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N126 Health Assessment II > Final > Flashcards

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Know the preferred way to monitor the fluid volume status REF: 898-899


Daily weights are an important indicator of fluid status (Metheny, 2010). Each kilogram (2.2 lbs) of weight gained or lost overnight is equal to 1 L of fluid retained or lost. These fluid gains or losses indicate changes in the amount of total body fluid, usually ECF, but do not indicate shift between body compartments. Weigh the patient at the same time each day with the same scale after a patient voids.

Measuring and recording all liquid intake and output (I&O) during a 24-hour period is an important aspect of fluid balance assessment. Compare a patient’s 24-hour intake with his or her 24-hour output. The two measures should be approximately equal if the person has normal fluid balance.
Intake - liquids in food, drinks, IV fluids, blood components
Output - urine, diarrhea, vomitus, gastric suction, and drainage from postsurgical wounds or other tubes. Record a patient’s urinary output after each voiding. (Potter 898)


Know which fluid therapy is given initially REF: 905


Best guess - IV therapy for normal saline .9% - isotonic, won’t cause dangerous shifts in volumes between ECF, ICF, fastest route, only fluid compatible with blood


Know the symptoms of Fluid volume overload REF: 909-913

Extracellular Fluid Volume Excess—Body Fluids Have Increased Volume but Normal Tonicity


Sodium and water intake greater than output, causing isotonic gain:
Excessive administration of sodium-containing isotonic parenteral fluids
Excessive oral intake of salty foods and water
Decreased renal output caused by elevated aldosterone: Chronic heart failure, cirrhosis, aldosterone-secreting tumor
Decreased renal output from other causes: Oliguric acute kidney disease, end-stage chronic renal disease, glucocorticoid excess
Physical examination: Sudden weight gain (e.g., overnight), edema (especially in dependent areas), neck veins full when upright or semi-upright, crackles in dependent portion of lungs, pulmonary edema

Laboratory findings: Decreased hematocrit; BUN less than 10 mg/dL (3.6 mmol/L) caused by hemodilution (Potter 889)


Know the symptoms of Fluid volume overload REF: 909-913

Signs of ECV excess


Gain of 2.2 lbs (1 kg) or more in 24 hours for adults
Pulse rate and character: Bounding
Fullness of neck veins: Full or distended when upright or semi-upright
Lung auscultation, dependent portions: Crackles or rhonchi with progressive dyspnea
Presence of edema: Present in dependent areas (ankles or sacrum) and possibly fingers or around eyes (Potter 899)


Know the symptoms of Fluid volume overload REF: 909-913

Circulatory overload of IV solution


Depends on type of solution
ECV excess with Na+ containing isotonic fluid (crackles in dependent portions of lungs, shortness of breath, dependent edema)
Hyponatremia with hypotonic fluid (confusion, seizures)
Hypernatremia with Na+ containing hypertonic fluid (confusion, seizures)
Hyperkalemia from K+ containing fluid (cardiac dysrhythmias, muscle weakness, abdominal distention)

If symptoms appear, reduce IV flow rate and notify patient’s health care provider.
With ECV excess raise head of bed; administer oxygen and diuretics if ordered.
Monitor vital signs and laboratory reports of serum levels.
Health care provider may adjust additives in IV solution or type of IV fluid; watch for and implement order. (Potter 910)


Differentiate between oliguria anuria and polyuria REF: 1045


An excessive output of urine is polyuria. A urine output that is decreased despite normal intake is called oliguria. Oliguria often occurs when fluid loss through other means (e.g., perspiration, diarrhea, or vomiting) increases. It also occurs in early kidney disease. Often in severe kidney disease no urine is produced (anuria). (Potter 1045)


Identify factors that commonly influence urinary elimination REF: 1045


Most patients with urinary problems are unable to store urine or fully empty the bladder. These disturbances result from impaired bladder function, obstruction to urine outflow, or inability to voluntarily control micturition.
Some patients may have permanent or temporary changes in the normal pathway of urinary excretion. The surgical formation of a urinary diversion temporarily or permanently bypasses the bladder and urethra as the exit routes for urine. The patient with a urinary diversion has a stoma (artificial opening) on the abdomen to drain urine.

Retention occurs as a result of urethral obstruction, surgical or childbirth trauma, and alterations in motor and sensory innervation of the bladder such as occurs with neuropathy secondary to diabetes. It may occur after removal of an indwelling catheter. Medication side effects or anxiety may also result in urinary retention. If a patient cannot void or completely empty the bladder, he or she must be catheterized because a UTI, kidney stones, and hyperreflexia can occur.

Retained or residual urine, also referred to as postvoid residual (PVR), occurs if a patient has urinary retention or cannot empty the bladder completely. Spastic bladders and some medications and problems such as using a bedpan or not sitting upright to void cause inconsistent emptying. (Potter 1046)


Know common causes of urinary tract infections (UTI) REF: 1046-1047


80% of these infections result from the use of an indwelling urethral catheter
Women are more susceptible to infection because of a short urethra and the proximity of the anus to the urethral meatus. In men prostatic secretions containing an antibacterial substance and the length of the urethra reduce the susceptibility to UTIs.
However, men are at increased risk for infection-related renal disease. Older adults and patients with progressive underlying disease or decreased immunity are also at increased risk.
Any condition resulting in urinary retention such as a kinked, obstructed, or clamped catheter increases the risk of a UTI.
Poor perineal hygiene is another cause of UTIs in women. Inadequate handwashing, failure to wipe from front to back after voiding or defecating, and frequent sexual intercourse predispose women to infection.
Another common cause of infection is the introduction of instruments into the urinary tract. For example, the introduction of a catheter through the urethra provides a direct route for microorganisms (Potter 1046-1047)


Know nursing diagnoses appropriate for patients with alterations in urinary elimination REF: 1047 (What are the two types?)


Invasive and non invasive


Name the types of Urinary diagnosis that are non-invasive

Abdominal roentgenogram
Computerized axial tomography (CT) scan
Intravenous pyelogram (IVP)
Urodynamic testing (uroflowmetry)

Name the types of Urinary diagnosis that are invasive


Surgery on the male prostate is also performed using a special endoscope.
Arteriogram (angiography)


Visualize the renal arteries and/or their branches to detect narrowing or occlusion. A catheter is placed in one of the femoral arteries and introduced up to the level of the renal arteries. Radiopaque contrast is injected through the catheter while x-ray film images are taken in rapid succession.
(Question: What type of diagnosis is this, invasive or non invasive and how is this diagnosis done?).


Arteriogram (angiography)


Provide direct visualization, specimen collection, and/or treatment of the interior of the bladder and urethra.
Although this procedure is usually performed using local anesthesia, general anesthesia or conscious sedation is more common to avoid unnecessary anxiety and trauma for the patient
(Question: What type of diagnosis is this, invasive or non invasive and how is this diagnosis done?).




What diagnosis tool is used to perform surgery on the prostate?




What is the checklist after a prostate surgery?


After patient’s return assess the vital signs and the characteristics of urine; monitor intake and output (I&O); encourage fluids; and observe for fever, dysuria, and pain in suprapubic region for bladder distension (expansion)


What is the checklist after an Arteriogram (angiography)?


After the procedure monitor vital signs frequently until stable. Patient maintains bed rest for prescribed time interval. Encourage fluids to flush the contrast from the system. Also monitor the affected extremity for neurocirculatory function (pulse, skin temperature, sensation, and movement) and observe catheter site for bleeding, swelling, increased tenderness, or hematoma formation.
Notify health care provider immediately of any postprocedure abnormality


What are the nursing interventions for urinary retention?

Patient education
Promoting Normal Micturition
Maintaining Elimination Habits

How do you educate patient on urinary retention?


First focus the teaching on their specific elimination problems. For example, patients who practice poor hygiene benefit most from learning about normal sterility of the urinary tract and how frequent handwashing and proper perineal hygiene reduce the risks for infection. Patients also learn the significance of symptoms of urinary alterations so they can initiate early preventive health care. (Potter 1059)


How do you promote normal micturition?


1) Stimulate Micturition Reflex
2) Maintain elimination habits
3) Maintain adequate fluid levels
4) Promote complete bladder emptying
5) Preventing infection


What do the following exercises help to do?
Help patients learn to relax and stimulate the reflex to void by helping them assume the normal position for voiding. A woman voids better - squatting / sitting. A man voids better - standing. Sensory stimuli. The sound of running water. Stroking the inner aspect of the thigh promotes the micturition reflex. You can also pour warm water over the patient’s perineum and create the sensation to urinate. If you need to measure urine output, first measure the volume of water that you pour over the perineal area.


Stimulating Micturition Reflex -


What are the three things the patient depends on in or to have the ability to void (micturition)


1) A patient’s ability to void depends on feeling the urge to urinate,
2) being able to control the urethral sphincter,
3) being able to relax during voiding.


How do you maintain elimination habits?


patients follow routines to promote normal voiding. Integrating patients’ habits into the care plan fosters normal voiding


In regards to the urinary system, why is maintaining adequate fluid intake important? How much should you intake?


helps flush out solutes or particles that collect in the urinary system
normal renal function no heart or kidney disease - drink 2200 to 2700 mL of fluid daily
a minimal daily intake of 1200 to 1500 mL of fluids ok unless the patient has a history of UTI
encourage fluids that the patient prefers, veggies/fruits. At home it helps to set a schedule for drinking fluids (e.g., with meals or medications). To minimize nocturia, avoid fluids 2 hours before bedtime.


How do you Promote Complete Bladder Emptying?


Encouraging patients to wait until urine stops flowing or to attempt to void again (double voiding) can improve bladder emptying (Table 45-5). Urinary retention care includes scheduled toileting (Lewis et al., 2011). In addition, Credé’s method or manual compression of the bladder walls with each attempted void may be used (Madineh, 2008). Instruct the patient to place both hands flat on the abdomen below the umbilicus and above the symphysis pubis with the fingers pointed down toward the bladder dome. Have him or her compress the hands downward against the walls of the bladder while tightening the perineum, contracting the abdominal wall, and holding the breath. The maneuver promotes bladder emptying by relaxing the urethral sphincter. (Potter 1060)


How do you prevent infection of the bladder?


Good perineal hygiene that includes cleaning the urethral meatus after each voiding or bowel movement is essential. A minimal daily fluid intake of 1200 to 1500 mL flushes the urethra of microorganisms. Voiding after intercourse; not using excessive soap or taking bubble baths; wearing cotton underwear; and drinking enough fluids, especially fluids high in acid ash such as apple or cranberry juice help prevent UTI.


What are the things to take into consideration when maintaining elimination habits?


Patients usually require time to void. 30 minutes to provide a specimen. Patients normally void on awakening or before meals. Also important is the need to respond to and anticipate patients’ urges to urinate. Older-adult falls are related to the urge to urinate. Anticipate the need and provide for scheduled bathroom visits to help reduce the fall risk in these patients. Need privacy for voiding. Young children are often unable to void in the presence of persons other than their parents. Special measures - some patients are able to relax and void more easily while reading or listening to music. Having a cup or glass of fluids also promotes urination.


What are the important factors to consider when medications are used as intervention for urinary retention?


Drug therapy given alone or with other therapies often helps problems of incontinence or retention. The bladder is innervated by the parasympathetic nervous system. Drugs that block the muscarinic receptors suppress bladder contractions and reduce incontinence caused by bladder irritation. [solifenacin (Vesicare) and oxybutynin chloride (Ditropan)] Irritants present in the urine such as caffeine or alcohol may cause uncontrolled bladder contractions, and thus patients should avoid them.

When the bladder empties, the detrusor muscle contracts in response to parasympathetic stimulation. Incomplete bladder emptying results from impaired innervation or weakness of the detrusor muscle. The patient experiences retention and possible overflow incontinence. Cholinergic drugs increase contraction of the bladder and improve emptying. Bethanechol (Urecholine) stimulates parasympathetic nerves to increase bladder wall contraction and relax the sphincter.

The dribbling or overflow incontinence seen in men with prostatic enlargement can be treated with an alpha1-adrenergic blocker such as tamsulosin (Flomax).


How is catheterization used as an intervention for urinary retention?


involves introducing a latex or plastic tube through the urethra and into the bladder. The catheter provides a continuous flow of urine in patients unable to control micturition or those with obstructions. It also provides a means of assessing urine output in hemodynamically unstable patients.


What are the risks of using catheters?


Because bladder catheterization carries the risk of UTI, blockage, and trauma to the urethra, it is preferable to rely on other measures for either specimen collection or management of incontinence. (Potter 1060-1061)


What are the primary function of the kidney REF: 1043


The kidneys play a key role in fluid and electrolyte balance
Kidneys filter waste products of metabolism that collect in the blood.
The kidneys produce several substances vital to red blood cell (RBC) production, blood pressure, and bone mineralization. erythropoietin - stimulates RBC production, prolong RBC life, renin - vasoconstriction aldosterone release, aldosterone - water retention, increase blood volume, prostaglandin and prostacyclin - renal blood flow reg through vasodilation, Ca and PO4 regulation - convert vitamin D to active form (Potter 1042-1043)


Identify and differentiate between the different kinds of urinary incontinence


1) Urge incontinence
2) Stress incontinence
3) Hyperactive or overactive bladder


is more common in younger women and may be caused by local irritating factors such as UTIs. Individuals sense the urge to urinate but cannot keep from urinating long enough to reach a toilet.


Urge incontinence


occurs more often in older women when intraabdominal pressure exceeds urethral resistance. Muscles around the urethra become weak; thus even a small amount of urine may leak spontaneously. Some patients may have a mixed form of incontinence that has features of both stress and urge urinary incontinence.


Stress incontinence


is associated with individuals of all ages, but older adults are more likely to have incontinence associated with it following physical and cognitive decline associated with aging and effects of medications (Stewart, 2010). OAB results from sudden, involuntary


Hyperactive or overactive bladder (OAB)


what are guaiac tests for and what may cause a false positive REF: 1091 - 1099


fecal occult blood test (FOBT), or guaiac test, which measures microscopic amounts of blood in feces (Box 46-4). It is useful as a diagnostic screening tool for colon cancer (Box 46-5). One positive gFOBT result does not confirm GI bleeding. You need to repeat the test at least three 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-positive results (Peters, 2008). Patients who take anticoagulants or who have a bleeding disorder or a GI disorder known to cause bleeding (e.g., intestinal tumors, bowel inflammation, or ulcerations) need regular screening for fecal occult blood. (Potter 1099-1100)


where do Fecal impactions most likely occur & why


Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon. If not resolved or removed, severe impaction often results in intestinal obstruction. (Potter 1091-1092)

best guess why in rectum - rectum lacks teniae coli and haustra, smooth muscles that move feces, so rest of GI (small/large intestine) feces getting moved, rectum also is the last place before defecation, feces too dry/hard get stuck there


What is the relationship between narcotic analgesics and bowel elimination REF: 1091| 1101-1102


Opioid analgesics - Slow peristalsis and segmental contractions, often resulting in constipation (Lehne, 2010) (Potter 1091)


What are the nursing implications for common diagnostic examinations of the gastrointestinal tract REF: 1101


17.1. Upper GI/ Barium Swallow
x-ray film examination using a barium (an opaque contrast medium) examines the structure and motility (activity) of GI tract, pharynx, esophagus & stomach
before:- NPO after midnight & remove all jewelry or other metallic objects
after: drinks lots of H2O - facilitate passage of barium
17.2. Upper Endoscopy
lighted fiber optic tube w/ lens, forceps, and brushes for biopsy
same prep as Upper GI
light sedation required

17.3. Barium Enema with Air Contrast
x-ray w/ opaque contrast medium w/ air -> lower GI (colon & rectum)
NPO after midnight
bowel prep e.g. magnesium citrate or enemas

17.4. Ultrasound
high frequency sound waves echo off body organs-> picture
preparation depends on the organ like NPO or none

17.5. Colonoscopy
uses colonoscope inserted in the rectum
endoscopic examination of entire colon
day before: no drink the day before
bowel cleanser e.g. Go Lytely
light sedation

17.6. Felxible Sigmoidoscopy
interior of sigmoid colon w/ flexible or rigid lighted tube
same as colonoscopyor barium enema preparation
light sedation

17.7. Computerized Tomography Scan
x-ray different angles of body using a computer
usually NPO preparation 
patient lie very still
claustrophobia? -> light sedation
17.8. Magnetic Resonance Imaging
noninvasive, uses magnet and radio waves
picture of the inside of the body
NPO 4-6 hours before
remove all jewelry or other metallic objects on clothes and inside the room

17.9. Enteroclysis
jejunum to study entire small intestine
24 hour prep of clear liquid diet & colon cleansing e.g. GoLytely or enemas


Know the procedure for administering an enema REF: 1107| 1113


wear gloves, sterile technique not necessary. explain procedure (position, precautions to take to avoid discomfort, length of time to retain the solution before defacation).
at three enemas take caution - it depletes fluids and electrolytes
call health care provider if 3 enemas not enough
patient sitting on a bedpan

Delegation Considerations:

- Can be done by CNA, but nurse must assess it first for comfort, positioning, satble vs
- Instruct CNA: proper positioning of patients who have mobility restrictions, or other  therapeutic equipments e.g. IVs, drains, catheters, traction and when to stop doing the procedure because of abdominal pain, cramping, distention, or rectal bleeding

Assessment Proper:

  • last BM, bowel patterns, hemorrhoids, external sphincter control; abdominal pain
  • presence of increased intracranial pressure, glaucoma or recent rectal aor prostate surgery
  • patient’s medical record to clarify rationale of enema
  • review healthcare provider’s order of enema
  • 2 patient identifiers verification
  • abdominal assessment

- explain purpose of enema; determine patient’s understanding
- collect appropriate equipments and arrange at bedside
- assemble enema bag w/ appropriate solution and rectal tube
- hand hygiene and gloves
- privacy
- raise bed to appropriate working height and raise side rail on person’s left
- assist patient into Sim’s position w/ right knee flexed
- if patient is suspected of poor sphincter control, prep bedpan because of difficulty of retaining enema solution
- waterproof pad under hips and buttocks
- cover patient w/ blanket only butt exposed
- have bedside or commode easily accessible

  • Administering edema (main topic in question 18)

a. Enema bag
Add warm solution to enema bag using tap water flowing from the faucet. In a basin of hot water place saline container. Check temperature by pouring small amount over inner wrist. Raise container, release clamp and allow solution to flow long enough to fill tubing. Reclamp tubing. Lubricate 6-8 cm of tip of rectal tube w/ water soluble lubricating jelly.

Gently separate buttocls and locate anus. Instruct patient to relax by breathing out slowly through mouth. ouch patient’s skin next to anus with tip of rectal tube.

Next procedure in picture below (insert tubing of enema bag slowly pointing to the patient’s umbilicus)

Length varies by age:

Infant 2.5-3 cm (1-1.5 inches)
Child 5-7.5 cm (2-3 inches)
Adolescent 7.5-10 cm ( 3-4 inches)
Adult 7.5-10 cm (3-4 inches)

Hold tubing in rectum constantly until end of fluid instillation. Open regulating clamp and allow solution to enter slowly with container at patient’s hip level. Raise height of enema container slowly to appropriate level above anus:

high enema 30-45 cm (12-18”)
regular enema 30 cm (12”)
small enema 7.5 cm (3”)

Lower container to decrease flow of solution or clamp tubing if patient experiences cramping or fluid escapes around rectal tube. Clamp tubing after all solution is instilled. If pain occurs, stop procedure and call physician immediately. Do not force tube.

b. prepackaged disposable container

Remove plastic cap from rectal tip. Tip is already lubricated. Gently separate buttocks and locate rectum by breathing slowly through mouth. Insert tip gently to rectum with lenght same as the the length above for adult, adolescence, children and infants.

Squeeze bottle until all solution has entered the rectum & colon. Instruct patient to retian solution until urge to defacate occurs (2-5 min). Place layers of toilet around anus and getly w/draw rectal tube. Explain that feeling of distention is normal.

Discard enema container and tubing in proper receptacle or rinse with warm water and soap.
Assist patient to bathroom or help to position on bedpan. Assist cleaning if necessary. Remove and discard gloves and perform hand hygiene. 

- assess stool, abdomen, pain

When enemas are ordered “until clear” observe contents of solutions passed. “Clear” means no solid fecal materials exists, but the solution sometimes remains discolored.


Know the primary function of the components of the respiratory system


exchange of gases between blood and environment
respiration - exchange of oxygen and carbon dioxide during cellular metabolism
ventilation - process of moving gases in and out of lungs
perfusion - process of moving o2 blood in tissues and de-o2 blood back to lungs
intrapleural pressure is less than 760 mgHg at sea level (arterial carbon dioxide tension 35-45mmHg; arterial oxygen tension 80-100 mmHg).
oxygen from inspired air diffuses from alveoli in the lung into the blood in the pulmonary capillaries (J.Thompson’s ppt)
carbon dioxide produced during cell metabolism diffuses from the blood into the alveoli and is exhaled (J.Thompson’s ppt)
diaphragm relaxed and intercostal muscles allow air to escape from the lungs
for exchange of gases to occur, the organs, nerves, and muscles of respiration need to be intact, and the CNS need to be able to regulate the respiratory cycle.
surfactant - chemical produced in the lungs to maintain the surface tension of the alveoli and keep them from collapsing


What is atelectasis?


partial or complete collapse of the lung.


Describe the pathophysiology of atelectasis REF: 822-826



  • from hypoventialtion - alveolar ventilation decreases, co2 retains
  • collapse of alveoli that prevents normal exchange of oxygen and carbon dioxide
  • inadequate to meet o2 demand of the body or eliminate co2. alveoli collapse lung less ventilated

Know the interventions for IV infiltration (the escape of fluid into the subQ tissue; due to dislodged needle to the penetrated vessel wall).

What are the signs and symptoms?


remove the IV immediately; elevate the extremity and apply compress (warm or cool depending on the IV solution that was infusing & the physician’s prescriotion) over the affected area.
Signs and Symptoms: Swelling/pallor/coldness/pain around infusion site; significant decrease in the flow rate


list the devices used to deliver oxygen to patient in the order of lowest to highest oxygen delivery percentage.

  1. Nasal Canula (NC) - low concentrations;
  2. Simple Face Mask - higher concentration than NC
  3. Partial rebreather Mask - 60-80%; shorter period use only; rebreathes ⅓ of exhaled breathe that is high in o2 (skills lab)
  4. Non-rebreather Mask - highest concentrations 80-95%
    - for patients with physical trauma, chronic airway limitation/chronic obstructive pulmonary diseases, cluster headache, smoke inhalation, andcarbon monoxide poisoning, or any other patients who require high-flow oxygen, but do not require breathing assistance (wikepedia)

Explain the concept of perioperative nursing care


preoperative - before surgery; to ensure that the client is mentally and physically prepared for surgery
intraoperative - during surgery; to maintain client’s safety & homeostasis
postoperative - after surgery; promote comfort and healing; restore wellness of the highest level; prevent associated risks

fast-paced, changing and challenging field
nurse principles:
high quality and patient safety-focused care
multidisciplinary teamwork
effective therapeutic communicationand collaboration with patient, patient’s family and surgical team
Effective and efficient assessment and intervention in all phases of surgery.
Advocacy for the patient and the patient’s family
Understanding of cost containment

practice strict surgical asepsis, thoroughly document care, and emphasize patient safety in all phases of care


Know the reasons for assessment prior to surgery REF: 1369


to identify the patient’s normal preoperative function to recognize, prevent, and minimize possible postoperative complications
to make patient-centered decisions required for safe nursing care
not to waste time; to reveal any abnormality that delays or cancels surgery


Know the reasons for postoperative patient using the incentive spirometer


is a medical device used to help patients improve the functioning of their lungs. It is provided to patients who have had any surgery that might jeopardize respiratory function, particularly surgery to the lungs themselves,[1] but also commonly to patients recovering from cardiac or other surgery involving extended time under anesthesia and prolonged in-bed recovery. The incentive spirometer is also issued to patients recovering from rib damage to help minimize the chance of fluid build-up in the lungs….also helps with the expansion of lungs


Know how to protect an abdominal incision during coughing exercises


Splint the incision with you hands, a pillow or bath towel. Coughing and breathing causes the stitches of an incision to stretch and causes stress/discomfort to abdominal tissue. To prevent this from happening use you hands on both sides of incision to keep the stitches of the incision from coming undone (splint), or use pillow or towell . Splinting provides firm support and reduces pulling.


What are the post operative exercises?


1) diaphragmatic breathing,
2) coughing,
3) incentive spirometer use,
4) turning
5) leg exercises.


is breathing that is done by contracting the diaphragm, a muscle located horizontally between the chest cavity and stomach cavity. Air enters the lungs and the belly expands during this type of breathing.


Diaphragmatic breathing:


(This is done in the Semi Fowler Position) Explain to patient how to place mouthpiece of IS so lips completely cover mouthpiece (see illustration). Have patient demonstrate until position is correct.
Instruct patient to inhale slowly and maintain constant flow through unit, attempting to reach goal volume. When patient reaches maximal inspiration, have him or her hold breath for 3 to 5 seconds (see illustration) and exhale slowly (Pruitt, 2006). Ensure that number of breaths does not exceed 10 to 12 per minute.


incentive spirometer:


How do you do post operative exercise of “coughing”?


Explain importance of maintaining upright semi-Fowler’s or sitting position.
If surgical incision will be either abdominal or thoracic, teach patient to place pillow or bath blanket over incisional area and place hands over pillow to splint incision. During breathing and coughing exercises, have patient press gently against incisional area for splinting or support (see illustration).
Instruct and show how to inhale deeply a third time and hold breath to count of three. Cough fully for two or three consecutive coughs without inhaling between coughs. (Tell patient to push all air out of lungs.)
Have patient practice coughing exercises, splinting imaginary incision. Instruct patient to cough 2 to 3 times every 2 hours while awake.
Instruct patient to look at sputum each time for consistency, odor, amount, and color changes and what to report to nurse.


How do you do post operative exercise of “Leg exercise”?


Have patient assume supine position in bed. Guide through leg exercises by helping him or her perform passive range-of-motion exercises while simultaneously explaining exercise.
Rotate each ankle in complete circle. Instruct patient to draw imaginary circles with big toe (see illustration). Repeat 5 times.
Alternate dorsiflexion and plantar flexion of both feet. Direct patient to feel calf muscles contract and relax alternately (see illustrations A and B). Repeat 5 times.
Perform quadriceps setting by tightening thigh and bringing knee down toward mattress, then relaxing (see illustration). Repeat 5 times.
Have patient alternately raise each leg straight up from bed surface, keeping legs straight; have patient bend leg at hip and knee (see illustration). Repeat 5 times.


Know what to include in a preoperative teaching plan


Provided in a systematic and structured format with teaching and learning principles, preoperative teaching regarding a patient’s expected postoperative course has a positive influence on the patient’s recovery
It is ideal to attempt perioperative education before admission, during the hospital stay, and after discharge. Including family members in perioperative preparation is advisable
Perioperative preparation of family members before surgery lessens anxiety and misunderstanding.
Provide patients with information about sensations typically experienced after surgery. Preparatory information helps them anticipate the steps of a procedure and thus form realistic images of the surgical experience. eg: in the OR the anesthesia provider applies ointment to patients’ eyes to prevent corneal 12671268damage. Warning patients about sensations of blurred vision reduces their anxiety on awakening from surgery


Know how to Prepare a patient for surgery


Preparing a patient for surgery involves activities and procedures that help to decrease anxiety, ensure patient safety, and decrease the risk for complications (Perry 883)
Provide information to patients about what will occur during the perioperative experience and which sensations a patient can expect to feel (Perry 883)
Anxiety interferes with the effectiveness of anesthesia and the ability of patients to actively participate in their care. (Perry 883)
Demonstration of a caring attitude toward a patient, family members, and significant others increases feelings of trust and reduces anxiety (Fig. 36-1). Provide assurance that comfort measures will be implemented to manage pain (Perry 883)


How do you determine the length of the nasogastric tube in a patient?


Measure distance from tip of nose to earlobe to xiphoid process of sternum (see illustration). Length approximates distance from nose to stomach in 98% of patients.
note: For duodenal or jejunal placement, an additional 20 to 30 cm (8 to 12 inches) is required.


What is the most reliable method for verification of placement of a NG tube REF: 1029-1030| 1032


X-ray film examination is the gold standard for verifying tube placement …less reliable method is the pH reading of aspiration of NG tube after insertion through nasal gastral.


What are the procedures to prevent pulmonary aspiration with tube feedings REF: 1020-1022


regurgitation of formula:Verify tube placement. Place patient in high Fowler’s position or elevate head of bed a minimum of 30 (preferably 45) degrees during feedings and for 2 hours afterward.
Feeding tube displaced: Reposition tube and verify tube placement.
Deficient gag reflex: Reassess for return of normal gag reflex; until then place patient on aspiration precautions and in semi-Fowler’s position.
Delayed gastric emptying: Diabetic gastroparesis-Consult with health care provider regarding prokinetic medication for increasing gastric motility.


Know how to administer medications via the nasogastric tube. REF: 1118 - 1022


Investigate and use alternative routes of medication administration if possible (e.g., intravenous, transdermal, rectal).
Evaluate where medication is absorbed and ensure that point of absorption is not bypassed by feeding tube.
Determine if medication interacts with enteral feeding. If interaction occurs, hold the feeding for at least 30 minutes before giving the medication
Prepare medications in a liquid form (suspension, elixir, or solution) when possible to prevent tube obstruction (Bankhead et al., 2009).
Before crushing tablets, be sure that they are crushable. Buccal, sublingual, enteric-coated or sustained-release medications cannot be crushed (Williams, 2008).
Compare label of medications against MAR one more time at patient’s bedside
Grind simple compressed tablets to a fine powder. Open hard gelatin capsules and pour powder into a medication cup. Dissolve crushed tablets, contents of capsules, and powders in 15 to 30 mL of sterile water. Dissolve each medication separately
Do not give whole or undissolved medications through the feeding tube
Flush tube with at least 15 mL of sterile water
Draw up medication in syringe. Do not mix medications together
Connect syringe with medication to nasogastric tube, G-tube, J-tube, or small-bore feeding tube. Do not use pigtail vent.
Administer medication by either pushing the medication through the tube with the syringe or allowing it to flow into the body freely using gravity. Administer each medication separately. If resistance is felt when pushing medication through the tube, stop administration and contact the patient’s health care provider.
Flush tube with at least 15 mL of sterile water between each medication
After giving all the medications, flush tube with at least 15 mL of sterile water
Restart tube feeding if appropriate; hold feeding for 30 minutes or longer if needed to avoid alterations in medication bioavailability


Describe the methods for avoiding complications of tube feedings. REF: 1118 - 1022

A tube feeding is administered into the stomach or small intestine.
 Candidates for tube feeding include patients who have adequate digestion and absorption but cannot ingest, chew, or swallow food safely or in adequate amounts. A tube feeding is administered into the stomach or small intestine. The selection of the type of tube and placement method depends on the anticipated duration of feeding and other patient-related factors such as gastric emptying and risk for pulmonary aspiration, the most serious complication of tube feeding. For short-term feeding nasal or oral feeding tubes are appropriate. Terms used to describe these types of tubes includenasogastric (NG), orogastric (OG), and nasoenteric. When the duration of tube feeding extends beyond 4 weeks or in situations in which access to the GI tract through the nose or mouth is contraindicated, direct enteral access through the abdominal wall is the optimal choice. The stomach (gastrostomy tube) and jejunum (jejunostomy tube) are the usual sites for long-term feeding tubes.
More sophisticated aids such as fluoroscopy or electromagnetic tracking may be required to successfully direct a tube into the small bowel
Feeding tubes are positioned into the small bowel to reduce the incidence of pulmonary aspiration of stomach contents. Research has not consistently demonstrated this benefit, but newer techniques for detecting aspiration provide some evidence that small intestine feeding does reduce the incidence of pulmonary aspiration
Variation in the color and pH of fluid withdrawn from feeding tubes can help to differentiate tubes positioned in the stomach from those that rest in the small intestine. However, these indicators are not consistently reliable for distinguishing between placement in the GI tract and tracheobronchial system. X-ray film confirmation of correct tube placement is mandatory before enteral feeding or medication is administered through a blindly placed feeding tube
Carbon dioxide (CO2) detectors can help locate the position of tubes during insertion and potentially reduce insertion-related pulmonary injury. A sensor attached to the end of the feeding tube changes color in the presence of CO2, thus indicating that the tube may have entered the airway.
Maintaining and monitoring tube location during feeding and keeping the head-of-bed elevation at a minimum of 30 degrees (preferably 45 degrees) effectively reduces aspiration and subsequent pneumonia 
Measurement of gastric residual volumes (GRVs) is done routinely during tube feeding to identify risk for regurgitation and pulmonary aspiration of gastric contents. This technique involves withdrawing and measuring the contents of the stomach at regular intervals during tube feeding. Feeding is stopped when GRVs exceed a specified level; however, studies have failed to demonstrate a consistent relationship between GRV and risk of pulmonary aspiration (DeLegge, 2011; Metheny et al., 2008). Recommendations for stopping tube feeding for elevated GRVs range from 250 to 500 mL (source:  pg 776 Clinical nursing skills and techniques)
Be vigilant when manipulating components of enteral feeding systems for procedures such as medication administration or tube irrigation to avoid tubing misconnections with intravenous systems or other medical devices

Describe complications of (TPN) and the methods for avoiding them REF: 1023


Complications of PN include catheter-related problems and metabolic alterations
Pneumothorax results from a puncture insult to the pulmonary system and involves the accumulation of air in the pleural cavity with subsequent collapse of the lung and impaired breathing, most often occurs during CVC placement.

Air embolus possibly occurs during insertion of the catheter or when changing the tubing or cap. Turn the patient into a left lateral decubitus position, and have the patient perform a Valsalva maneuver (holding the breath and “bearing down”) during catheter insertion to help prevent air embolus. The increased venous pressure created by the maneuver prevents air from entering the bloodstream. Maintaining integrity of the closed IV system also helps prevent air embolus.

Catheter occlusion is present when there is sluggish or no flow through the catheter. Temporarily stop the infusion and flush with saline or heparin per protocol or orders. If this is unsuccessful, attempt to aspirate a clot. If still unsuccessful, follow institution protocol for use of a thrombolytic agent (e.g., urokinase).

Catheter sepsis if a patient develops fever, chills, or glucose intolerance and has a positive blood culture.
Change the TPN infusion tubing every 24 hours.
Do not hang a single container of PN for more than 24 hours or lipids more than 12 hours.
Change the administration system every 72 hours when infusing a 2-in-1 solution and every 24 hours for a 3-in-1 solution.
During CVC dressing changes, always use a sterile mask and gloves and assess insertion sites for signs and symptoms of infection. Change the CVC dressing per institution policy and anytime it becomes wet or contaminated.
Use either alcohol or an alcoholic solution of chlorhexidine gluconate to clean the injection port or catheter hub 15 seconds before and after each time it is used.
Use a 1.2-micron filter for 3-in-1 formulas and an inline 0.22-micron filter for PN solutions that do not include IV fat emulsions.

PN solutions contain most of the major electrolytes, vitamins, and minerals. Patients also need supplemental vitamin K as ordered throughout therapy. Vitamin K is synthesized by microflora found in the jejunum and ileum with normal use of the GI tract; however, because PN circumvents GI use, patients need to receive exogenous vitamin K.

Electrolyte and mineral imbalances often occur. Administration of concentrated glucose is accompanied by increases in endogenous insulin production, which causes cations (potassium, magnesium, and phosphorus) to move intracellularly. Monitor blood glucose levels every 6 hours to assess for hyperglycemia and administer supplemental insulin as needed. Check TPN for supplemental electrolyte levels. Notify health care provider of imbalances. Maintain steady rate of infusion. Monitor intake and output.

Too-rapid administration of hypertonic dextrose can result in an osmotic diuresis and dehydration (see Chapter 41). If an infusion falls behind schedule, do not increase the rate in an attempt to catch up. Sudden discontinuation of a solution can cause hypoglycemia. Usually 10% dextrose is infused when PN solution is suddenly discontinued. Patients with diabetes are more at risk. (Potter 1023-1024)


Know interventions that help the COPD patient who is having difficulty breathing REF: 832


Nursing interventions to maintain or promote lung expansion include noninvasive techniques such as ambulation, positioning, incentive spirometry, and noninvasive ventilation. Invasive medical interventions such as chest tube insertion and management assist in restoring lung expansion. (Potter 847)

Oxygen therapy - 6 rights of medication admin - patient, med, dosage, route, time, why, document

Respiratory muscle training - deeping breathing, coughing, pursed lip breathing, diaphragmatic breathing - stomach goes out


Know how to administer medications with an NG tube REF: 1031-1035


Put in NG tube

  1. bed to high fowler’s, towel over chest
  2. measure length of tube - tip of nose to earlobe to xiphoid process of sternum, tape to mark location
  3. lube tube and put in nose
  4. secure tube to nose with tape
  5. get gastric aspirate, measure gastric pH, verify placement of tube
  6. put back gastric aspirate
  7. ascultate lungs, check for difficulty breathing, x-ray to confirm placement

Giving Meds through NG tube
1. Assessment - need for enteral tube feeding, nutritional status - weight, lab values, verify order - formula, rate, route, frequency, look at tube site for breakdown, auscultate bowel sounds
2. Planning - id pt, explain, prep supplies,
3. Implementation - 30-45 degrees elevate bed, aspirate gastric secretions, check pH, put back, flush tubing 30 mL water, meds, flush tubing 30 mL water, cap
(Potter 1028 - 1035)


Know the indications of dysphagia and the interventions to help lessen complications REF 1010


Dysphagia refers to difficulty swallowing. Complications include aspiration pneumonia, dehydration, decreased nutritional status, and weight loss.

Be aware of warning signs for dysphagia. They include cough during eating; change in voice tone or quality after swallowing; abnormal movements of the mouth, tongue, or lips; and slow, weak, imprecise, or uncoordinated speech. Abnormal gag, delayed swallowing, incomplete oral clearance or pocketing, regurgitation, pharyngeal pooling, delayed or absent trigger of swallow, and inability to speak consistently are other signs of dysphagia. Patients with dysphagia often do not show overt signs such as coughing when food enters the airway. Silent aspiration is aspiration that occurs in patients with neurological problems that lead to decreased sensation. It often occurs without a cough, and symptoms usually do not appear for 24 hours (Palmer and Metheny, 2008). Silent aspiration accounts for most of the 40% to 70% of aspiration in patients with dysphagia following stroke (Kwon et al., 2006). (Potter 1010)

Patients with dysphagia are at risk for aspiration and need more assistance with feeding and swallowing.
30-minute rest period before eating
Position the patient in high Fowler’s. Have the patient flex the head slightly to a chin-down position
If unilateral weakness, place food in the stronger side of the mouth.
Determine the viscosity of foods that the patient tolerates best Thicker fluids are generally easier to swallow.
There are four levels of diet: dysphagia puree, dysphagia mechanically altered, dysphagia advanced, and regular. The four levels of liquid include thin liquids (low viscosity), nectar-like liquids (medium viscosity), honey-like liquids (viscosity of honey), and spoon-thick liquids (viscosity of pudding).
Feed a patient with dysphagia slowly, smaller-size bites.
Sometimes it is necessary to have oral suction

Enteral feeding - NG tube, preferred method if patient unable to swallow still able to digest/absorb nutrients, verify placement with x-ray check pH of fluid - low pH, elevate bed 30-45 degrees min

Parenteral feeding - IV, unable to digest/absorb through EN, assess nutritional needs, manage central venous catheter, monitor to prevent or treat metabolic complications, for sepsis, head injury, burns, asepsis and infusion management important


Know what Sequential compression devices are and why they are used REF: 1149-1150


SCDs are an independent nursing intervention, do not need a doctor’s order. SCDs consist of sleeves or stockings made of fabric or plastic that are wrapped around the leg and secured with Velcro. Once they are applied, connect the sleeves to a pump that alternately inflates and deflates the stocking around the leg. inflation for 10 to 15 seconds and deflation for 45 to 60 seconds. Inflation pressures average 40 mm Hg. Decreases venous stasis by increasing venous return through the deep veins of the legs. Use as soon as possible and maintain it until the patient becomes fully ambulatory. (Potter 1149)

Prevents DVT, to assess for a deep vein thrombosis (DVT), remove the patient’s elastic stockings and/or SCDs every 8 hours (or according to agency policy) and observe the calves for redness, warmth, and tenderness. (Potter 1142)