TEDS/neurovascular, nursing care plan etc. =Wound/s: check dressing/drains. =Oxygenation: suctioning (if applicable), breathing & leg exercises/coughing, O2 therapy (nasal/mask) incentive spirometry, pulse oximetry. =Hydration/nutrition: Water jug (if applicable), IVT and pole, NGT on drainage bag (if applicable) =Elimination: bed pan/urinals, vomit bowl, indwelling catheter to straight drainage or on hourly output measurement. =Hygiene: post op wash bowl, mouth care, dentures, hair etc. Catheter care - Check no tension, obstruction, kinks - Maintain gravity, - Drainage system: sealed - Observe flow: note amount, colour, odour & abnormalities - Report if < 30 mL/hr (0.5 mL/kg/day) - Maintain catheter and perineal care Promoting normal urination -Stimulating micturition reflex: relax, normal position (squat, sit) -Privacy -Sound of running water -Warm bed pan -Maintain adequate fluid intake -Monitor and record both intake and output (FBC) Report deficit -Promote and maintain effective elimination habits -Prevent infection: perineal hygiene, increase fluid intake -Others: medications (anticholinergic), bladder scan, catheterisation. Metabolism - all biochemical and physiologic processes involved in the growth and maintenance of the body - Anabolic -construct molecules from smaller units - Catabolic -large molecules to small Basal metabolic rate (BMR) - the rate at which the body metabolises food to maintain the energy requirements of a person at rest or awake Enteral Feeding- Care of Clients Stage 3 Students can give Oral care Securing NGT, GT or PEG Monitor bowel sounds Fluid Balance Chart (input/output) Monitor gastric drainage (colour, consistency, odour and amount) Skin integrity Education and reassurance Pressure Ulcer Risk =Sensory Impairment-Loss of protective reflexes- sensory deficit =Moisture- Incontinence g of urine or faeces Altered skin moisture: excessively dry/ excessively moist =Mobility-Immobility-Prolonged pressure on tissue =Nutrition-Malnutrition =Friction- sheering forces, trauma Advanced age Orthopaedic devices Poor skin perfusion oedema Stages of Pressure Ulcers 1: Epidermis - Intact skin with non-blanching erythema (redness) of a localised skin- 2: Partial thickness loss of dermis - shallow ulcer with red pink wound without slough 3: Full thickness tissue loss - epidermis, dermis subcutaneous fat may be visible, slough may be present but bone, muscle not exposed 4: Full thickness tissue loss with exposed bone, tendon or muscle; slough and eschar may be present Unstageable: full thickness tissue loss with slough, eschar or both in wound bed of ulcer. Wound Healing Complications -Haemorrhage: slipped suture, dislodged clot, FB -Infection (4th day post-op): fever, pain, redness, discharge, WBC, -Dehiscence (3 -4 days post): reopening of wound-strain/cough, increased exudate- -Evisceration: protrusion of visceral organ/s -Fistula: abnormal passage between organs, can be created -Delayed wound closure (third intention). Constipation -A symptom, not a disease. -Decrease in frequency of bowel movements, accompanied by prolonged or difficult passage of dry, hard stool. Impaction - Unrelieved constipation, hardened faeces collects & wedges in the rectum - cannot be expelled Collecting MSU (mid-stream urine) Instruct - Clean external genitalia, void, stop, void Collect 30 - 60 mL in sterile container and void Label and send