NR 302 Final Exam 3 Study Guide / NR302 Final Exam 3 Study Guide: Health Assessment I:, Study notes of Nursing

Download NR 302 Final Exam 3 Study Guide / NR302 Final Exam 3 Study Guide: Health Assessment I: and more Study notes Nursing in PDF only on Docsity! R302 Exam 3 Final Exam Exam 3 - Final ExamReview of Knowledge Exam 3: 200 points, 50 questions This is a review of major concepts from the session. This study guide is not exclusive. Also review the PowerPointsand read assigned chapters in Perry & Potter. Review all unfamiliar terminology both in ppt and book. Review all questions at the end of chapters. Review math med calc problems reviewed in class. Review all skills performed in lab—rationale for all steps when completing skills. Review any material in the ATI Skills Modules. Comprehensive final blueprint: 54% Comprehensive (Weeks 1-5) 20% Medication Administration/patient safety20% Bowel Elimination 6% Medication CalculationTissue Integrity Pressure Ulcers: - Braden scale & risk based on score o Sensory Perception, Moisture, Activity, Mobility, Nutrition, and Friction & Shear. Moderaterisk is a score of 13 or 14 and a high risk is a score of 12 or less. - Prevention o Relieve pressure, keep skin clean, dry, and moisturized, provide proper nutrition, preventdehydration, and minimize shearing and friction. - Staging and assessment o Stage I Pressure Uleer Pressure related alteration of intact skin usually over bony prominenc ~Presentation: -Non-blanchable erythema in lighter skin tones -Difficult to assess in darker skinned patients -Discoloration -Warmth/coolness -Edema -Induration -Itching sensation o Stage II Pressure Ulcer -Partial thickness loss of dermis -Presentation: -Shallow, open ulcer with a red-pink wound bed -Wounds are clean and vascular -Intact or open blister -Without slough, eschar, ecchymosis or undermining -It is NOT: Skin tears, tape burns, incontinence dermatitis, maceration, excoriation o Stage III Pressure Ulcer -Pressure related full-thickness tissue loss - Perform oral care frequently for patients on oxygen (especially masks) to prevent drying of the oralmucosa. Moisten the lips with an approved (non-petroleum) lip moisturizer. Artificial airways: Nasal airway — prevents airway obstruction of a conscious patient (also called a nasal trumpet) Oral airway - prevents obstruction of the trachea by displacement of the tongue into the oropharynx for unconsciouspatients The oral airway extends from the teeth to the oropharynx, maintaining the tongue in the normal position. Use the correct-size airway. Determine the proper oral airway size by measuring the distance from the corner of the mouth to the angle of the jawjust below the ear. If the airway is too small, the tongue does not stay in the anterior portion of the mouth If the airway is too large, it forces the tongue toward the epiglottis and obstructs the airway. Insert the airway by turning the curve of the airway toward the cheek and placing it over the tongue. When the airway is in the oropharynx, turn it so the opening points downward. Correctly placed, the airway moves the tongueforward away from the oropharynx, and the flange (e.g., the flat portion of the airway) rests against the patient’s teeth. Incorrect insertion merely forces the tongue back into the oropharynx. When a patient is “intubated” typically an endotracheal (ET) tube is used. The tube is passed through the patient’s mouth, past the pharynx, and into the trachea. It is generally removed within 14 days; however, it is sometimes used for a longer period of time if the patient is stillshowing progress toward weaning from invasive mechanical ventilation and extubation. If a patient requires long-term assistance from an artificial airway, a tracheostomy is considered. A surgical incision is made into the trachea, and a short artificial airway (a tracheostomy tube) is inserted.Most tracheostomies have a small plastic inner tube that fits inside a larger one (the inner cannula). The most common complication of a tracheostomy tube is partial or total airway obstruction caused by buildup of respiratory secretions. If this occurs, the inner tube can be removed and cleaned or replaced with a temporary spareinner tube that should be kept at the patient’s bedside. Keep tracheal dilators at the bedside to have available for emergency tube replacement or reinsertion. Humidification from air humidifiers or humidified oxygen tracheostomy collars can help prevent drying ofsecretions that cause occlusion. Tracheostomy suctioning should be done as often as necessary to clear secretions. - Types * - Indications * - Insertion (who can insert, how) “Suctioning: Suctioning is necessary when patients are unable to clear respiratory secretions from airways by coughing. Whatassessment findings indicate the need for suctioning? Use sterile technique Suction at 100-150mmHg for adults Utilize intermittent suction on withdrawal of the catheter, never on insertionSuctioning techniques include: Oro/Nasopharyngeal — used when the patient is unable to cough effectively but able to clear secretions byexpectorating Perform oral hygiene prior to suctioning Apply suction after the patient has coughed to remove secretions Oro/Nasotracheal — used when a patient is unable to manage secretions by coughing and does not have an artificialairway present The nose is the preferred route because gag reflex is minimal The process is similar to the pharyngeal suctioning, but the catheter is passed farther into the tracheaTracheal Open and closed methods: Open suctioning involves using a new sterile catheter for each suction session (AARC, 2010a). Wear sterile glovesand follow Standard Precautions during the suction procedure. Closed suctioning involves using a reusable sterile suction catheter that is encased in a plastic sheath to protect it between suction sessions. Closed suctioning is most often used on patients who require invasive mechanical ventilation to support their respiratory efforts because it permits continuous delivery of oxygen while suction is performed and reduces the riskof oxygen desaturation. Although sterile gloves are not used in this procedure, nonsterile gloves are recommended to prevent contact withsplashes from body fluids. - Indications for different types of suctioning “ - Tracheal suctioning procedure * - Hyperoxygenation with tracheal suctioning- with closed suctioningLung expansion: - Different patient positions and when they are indicated to increase lung expansion The 45-degree semi-Fowler’s is the most effective position for promoting lung expansion and reducingpressure from the abdomen on the diaphragm. In the presence of pulmonary abscess or hemorrhage, position the patient with the affected lung down. Why? prevent drainage to healthy lung, and promote full expansion of that lung For bilateral lung disease, the best position depends on the severity of the disease. - Chest tube indications (hemothorax versus pneumothorax presentations) - The pleural space is a potential for space in between the visceral and parietal pleura. When this spacefills with air or fluid/blood, it collapses the lung. - Achest tube pulls the fluid or air out of the pleural space and allows for lung re-expansion. - Placement of the chest tube: - Bases — Fluid - Apices — Air (remember air rises to the top) - Apneumothorax is the collection of air in the pleural space. - Spontaneous pneumothorax — genetic condition that occurs unexpectedly in healthy individuals (usually thin males) who develop blisterlike formations (blebs) on the visceral pleura, then they ruptureduring sleep or exercise, causing air to enter the pleural space - Secondary pneumothorax - Chest trauma - Emphysema - Invasive procedures - Hemothorax is the accumulation of blood and fluid in the pleural space. Urinary Elimination Urinary pathophysiology & terminology: - Urinary retention (signs and symptoms) o Inability to partially or completely empty the bladder. o Symptoms: bladder distension, pain, restlessness, diaphoresis - UTI (signs and symptoms) o Infection of the bladder, urethra, or kidney o Symptoms: dysuria, urgency, frequency, incontinence, suprapubic tenderness, foul smelling orcloudy urine, fever, confusion in older adults, and hematuria - Urinary incontinence (signs and symptoms) o Involuntary loss of urine o Symptoms: leakage with urgency, leakage with stress Assessment: - Urine (color, clarity, odor and what these mean) o Color: indicates hydration and bleeding; may be from medications = Straw color: normal = Dark yellow: concentrated urine (AM void) = Amber: dehydrated = Hematuria: bleeding o Clarity: there is cloudy and clear. Cloudy could indicate infection o Odor: there is ammonia and foul odor. Foul odor could indicate infection - Laboratory collection o CBC ~assessing for bleeding (low H&H) and leukocytosis (high white blood cells) o BMP- Kidney function (Creatinine/BUN) Electrolyte status (K, Na, Cl, Glucose) o Urinalysis — indicators of UTI, dehydration o Urine culture looking for specific bacteria = Flush the line with 20mL of normal saline after TPN administration co Pneumothorax = Might not be able to prevent it because it occurs on insertion. Monitor for symptomsof pulmonary distress o Air embolus = Maintain integrity of the closed CVC system, especially during cap changes andblood draws Diet: - Types of diets and when each is indicated o Clear liquids: broths, coffee, tea, carbonated beverages, clear fruit juices, jello, popsicles o Full liquids: (cloudy) milk, cream soups, custards, refined cooked cereals, vegetable juice,sherbets, puddings, frozen yogurts o Dysphagia stages Pureed: Scrambled eggs, pureed meats, vegetables and fruits, mashed potatoes and gravy; (Mechanically altered, advanced and regular) o Mechanical soft: Finely diced meats, flaked fish, cottage cheese, cheese, rice potatoes, pancakes, light breads, cooked vegetables/fruits, bananas, peanut butter o Regular: No restrictions unless specified - Advancing a diet o Start the patient off at a clear liquid then slowly advance them until they reach regular foods.If you think that they can’t handle a certain diet type then lower them to the diet below that - Thickened liquids o Nectar like liquids = Easily pourable, comparable to thick syrup, forms a thin web over the prongs of afork o Honey like liquids = Slightly thicker, drizzles when poured = Comparable to honey = Forms a thick web over the prongs of the fork o Spoon thick/ pudding like liquids = Not pourable, holds shape = Comparable to yogurt = Sits on the prongs of fork HIPAA Protecting patient confidentiality * Do not display patients’ identifying information (name, social security number, address, telephone number)in public places. This includes charts left outside of the nurses’ station, where people can see patients’ names or gain access to the charts. If you must take patients’ charts to other areas, make sure that you keep them in view and that others cannot see the patients’ names. * Computer workstations should be password protected so that the agency can track who is accessing patients’ records. Do not share your password with anyone, so that your tracking information will not be linked to medical records of patients who are not under your care. Be sure to sign off from your workstationeach time you leave the console so that other individuals do not use your password to gain access to patient records and unauthorized individuals cannot gain access to medical records. * Make sure that any paper documents that are not part of the medical record are shredded after use so thatprivacy of PHI is maintained. This includes the notes of individuals providing care. * Communicate orally in a way that others not involved in the patient’s care cannot hear you. * Communicate by telephone using a private line, and verify the identity of the person or agency receivingthe information. ¢ Nurses must be mindful of the prohibition against posting PHI, including non-identifying images ofpatients on social media sites. ¢ Patient must give consent before nurse or physician gives out their informationExamples of violations of patient confidentiality * Not following any of the above* Types of Communication Documentation in the medical health record ¢ — Written communication o Must be timely and accurate and support the action of nurse/physician Infection Control- Nursing process related to infections—nursing interventions to control/eliminate infections = properly administering antibiotics, monitoring response to therapy, hand hygiene, following standard andisolation precautions, cleaning/disinfecting environment, medical asepsis and sterile techniques for procedures Surgical (sterile) versus medical (clean) asepsis —when each is used and how to maintain each = Medical asepsis or clean technique, includes procedures for reducing the number of organisms present andpreventing the transfer of organisms = Surgical asepsis or sterile technique prevents contamination of an open wound, isolate the operative area from the unsterile environment, and maintains a sterile field for invasive or surgical procedures. Standard precautions- what this is and when it is used, difference between standard precautions and other isolationtypes = Standard precautions apply to contact with blood, bodily fluids, nonintact skin, and mucous membranes. Isolation—when this is used, reasons for isolation, types of isolation—differences in the types of isolation, nursingconsiderations, patient response, patient transport, linen removal, specimen, = Isolation is used when you have a patient with an infection that is very contagious or when you aren’t surewhat kind of infection the patient has and you don’t want to risk spreading it to others. = Three types of isolation: o Contact isolation: used for direct or indirect contact. It can be touching the patient’s things or theirbodily fluids. Nurse should wear gloves and gown to protect from infection. If the patient needs tobe transported then they should wear a gown. o Droplet: within 3 feet of the patient a surgical mask and gloves when necessary. Patient should wear a surgical mask if they need to be transported. o Airborne: patients should be in a special room with a negative air flow. A N95 respirator should be worn when entering the room. If a patient needs to be transported then they should wear a surgicalmask = Apatient may feel lonely, have altered body images, and disrupted social relationships. A nurse should take this into consideration and possibly help by educating the family on isolation measures, listen to the patients, open the blinds for them, provide comfort measures, and encourage the patient to move if eligible. Sterile procedures—skill of doing sterile dressing, principles of surgical asepsis, when to use surgicalasepsis, proper skill of placing on sterile gloves Isolation is used when you have a patient with an infection that is very contagious or when you aren’t sure what kind of infection the patient has and you don’t want to risk spreading it to others. - Three types of isolation: Contact isolation: used for direct or indirect contact. It can be touching the patient’s things or ° theirbodily fluids. Nurse should wear gloves and gown to protect from infection. If the patient needs tobe transported then they should wear a gown. o Droplet: within 3 feet of the patient a surgical mask and gloves when necessary. Patient should wear a surgical mask if they need to be transported. o Airborne: patients should be in a special room with a negative air flow. A N95 respirator should be worn when entering the room. If a patient needs to be transported then they should wear a surgicalmask A patient may feel lonely, have altered body images, and disrupted social relationships. A nurse should take this into consideration and possibly help by educating the family on isolation measures, listen to the patients, open the blinds for them, provide comfort measures, and encourage the patient to move if eligible. PPE- placing on and taking off, proper order to remove = Put on gown, mask, googles, and gloves last, always outside the room or in ante-room = Taking off with a tie gown: take off gloves first, then goggles, then gown, then mask. Without a tie: gownand gloves first, goggles, and then mask. Always wash hands afterwards. Mobility and Immobility Safe patient handling guidelines = -determine the amount and type of assistance required for safe positioning, including any transfer equipment and the number of personnel to safely transfer and prevent harm to patient and health careproviders = -raise the side rail on the side of the bed opposite of where you are standing to prevent the patient from falling out of bed on that side = -arrange equipment so it does not interfere with the positioning process = -evaluate the patient for correct body alignment and pressure risks after repositioning Systemic effects of immobility-review all body affects from immobility, how this affects patient and nursing actionsto prevent and treat these effects = Endocrine system -immobility disrupts normal metabolic functioning: decreasing the metabolic rate; altering ° themetabolism of carbohydrates, fats, and proteins; causing fluid, electrolyte, and calcium imbalances; and causing gastrointestinal disturbances such as decreased appetite and clowing peristalsis o -immobility causes the release of calcium into the circulation; normally kidneys filter this but they are unable to respond correctly resulting in hypercalcemia o -GI function is impaired by decreased mobility = Respiratory o -atelectasis: collapse of alveoli o -hypostatic pneumonia: caused by the pooling of secretion in the lungs during immobility o -decreased diffusion and perfusion = Cardiovascular System « -Back-injury resource nurses « -An “after-action review” that allows the health care team to apply knowledge about moving patients safelyin different settings « -Ano-lift policy Assistive devices correct size, measurement and usage for patient, teaching associated with these devicesCane « -Two common types of canes are the single straight-legged cane and the quad cane. « -The single straight-legged cane is more common and is used to support and balance a patient withdecreased leg strength. « -The quad cane provides the most support and is used when there is partial or complete leg paralysis or some hemiplegia. « -Have the patient keep the cane on the stronger side of the body. « -For maximum support when walking, the patient places the cane forward 15 to 25 cm (6 to 10 inches), keeping body weight on both legs. The weaker leg is moved forward to the cane so body weight is dividedbetween the cane and the stronger leg. The stronger leg is then advanced past the cane so the weaker leg and the body weight are supported by the cane and weaker leg. During walking the patient continually repeats these three steps. « -The patient needs to learn that two points of support such as both feet or one foot and the cane are on the floor at all times. Crutches ¢ — -Position the handgrips so the axillae are not supporting the patient’s body weight. « -Pressure on the axillae increases risk to underlying nerves, which sometimes results in partial paralysis ofthe arm. « — -Determine correct position of the handgrips with the patient upright, supporting weight by the handgrips with the elbows slightly flexed at 20 to 25 degrees. « -Elbow flexion may be verified with a goniometer. « -When you determine the height and placement of the handgrips, verify that the distance between the crutchpad and the patient’s axilla is approximately 2 inches (two to three finger widths). Review uses of restraints-types, uses, legal issues, preventing patients from having to be in restraints « — -soft limb restraints « — -leather restraints « — -chemical restraints « © Reduce the risk of patient injury from falls « + Prevent interruption of therapy such as traction, IV infusions, nasogastric (NG) tube feeding, or Foleycatheterization « © Prevent patients who are confused or combative from removing life-support equipment « © Reduce the risk of injury to others by the patientRestoring activity with chronic illnesses Increase activity and exercise to help living outcomes with chronic illnesses Vital Signs Reason VS are completed on patients To tell us the status of the patient. Baseline: done at the beginning of the shift to tell the patient’s normal ranges What are the 6 VS that are taken on patients? 1) Temperature 2) Pulse 3) Oxygen Saturation 4) Blood Pressure 5) Respiratory Rate 6) Pain level Guidelines for taking VS It is the nurse’s responsibility to ensure accurate data is collected. This means making sure the equipment is thecorrect size for the patient and that it is working properly, and that the correct technique is being used. Frequency of VS - Baseline (beginning of the shift)- so you have a starting point to compare to in case of patient statuschanges - When you observe changes in patient status (to see if vitals indicate any further information) - Before certain medication administration (based on contraindications and indications for medications) - When might you obtain vital signs more frequently? — post operatively, during blood administration, forcertain medications/drips, and certain patient conditions. Temperature- + Normal ranges Axillary (36.5C/ 97.7F), Oral and Tympanic (37C/ 98.6F), Rectal and Temporal (37.5C/ 99.5F) + Temperature sites — nursing considerations o Axillary- long measurement times and not as accurate o Oral- Hot/cold beverages and food may alter results o Tympanic- Not as accurate, position correctly in children under three o Rectal- Contraindicated in patients with diarrhea, GI bleed, rectal surgery/disorders o Temporal- Inaccurate if the patient is diaphoretic + Factors that influence temperature Age, exercise, hormone levels, circadian rhythms, stress, and the environment Pulse- * — Correct assessment of pulse Find the rate, rhythm, strength, and equality + Normal range of adult pulse60-100 beats per minute + Locations of pulse, factors that influence a pulse rate Temporal (children), carotid (emergency), brachial (getting a blood pressure), radial (routine vital signs andcirculation status), femoral (emergencies — shock), popliteal (used for lower extremity blood pressure whennecessary), posterior tibial (circulation status to foot) and dorsalis pedis (circulation status to foot). Different pulses may be used at different times to assess circulatory status and obtain vital signs. Apicalpulse is used when the radial is irregular, difficult to obtain, or patient takes certain cardiac medications.Factors that influence a pulse includes exercise, temperature, pain & anxiety, medications, hemorrhage,postural changes, and pulmonary conditions + Difference in apical and peripheral pulses When palpating peripheral pulses, locate the pulse site and using firm pressure with the first two fingers,palpate for a pulse. Do not use the thumb, as it has its own pulse. You must auscultate the apical pulse located at the PMI. You should use the diaphragm of the stethoscope and you should listen for a full minute. * Correct use of stethoscope to auscultate an apical pulse Use diaphragm and listen for one full minute o What sounds are heard using bell and diaphragm of stethoscope, character of pulses, pulse deficit nursing process related to pulse Diaphragm is used to listen to the high pitched sounds, which would be the regular heart beat sound (lub-dub). Bell is used to hear heart murmurs. Character of pulses is the rate, rhythm, strength, and equality. Pulse deficit is the difference in a minute's time between the number of beats of the heart and the number of beats of the pulse observed in diseases of the heart. Some nursing diagnoses are activity intolerance, anxiety, decreased cardiac output, deficien/lexcess fluidvolume, impaired gas exchange, acute pain, and ineffective peripheral tissue perfusion. Outcome planning is focused on treating the underlying cause for the pulse abnormality. The goal is the getthe pulse back to normal. Respirations- « — Ventilation/perfusion/diffusion Ventilation is the movement of gas into and out of the lungs. Perfusion is oxygenation of tissues through distribution of red blood cells to and from the pulmonary capillaries. Diffusion could be the movement ofoxygen to the blood vessel or carbon dioxide back to the lungs. + — Correct assessment of respirations ~Assess ventilation by determining respiratory rate, depth, rhythm and end-tidal carbon dioxide (ETCO2)value. Assess diffusion and perfusion by determining oxygen saturation. ~Accurate assessment of respirations depends on the recognition of normal thoracic and abdominal movements. During quiet breathing, the chest wall gently rises and falls. Contraction of the intercostal muscles between the ribs or contraction of the muscles in the neck and shoulders (the accessory muscles ofbreathing) is not visible. During normal quiet breathing, diaphragmatic movement causes the abdominal cavity to rise and fall slowly ~To assess respirations: Do not let a patient know that you are assessing respirations. A patient aware of the assessment can alter the rate and depth of breathing. Assess respirations immediately after measuring pulserate, with our hand still on the patient’s wrist as it rests over the chest or abdomen. If the rhythm is regular count respirations for 30 seconds and multiply by 2. ~Always assess the quality to get an accurate picture of patient status. What does the quality tell us? Depth —shallow/labored breathing does not allow for full ventilation of the lungs, Rate/Rhythm — if the patienthas tachypnea (over 20) or bradypnea (under 12) ventilation is altered, Effort — if patient is reporting dyspnea or difficulty breathing there may be a ventilation or oxygenation problem. How do you know ifyour patient is dyspneic? Subjective patient report, anxiety, diaphoresis, tripod positioning, use of refractory muscles + Normal respiratory rate pulse oximeter reading and end tidal CO2 monitoring Normal pulse ox reading is 95-100%. Normal ETCO2 is 35-45mmHg + Factors that influence a respiratory rate, alterations in breathing pattern, nursing process related torespirations ~Exercise — increased rate and depth to meet oxygen demands ~Pain/anxiety — pain makes breathing becomes shallow and anxiety increases the rate ~Lung Diseases — Certain lung tissue damage may cause issues with oxygenation (diffusion & perfusion)and so the respiratory rate and depth may be increased to compensate ~Smoking — Chronic smoking leads to many lung diseases as it causes tissue damage and the respiratory rate will increase ° ° Obtain information on when the patient took the medication last. Obtain information on the patient’s learning needs related to prescribed medications. Order review — ensuring all order contents are present, what to do if something is incorrect or order components aremissing ° ° When reviewing orders the nurse assesses the order for accuracy and preparation considerations. Orders should use approved abbreviations only — see table 32-7 for a list of inappropriate abbreviations thatmight be used. Dosages should be clear — no use of trailing zeros or naked decimal points. Example: .50 or .5 — these are error prone Orders should contain drug name, dose, route, frequency, rationale and any special instructions. Consider nursing implications of orders when reviewing. 6 Rights: Right medication, right dose, right patient, right route, right time, right documentation How doyou find out that information? Look up your medications until you are used to standard doses and drug information associated with the drug) Nurses should know the considerations associated with each drug. These include: assessments to make prior to/during administration, how to evaluate the effectiveness of the drug, contraindications and safetyparameters when giving the drugs, side effects to be expected, side effects that are considered normal versus dangerous If the order is wrong, contact the physician to verify and then the pharmacy to change 3 Checks — what they are when to do them ly 2) 3) ° ° ° Dispense Preparation Bedside ‘When you are comparing the MAR to the drugs when dispensing When you are preparing the medications At the immediate bedside prior to giving to the patient6 rights — what they are and how to assess each The right Grug ‘© Is this the medication the physician ordered? ‘= Does the medication label match the MAR? ‘© Verify the drug's expiration date. © Ifthe drug is unfamiliar. consult a drug guide ora pharmacist. ‘The right dose ‘© Is this the dose the physician ordered? ‘= Perform any necessary conversions or calculations. ‘© you need to cut or crush the medication. check with 2 pharmacist or a drug guide first. The right route ‘= Can this medication be given by the route ordered? ‘© If giving an injection. verify that the preparation is for parenteral use. The right time ‘= Is time for you to give the medication? The right patient (© Was the medication ordered for this patient? © Use two identifiers to confirm that you have the ‘© Hyou did net give the medication. indicate on the MAR and document in the purses’ notes the reason you did not give it Proper administration technique: + IV push (ampules versus vials) Injection of a bolus or small volume of medication through an existing IV siteAmpules: o Contain single doses of medication in a liquid. o They are available in several sizes, from 1 mL to 10 mL or more. o An ampule is made of glass with a constricted neck that must be snapped off to allow access to themedication. A colored ring around the neck indicates where the ampule is prescored so you can break it easily. o Carefully aspirate the medication into a syringe with a filter needle. The use of a filter needle prevents particulate matter such as small glass fragments from entering the syringe. - Vials o Single-dose or multidose container with a rubber seal at the top. A metal cap protects the seal untilit is ready for use. o Vials contain liquid or dry forms of medications. Medications that are unstable in solution are packaged dry. The vial label specifies the solvent or diluent used to dissolve the medication andthe amount of diluent needed to prepare a desired medication concentration. o Normal saline and sterile distilled water are commonly used to dissolve medications. o Unlike the ampule, the vial is a closed system, and air needs to be injected into it to permit easy withdrawal of the solution. Failure to inject air when withdrawing creates a vacuum within the vialthat makes withdrawal difficult. If concerned about drawing up parts of the rubber stopper or otherparticles into the syringe, use a filter needle when preparing medications from vials. Some vials contain powder, which is mixed with a diluent during preparation and before injection. IV piggyback Infusion of a solution containing the prescribed medication and a small volume of IV fluid through anexisting IV line Piggyback administration: - Asmall (25 to 250 mL) IV bag or bottle connected to a short tubing line that connects to the upper Y- portof a primary infusion line or to an intermittent venous access. The label on the medication follows the ISMP IV piggyback medication label format. The set is called a piggyback because the small bag or bottle is higher than the primary infusion bag or bottle. In the piggyback setup the main line does not infuse when the piggybacked medication is infusing.The port of the primary IV line contains a back-check valve that automatically stops flow of the primary infusion once the piggyback infusion flows. After the piggyback solution infuses and the solution within the tubing falls below the level of the primary infusion drip chamber, the back-check valve opens, and the primary infusion again flows.Can be given intermittently or with a continuous infusion. Flush before and after administration of IV piggyback and syringe pump medications. IM, Subcutaneous, intradermal injectionsIM o Can be given in the deltoid, ventrogluteal, or vastus lateralis o Z-track method to minimize local skin irritation by sealing the medication in muscle tissue o Use new needle for injection o Place the ulnar side of the nondominant hand just below the site and pull the overlyingskin and subcutaneous tissues approximately 2 to 3 cm (1 to 1.2 inches) laterally or downward. Hold the skin in this position until you administer the injection. o After preparing the site with an antiseptic swab, inject the needle deep into the muscle. o Grasp the barrel of the syringe with the thumb and index finger of the nondominant handand slowly inject the medication if there is no blood return on aspiration. o The needle remains inserted for 10 seconds to allow the medication to disperse evenly rather than channeling back up the track of the needle. o Release the skin after withdrawing the needle. o This leaves a zigzag path that seals the needle track where tissue planes slide across oneanother. The medication cannot escape from the muscle tissue. Subcutaneous o Subcutaneous tissue is not as richly supplied with blood as the muscles - medication absorption isslower than with IM injections o The best subcutaneous injection sites include the outer posterior aspect of the upper arms, the abdomen from below the costal margins to the iliac crests, and the anterior aspects of the thighs. o The injection site you choose needs to be free of skin lesions, bony prominences, and largeunderlying muscles or nerves. Insulin syringes are dosed in 100 units. Use insulin syringes for insulin only. Usually dark orange in color Injections must be verified by another RN There are different types of insulin that have various onset and peaks of action — this is importantinformation to know when you are administering insulin o000 Factors affecting bowel elimination ° 20 O° of0%0 o 0° Age: Infants have a smaller stomach capacity, less secretions of digestive enzymes and more rapid intestinalperistalsis. The ability to control defecation does not occur until 2-3 years. Older adults have decreased chewing ability, peristalsis declines, esophageal emptying slows, impairedabsorption, decreased muscle tone in the perineal floor and anal sphincter Diet: Regular intake, fiber (whole grains, fresh fruits, vegetables) Fluid Intake: 3L/day for men; 2.2L/day for women; fluid liquefies intestinal contents by absorbing into the fiber from thediet to create a larger, softer stool mass Physical Activity: Promotes peristalsis, immobility depresses it; encourage early ambulation after illness Stress: The digestive process is accelerated, and peristalsis is increased (diarrhea/gaseous distention) Personal Habits: Own toilet, at a convenient time Squatting is the normal position for defecation, lean forward to exert intraabdominal pressure; supineposition for defecation is difficult; raise the HOB for patient on a bedpan Pain: hemorrhoids, rectal surgery, anal fissures, post-partum vaginal delivery with tearing Pregnancy: As the size of the baby increases, pressure is placed on the rectum, slowing of peristalsis and constipation Surgery: General anesthesia causes cessation of peristalsis, any surgery that involves direct manipulation of thebowel temporarily stops peristalsis (ileus) Medications: Opioids- decrease peristalsis Laxatives/stimulants- increase peristalsis How do antibiotics affect bowel elimination? - decrease Diagnostic Examinations: Diagnostic examinations involving visualization of GI structures often require a prescribed bowelpreparation (what is this?) to ensure that the bowel is empty. Usuallly patients are NPO prior to endoscopy/colonoscopy (tests that visualize the bowel) After the procedure the patient may experience gas or loose stools GI assessment - Bristol stool chart/various stool colors and nursing actions associated with each Usual pattern/routines Determination of the usual elimination pattern: Include frequency and time of day. Having the patient or caregiver complete a bowel elimination diary provides an accurate assessment of a patient’s current bowelelimination pattern. Identification of routines followed to promote bowel elimination: Examples are drinking hot liquids, eating specific foods, or taking time to defecate during a certain part of the day. Use of laxatives, enemas, or bulk- forming fiber additives. Usual stool characteristics Patient’s description of usual stool characteristics: Determine if the stool is normally watery or formed, softor hard, and the typical color. Ask the patient to describe a normal stool’s shape and the number of stools per day. Use a scale such as the Bristol Stool Form Scale to get an objective measure of stoolcharacteristics. Nutritional screening Changes in appetite: Include changes in eating patterns and a change in weight (amount of loss or gain). Ifa loss of weight is present, ask if the patient intended to lose weight, as with a diet or exercise routine or ifit happened unexpectedly. Diet history Determine the patient’s dietary preferences for a day. Determine the intake of fruits, vegetables, wholegrains, and regularity of mealtimes. Description of daily fluid intake This includes the type and amount of fluid. The patient often estimates the amount using commonhousehold measurements. Past _medical/surgical history History of surgery or illnesses affecting the GI tract: This information helps explain symptoms, the potential for maintaining or restoring normal bowel elimination pattern, and whether there is a familyhistory of GI cancer. Medication history Medication history: Ask the patient for a list of all the medications they take and assess whether there areany such as laxatives, antacids, iron supplements, and analgesics that alter defecation or fecal characteristics. Psychosocial history, Emotional state: The patient’s emotional status may alter frequency of defecation. Ask the patient if theyhave experienced unusual stress, and if they feel this may have caused a change in bowel movements. Social history: Patients have many different living arrangements. Where patients live affects their toileting habits. If the patient shares living quarters, ask how many bathrooms there are. Find out if the patient has toshare a bathroom, creating a need to adjust the time they use the bathroom to accommodate others. If the patient lives alone, can they ambulate safely to the toilet? When patients are not independent in bowel management, determine who assists them and how. Pain assessment History of pain or discomfort: Ask the patient whether there is a history of abdominal or anal pain. The type, frequency, and location of pain help identify the source of the problem. For instance, cramping pain,nausea, and the absence of bowel movements could indicate that there is an intestinal obstruction. Mobility assessment Mobility and dexterity: Evaluate patients’ mobility and dexterity to determine if they need assistive devicesor help from personnel. History of exercise ¢ Ask the patient to specifically describe the type and amount of daily exercise The Bristol Stool Chart ery, NO Solid pieces. ENTIRELY LIQUID - Inspect all four abdominal quadrants. - Auscultate the abdomen with a stethoscope to assess bowel sounds in each quadrant. - Use percussion to identify underlying abdominal structures and detect lesions, fluid, or gas within theabdomen. - Gently palpate the abdomen for masses or areas of tenderness. - What does absent or hypoactive bowel sounds indicate? Ileus - What does hyperactive bowel sounds indicate? Small intestinal obstruction and inflammatory disorders: «Rectum - Inspect the area around the anus for lesions, discoloration, inflammation, and hemorrhoidsFecal occult blood testing- what it detects « Fecal occult blood test (FOBT) also called hemoccult « A common laboratory test that patients perform at home or nurses perform at the patient’s bedside is thefecal occult blood test (FOBT), or guaiac test, which measures microscopic amounts of blood in feces. + Apply the fecal specimen on guaiac paper and then apply the Hemoccult developing solution on guaiac paper on the reverse side of the test kit. « — It is useful as a diagnostic screening tool for colon cancer. The noninvasive FOBT is one of five colorectalcancer screening regimens recommended by the American Cancer Society. Three types of FOBT are available to date. They include the most commonly used guaiac fecal occult blood test (gFOBT), the immunochemical fecal occult blood test (iFOBT), and the stool deoxyribonucleic acid (DNA) test. * One positive gFOBT result does not confirm GI bleeding. You need to repeat the test at least 3 times while the patient refrains from ingesting foods (e.g., some raw vegetables, red meat, poultry, fish) and medications (e.g., vitamin C, aspirin, nonsteroidal anti-inflammatory drugs) that cause false- positiveresults. « — Patients who take anticoagulants or who have a bleeding disorder or a GI disorder known to cause bleeding (e.g., intestinal tumor, bowel inflammation, ulcerations) need regular screening for fecal occult blood. Bedpans-types, how to properly place patient on bedpan, when fracture pans are most commonly used * — Two types of bedpans are available: « Regular bedpan has a curved smooth upper end and a sharper-edged lower end and is 2 inches deep. « — The smaller fracture pan, designed for patients with lower-extremity fractures has a shallow upper end. andis about 1 inch deep. - The shallow end of the bedpan fits under the buttocks behind the sacrum, the deeper end goes under the patient’s thighs. - Ensure that if this is used the bedpan is back far enough for feces to go into it. « When positioning a patient, it is important to prevent muscle strain and discomfort. Never try to lift a patient onto a bedpan. Never place a patient on a bedpan and then leave with the bed flat unless activityrestrictions demand it. This forces the patient to hyperextend the back to lift the hips onto the pan. « The proper position for the patient on a bedpan is with the head of the bed elevated 30 to 45 degrees. When patients are immobile or it is unsafe to allow them to raise their hips, it is safest for the caregiver and thepatient to roll them onto the bedpan. + Always wear gloves when handling a bedpan. « When patients are immobile or it is unsafe to allow them to raise their hips, they remain flat and roll ontothe bedpan by using the following steps: - 1. Lower the head of the bed flat, and help the patient roll onto one side, backside toward the nurse. - 2. Apply a small amount of powder to back and buttocks, or cover bedpan edge with tissue to prevent skinfrom sticking to the pan. - 3. Place the bedpan firmly against the buttocks, down into the mattress, with the open rim toward the patient’s feet. - 4, Keeping one hand against the bedpan, place the other around the patient’s fore hip. Ask the patient to rollback onto the pan, flat in the bed. Do not shove the pan under the patient. - 5. With the patient positioned comfortably, raise the head of the bed 30 degrees. - 6. Place a rolled towel or a small pillow under the lumbar curve of the patient’s back for added comfort. - 7, Raise the knee gatch or ask the patient to bend the knees to assume a squatting position. Do not raise theknee gatch if contraindicated. Types of laxatives, common examples, mechanism of action of each type « Antidiarrheal agents decrease intestinal muscle tone to slow the passage of feces. As a result, the bodyabsorbs more water through the intestinal walls. « The most commonly used antidiartheal agents are loperamide and diphenoxylate with atropine. Codeine or tincture of opium may be used for management of chronic severe diarrhea in patients with diseases such asCrohn’s disease, ulcerative colitis, and acquired immunodeficiency syndrome (AIDS). Antidiarrheal agentsthat contain opiates must be used with caution because opiates are habit forming. Bulk forming Least irritating; adds bulk to stool to methylcellulose (Citrucel) & psyllium promote peristalsis (Metamucil) Emollient “Stool softeners”-lower surface tension of —_docusate sodium (Colace) the feces, allowing water and fat to penetrate; short term to be used after surgery Osmotic Osmotic effectincreases pressureinthe _ polyethylene glycol & sodium phosphate bowel to promote peristalsis (Fleet Phospho-soda) Stimulant Cause local irritation to the intestinal Senna & bisacodyl mucosa which increases peristalsis Enemas- types, indications, administration (high/regular/low), hypertonic versus large volume enemas + — An enema is the instillation of a solution into the rectum and sigmoid colon. « The primary reason for an enema is to promote defecation by stimulating peristalsis. The volume of fluidinstilled breaks up the fecal mass stretches the rectal wall and initiates the defecation reflex. Enemas are also a vehicle for medications that exert a local effect on rectal mucosa. « Enemas are most commonly used for the immediate relief of constipation, emptying the bowel before diagnostic tests or surgery and beginning a program of bowel training. « — Cleansing enemas: - Promote the complete evacuation of feces from the colon. They act by stimulating peristalsis through theinfusion of a large volume of solution or through local irritation of the mucosa of the colon. They includetap water, normal saline, soapsuds solution, and low-volume hypertonic saline. - Each solution has a different osmotic effect, influencing the movement of fluids between the colon and interstitial spaces beyond the intestinal wall. - Infants and children receive only normal saline because they are at greater risk for fluid imbalance. « — Tap water is hypotonic and exerts an osmotic pressure lower than fluid in interstitial spaces. After infusioninto the colon, tap water escapes from the bowel lumen into interstitial spaces. The net movement of wateris low. The infused volume stimulates defecation before large amounts of water leave the bowel. Use caution if ordered to repeat tap-water enemas because water toxicity or circulatory overload could developif the body absorbs large amounts of water. « Normal saline is the safest solution to use because it exerts the same osmotic pressure as fluids in interstitial spaces surrounding the bowel. The volume of infused saline stimulates peristalsis. Giving salineenemas lessens the danger of excess fluid absorption. « Hypertonic solutions infused into the bowel exert osmotic pressure that pulls fluids out of interstitial spaces. The colon fills with fluid and the resultant distention promotes defecation. Patients unable to tolerate large volumes of fluid benefit most from this type of enema, which is by design low volume. Thistype of enema is contraindicated for patients who are dehydrated and young infants. A hypertonic solutionof 120 to 180 mL (4 to 6 ounces) is usually effective. The commercially prepared Fleet enema is the mostcommon. « — Soapsuds enema is the tap water or saline enema with soapsuds added to produce intestinal irritation and stimulate peristalsis. - Use only pure castile soap that comes in a liquid form that is included in most soapsuds enema kits. Use soapsuds enemas with caution in pregnant women and older adults because they could cause electrolyteimbalance or damage to the intestinal mucosa. «The health care provider sometimes orders a high (12-1 8inches) or low (3 inches) cleansing enema. The terms high and low refer to the height from which, and hence the pressure with which, the fluid isdelivered. High enemas cleanse more of the colon. « After the enema is infused, ask the patient to turn from the left lateral to the dorsal recumbent, over to the right lateral position. The position change ensures that fluid reaches the large intestine. A low enemacleanses only the rectum and sigmoid colon. « Oil-retention enemas lubricate the feces in the rectum and colon. The feces absorb the oil and become softer and easier to pass. To enhance action of the oil, the patient retains the enema for several hours ifpossible. « Carminative enemas provide relief from gaseous distention. They improve the ability to pass flatus. An example of a carminative enema is MGW solution, which contains 30 mL of magnesium, 60 mL ofglycerin, and 90 mL of water. * Medicated enemas contain drugs. An example is sodium polystyrene sulfonate (Kayexalate), used to treat patients with dangerously high serum potassium levels. This drug contains a resin that exchanges sodium ions for potassium ions in the large intestine. Another medicated enema is neomycin solution, an antibioticused to reduce bacteria in the colon before bowel surgery. An enema containing steroid medication may beused for acute inflammation in the lower colon. « — Giving an enema to a patient who is unable to contract the external sphincter poses difficulties. Give the enema with the patient positioned on the bedpan. Giving the enema with the patient sitting on the toilet isunsafe because the curved rectal tubing scrapes the rectal wall. « Digital removal - break up the fecal mass with the fingers, and remove it in sections. - Digital removal is a last resort in the management of severe constipation and is practiced when all other methods have failed. The procedure is very uncomfortable for the patient. Excessive rectal manipulationcauses irritation to the mucosa, bleeding, and stimulation of the vagus nerve, which results in a reflex slowing of the heart rate. - Because of the potential complications of the procedure, a health care provider's order is necessary to remove a fecal impaction. NG tubes in the treatment of bowel obstruction It allows the bowel to rest by taking the fluids and excess out in the hopes that it will start peristalsis back up on itsown. Patient education: Bowel training, nutrition, fluid intake