NUR 432 - Exam #3 questions with accurate answers
"provoked" seizure Ans✓✓✓ related to acute, reversible condition
Example: alcohol withdrawal seizures
acute pancreatitis - clinical manifestations Ans✓✓✓ Abdominal
distention, decreased peristalsis, nausea & vomiting
acute pancreatitis - goal of medical management Ans✓✓✓ relieve
symptoms, prevent complications
acute pancreatitis - medical management Ans✓✓✓ NPO to inhibit
stimulation of pancreas to secrete its enzymes then low fat, low protein
diet. No caffeine or alcohol when they restart eating (one of big things
for these pts, dont stimulate the digestive enzymes (they will complain
about not eating), alcohol is one of the biggest causes of this)
NGT if severe nausea & vomiting
Pain management with opioids (high doses and takes quite a bit get that
pain down, high risk of opioid dependence)
ICU care if acutely ill
Aggressive respiratory care (possible atelectasis, secretions that pool.
Really need that cough/deep breath, use that incentive spirometer!)
Biliary drainage
acute pancreatitis - nursing interventions improving breathing pattern
Ans✓✓✓ Semi-Fowler position to decrease pressure on diaphragm
,(depends on the pt, if they have good stats where they are comfy not the
worst to keep them there but preferably semi-fowler)
Frequent position changes, cough & deep breathe, incentive spirometer
Reduce excessive metabolism of the body (administer antibiotics as
prescribed, administer nasal oxygen as required for hypoxia, use a
hypothermia blanket if necessary)
acute pancreatitis - nursing interventions improving nutritional status
Ans✓✓✓ Monitor nutritional status (I&Os, albumin level, daily
weights)
Enteral or parenteral nutrition (IV fluids and electrolytes as prescribed)
Monitor glucose levels q 4-6h (Can become hypoglycemic very easily,
administer insulin as prescribed)
Oral nutrition once symptoms improve (high-carb, low-protein, low-fat
diet)
Avoid alcohol, coffee, spicy foods
acute pancreatitis - nursing interventions maintaining skin integrity
Ans✓✓✓ Risk for skin breakdown
Higher risk than other pts since they aren't getting protein
acute pancreatitis - nursing interventions monitoring/managing potential
complications (ascites) Ans✓✓✓ assess abdomen, daily weights,
abdominal girth measurements
,acute pancreatitis - nursing interventions monitoring/managing potential
complications (fluid/electrolyte disturbances) Ans✓✓✓ Assess skin
turgor, mucous membranes, urine output, vital signs, hemodynamic
parameters
Assess sources (vomiting, diarrhea, NG drainage, diaphoresis)
acute pancreatitis - nursing interventions monitoring/managing potential
complications (hypovolemic, hemorrhagic, or septic shock) Ans✓✓✓ If
they get peritonitis mostly likely to end up in septic shock
Extensive acute pancreatitis may cause peripheral vascular collapse and
shock
Blood and plasma may be lost into the abdominal cavity; therefore, there
is a decreased blood and plasma volume
The toxins from the bacteria of a necrotic pancreas (pancreatic necrosis,
another complication!) may cause shock.
acute pancreatitis - nursing interventions monitoring/managing potential
complications (multiple organ dysfunction Ans✓✓✓ monitor for
neurologic, cardiovascular, renal, and respiratory dysfunction
acute pancreatitis - nursing interventions monitoring/managing potential
complications (tetany) Ans✓✓✓ keep supply of IV calcium gluconate
or calcium chloride available
acute pancreatitis - nursing interventions relieving pain and discomfort
associated with edema, distention of pancreas, peritoneal irritation, and
, excess stimulation of pancreatic secretions Ans✓✓✓ Administration of
opioids
NPO (pancreatic secretion is increased by food and fluid intake)
Parenteral fluids & electrolytes (depends on how long the episode last, if
they come in hypotensive/tachy they def will be on fluids)
Continuous NG tube suction (measure gastric secretions at specified
intervals, observe and record color and viscosity of gastric secretions,
ensure that the nasogastric tube is patent to permit free drainage, turn
patient at intervals to avoid pressure/tension on tube)
acute pancreatitis - pt appears acutely ill Ans✓✓✓ hypotension,
tachycardia, cyanosis, cold/clammy skin, AKI, respiratory distress &
hypoxia, diffuse pulmonary infiltrates, dyspnea, tachypnea, abnormal
blood gas
- Not taking in the fluids they need because of how painful so
hypotensive, the hypotension leads to the cold/clammy skin
- Cyanotic because in so much pain not taking proper breaths
- Shit cardiac output leads to AKI
- Abnormal blood gasses happen when far enough in
acute pancreatitis - rigid abdomen = Ans✓✓✓ peritonitis!!!
acute pancreatitis - severe abdominal pain Ans✓✓✓ acute onset 24-48
hours after a very heavy meal or alcohol ingestion, not relieved by
antacids
"provoked" seizure Ans✓✓✓ related to acute, reversible condition
Example: alcohol withdrawal seizures
acute pancreatitis - clinical manifestations Ans✓✓✓ Abdominal
distention, decreased peristalsis, nausea & vomiting
acute pancreatitis - goal of medical management Ans✓✓✓ relieve
symptoms, prevent complications
acute pancreatitis - medical management Ans✓✓✓ NPO to inhibit
stimulation of pancreas to secrete its enzymes then low fat, low protein
diet. No caffeine or alcohol when they restart eating (one of big things
for these pts, dont stimulate the digestive enzymes (they will complain
about not eating), alcohol is one of the biggest causes of this)
NGT if severe nausea & vomiting
Pain management with opioids (high doses and takes quite a bit get that
pain down, high risk of opioid dependence)
ICU care if acutely ill
Aggressive respiratory care (possible atelectasis, secretions that pool.
Really need that cough/deep breath, use that incentive spirometer!)
Biliary drainage
acute pancreatitis - nursing interventions improving breathing pattern
Ans✓✓✓ Semi-Fowler position to decrease pressure on diaphragm
,(depends on the pt, if they have good stats where they are comfy not the
worst to keep them there but preferably semi-fowler)
Frequent position changes, cough & deep breathe, incentive spirometer
Reduce excessive metabolism of the body (administer antibiotics as
prescribed, administer nasal oxygen as required for hypoxia, use a
hypothermia blanket if necessary)
acute pancreatitis - nursing interventions improving nutritional status
Ans✓✓✓ Monitor nutritional status (I&Os, albumin level, daily
weights)
Enteral or parenteral nutrition (IV fluids and electrolytes as prescribed)
Monitor glucose levels q 4-6h (Can become hypoglycemic very easily,
administer insulin as prescribed)
Oral nutrition once symptoms improve (high-carb, low-protein, low-fat
diet)
Avoid alcohol, coffee, spicy foods
acute pancreatitis - nursing interventions maintaining skin integrity
Ans✓✓✓ Risk for skin breakdown
Higher risk than other pts since they aren't getting protein
acute pancreatitis - nursing interventions monitoring/managing potential
complications (ascites) Ans✓✓✓ assess abdomen, daily weights,
abdominal girth measurements
,acute pancreatitis - nursing interventions monitoring/managing potential
complications (fluid/electrolyte disturbances) Ans✓✓✓ Assess skin
turgor, mucous membranes, urine output, vital signs, hemodynamic
parameters
Assess sources (vomiting, diarrhea, NG drainage, diaphoresis)
acute pancreatitis - nursing interventions monitoring/managing potential
complications (hypovolemic, hemorrhagic, or septic shock) Ans✓✓✓ If
they get peritonitis mostly likely to end up in septic shock
Extensive acute pancreatitis may cause peripheral vascular collapse and
shock
Blood and plasma may be lost into the abdominal cavity; therefore, there
is a decreased blood and plasma volume
The toxins from the bacteria of a necrotic pancreas (pancreatic necrosis,
another complication!) may cause shock.
acute pancreatitis - nursing interventions monitoring/managing potential
complications (multiple organ dysfunction Ans✓✓✓ monitor for
neurologic, cardiovascular, renal, and respiratory dysfunction
acute pancreatitis - nursing interventions monitoring/managing potential
complications (tetany) Ans✓✓✓ keep supply of IV calcium gluconate
or calcium chloride available
acute pancreatitis - nursing interventions relieving pain and discomfort
associated with edema, distention of pancreas, peritoneal irritation, and
, excess stimulation of pancreatic secretions Ans✓✓✓ Administration of
opioids
NPO (pancreatic secretion is increased by food and fluid intake)
Parenteral fluids & electrolytes (depends on how long the episode last, if
they come in hypotensive/tachy they def will be on fluids)
Continuous NG tube suction (measure gastric secretions at specified
intervals, observe and record color and viscosity of gastric secretions,
ensure that the nasogastric tube is patent to permit free drainage, turn
patient at intervals to avoid pressure/tension on tube)
acute pancreatitis - pt appears acutely ill Ans✓✓✓ hypotension,
tachycardia, cyanosis, cold/clammy skin, AKI, respiratory distress &
hypoxia, diffuse pulmonary infiltrates, dyspnea, tachypnea, abnormal
blood gas
- Not taking in the fluids they need because of how painful so
hypotensive, the hypotension leads to the cold/clammy skin
- Cyanotic because in so much pain not taking proper breaths
- Shit cardiac output leads to AKI
- Abnormal blood gasses happen when far enough in
acute pancreatitis - rigid abdomen = Ans✓✓✓ peritonitis!!!
acute pancreatitis - severe abdominal pain Ans✓✓✓ acute onset 24-48
hours after a very heavy meal or alcohol ingestion, not relieved by
antacids
