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exam 5

chapters 18, 26, 42-43 (see next stacks for 44&45)

normal concentration of electrolytes in the body 285 mEq/L
hypertonic to body >300 mEq/L
hypotonic to body <280 mEq/L
hypertonic fluid draws fluids into the circulation, increasing blood volume
hypotonic fluid draws fluids into body tissues, decreasing blood volume
tonicity a measure of the concentration of electrolytes in the fluid
a fluid is any liquid or gas (that's what the book says)
a solution is a liquid containing one or more dissolved electrolytes
crystalloids water and electrolytes in fluid
colloids blood or blood components
each 1% of dextrose in a liter of fluid equals 34 calories
isotonic solution 0.9% NaCl = NS
hypotonic solution may be ordered if the pts body fluids are concentrated owing to excessive water loss
hypertonic solution may be ordered for a pt with excessive loss of both Na and Cl
amount of dextrose that can be infused in a peripheral vein 2.5, 5, or 10%
where is catheter placed for TPN distal superior vena cava
peripheral veins are located in the extremities and scalp (for infant)
central lines are inserted into lt or rt subclavian, jugular, femoral veins or superior vena cava
percutaneous catheters devices placed through a cut-down incision
peripherally inserted central catheter (PICC) central line threaded through a peripheral vein
port device with a central catheter that is surgically implanted in the subq tissue, it has no external parts, has a rubber septum that can be felt under the skin; less restrictive than other access devices but does require a needle stick for each infusion
tunneled catheters and implanted ports are for long-term use
midline catheters are inserted above the AC region of the arm, in the mid upper section of the basilic vein
advantage of PICC or other central lines easier insertion, cost savings, no risk of pneumothorax or hemothorax, very low risk of infection or air embolism, can be left in place unless compromised for up to 3+ years
tunneled catheters are inserted by the physician only, into the vena cava, have growth cuff so that tissue at the exit will grow into it and prevent accidental displacement
placement of any central catheter must be confirmed by radiograph before use
infusion pumps are used to admin chemo and TPN
14-16 gauge cannula is appropriate for multiple trauma, transplantation or heart surgery
18-20 gauge cannula is appropriate for other surgical pts, those receiving blood
22 gauge cannula is appropriate for most adults receiving crystalliod fluids
when not to use an arm for venipuncture impaired circulation, poor lymphatic drainage, radical mastectomy, affected site after stroke, pt has a fistula or shunt for hemodialysis
The Inravenous Nurses Society does not recommend lidocaine or normal saline for numbing site prior to venipuncture; complications: vasospasm, allergic reactions, anaphylaxis
documentation date, time, length and gauge of cannula, initials on IV site; label bag of IV fluid with date & time, tubing size, expiration date
the clamp on tubing should be positioned on the upper third, slide clamp should not be used to set the infusion rate, it is not reliable
check infusion rate hourly
if infusion is running ahead/behind of schedule do not attempt to catch up, adjust the flow rate; watch for signs of fluid overload
factors affecting infusion rate height of container, volume in the container, viscosity, cannula diameter, position of extremity,
potassium is given NEVER IV push; 10 mEq/hr for peripheral IV; 40 mEq/hr for central IV
short peripheral tubing and cannulas are changed q 48-72 hrs
continuous peripheral and central infusion sets are changed q 72 hrs
tubing that has been used for blood, TPN or lipids must be changed q 24 hrs; IV fluid container must not be used for more than 24 hrs
D/C of IV therapy stop flow or fluid, gently press dry gauze pad over site, remove cannula, elevate extremity and apply pressure for 2-3 minutes to prevent bleeding
most serious pathogens transmitted by blood HIV, hep B
IV therapy considerations for older adult anchor vein with thumb until the catheter is inserted to the hub, protect fragile skin, pad the arm board, they have less subq tissue, monitor for fluid volume excess b/c they have less efficient cardiac and renal function
never apply immobilizer over the IV site, it must be below the site
best means of evaluating for infiltration inspection and palpation
extravasation leakage of fluid from blood vessel
infiltration leakage at the point where cannula enters vein or secondary puncture site in the vein
S&S of infiltration burning sensation, pale, puffy, hard, COOL
S&S of phlebitis red edema, WARM, tender, purulent drainage, fever
common vesicants vasopressors, KCl, antineoplastic agents; flush cannula after vessicant is given
when evidence of infiltration is noted stop infusion, restart in a different vein, elevate affected arm to promote reabsorption
if infusion site appears to be inflamed or infected stop infusion, restart it in another site, warm compress, notify provider, antibiotics may be ordered
most at risk for fluid volume overload young children and older adults
if s&s of fluid volume overload slow infusion, elevate HOB, notify provider
if a large amount of blood is lost assess vital signs and notify provider
ineffective tissue perfusion caused by embolus, thrombus, air embolus of as little as 10 mL can cause serious complication
s&s of air embolus SOB, hypotension, shock, cardiac arrest
catheter embolus a piece of catheter breaks off into the vein; chest discomfor should be reported to the physician immediately; keep pt calm, elevate HOB; usually found by radiograph in rt ventricle or pulmonary artery
if cannula seems to be obstructed irrigation is not recommended b/c it may force clots into the bloodstream; aspiration may be attempted, alteplase (t-PA) may be ordered to dissolve clots
care if air embolus from central line when removing instruct pt to take a deep breath and bear down, if air enters the line close the leak immediately, turn pt on the left side with the HOB lowered; this allows the air to be trapped in the rt atrium where it can be absorbed gradually; 100% O2 with a nonrebreather mask, emergency cart nearby, notify provider
indications for ostomy surgery trauma, severe inflammation, infection, bladder or colon cancer,
WOC nurse wound, ostomy, continence nurse
placement of stoma factors secure pouch placement, ease of self-care
assessment of pt having ostomy determine pts expectations, fears; health hx reveals reason for procedure; med hx documents other acute and chronic conditions; mark on skin is where stoma will be placed
interventions for pt having ostomy inform them of support groups, moderate or severe anxiety interferes with learning;
fecal matter in the ileum is liquid
double barreled stoma has two stomas; proximal stoma is continuous with upper intestinal tract and drains fecal matter; distal stoma is nonfunctional and sometimes refereed to as the mucus fistula
temporary ostomies loop and double barrel
prep before decal diversion low fiber diet for several days; no whole grains or fruits and veggies; antibiotic agents that that are not absorbed will be given to reduce bacterial flora, cathartic and laxatives are given to empty digestive tract; lowers the risk of bacterial contamination of the abd cavity when bowel is opened
ileum distal portion of sm intestine that empties into large intestine; necessary when the entire colon must be bypassed or removed; congenital defects, cancer, inflam bowel disease, trauma, familial conditions, polyposis
postop care of ileostomy pt has NG tube attached to low intermittent suction; IV fluids; assessment: general status, take VS and compare with preop, inspect and palpate for color, warmth and turgor, inspect oral tissues for moisture, examine abd for distention and bowel sounds,
what does a new intestinal stoma look like beefy red, swelling is expected (shrinks in 6-8 weeks), sm amt of bleeding is normal, ileostomy drainage begins 24-48 hrs after surgery, presences of mucus is normal
what should an intestinal stoma NOT look like pale, bluish or black = impaired circulation and must be reported to provider immediately; redness, skin breakdown and purulent drainage should not be seen in healed stoma
maintain accurate I&O by measuring urine, gastric contents, fecal drainage
loss of bicarbonate in ileostomy drainage can lead to metabolic acidosis; provider may order bicarbonate replacement
impaired skin integrity check pouch hourly at first to detect leakage; clean around stoma gently but thoroughly when emptying pouch
presence of fecal matter on the skin is a medium for bacterial, fungal and yeast infections
a good pouch is one that protects the skin, contains wastes and gas, is odor proof, permits freedom of movement, provides security for the pt and is not noticeable
remove the appliance for through cleaning q3-5 days
procedure for replacing appliance wash the stoma, rinse, pat dry, protective barrier, skin; opening in wafer should be no more than 1/8 inch larger than the stoma; pouch, clamp
odor is normal when pouch is being changed or emptied but can be controlled at other times; delete and reintroduce various foods to find those that are troublesome, rinse pouch with vinegar solution, odor proof pouches
sex after ostomy empty pouch and tape it down before sex, pouch cover, experiment with positions, does not interfere with pregnancy or delivery
teaching should be done every time stoma care is done
risk for injury lumen of an ileostomy is less than 1 inch, can easily be obstructed, low fiber diet initially, high fiber foods added gradually, chew dried fruit, mushrooms, olives, opocorn and foods with skins very thoroughly
continent ileostomy internal pouch created from a loop ileum for storing fecal matter, pt does not have continuous drainage and does not wear a pouch; ulcerative colitis is a candidate but crohns disease is not;
postop care of continent ileostomy catheter is connected to low intermittent suction to keep the pouch empty to prevent stress on the suture lines while healing; absence of drainage or pt complaints of feeling of fullness suggest obstruction; drainage will be bloody at first; at first pouch can hold 70-100 mL, later it can hold up to 600 mL; first 2 weeks the pouch is drained q3-4 hrs, next 2 weeks q5 hrs, eventually the pt will only need to drain 2-4 times per day
draining continent ileostomy pt sits or lays down, lube catheter, resistance is felt when it reaches the nipple valve approx 2 inches past stoma, have pt bear down, roll cath b/t fingers and advance it into the pouch, drainage continues for up to 10 minutes, if too thick instill 30 mL NS, gently aspirate only if necessary or dislocation of nipple, remove cath quickly, place gauze to absorb any secretions, measure, describe and discard drainage, wear med alert bracelet
ileoanal reservoir fecal matter is stored and then eliminated through rectum; not recommended for pts with crohn's disease or poor sphincter control; care is same as for other types except need for assessment of rectal drainage and condition of perianal skin
complications of ileoanal reservoir leaking of suture lines leading to peritonitis, small bowel obstruction, inflammation of the reservoir
the muslim pt is expected to perform a washing ritual and pray 5x per day. needs clean appliance for each prayer, a two-piece appliance should be used
considerations for ileoanal reservoir perineal pads may be needed to prevent soiling of clothing, tighten anus for count of 10 and relax 5-6x per day, avoid fatty foods at first, no absolute restrictions exist, if obstruction - call provider, IV, NPO, NG tube
colostomy opening in the colon; the closer to the rectum the more formed the stool; temp or perm, begins to function 3-5th postop day,
how is a colostomy classified according to location; ascending, transverse, descending, sigmoid
complication of colostomy prolapse - protrudes further than it is supposed to, coughing or sneezing; stenosis - narrowing of abd opening
irrigation of colostomy no longer routinely done, can cause complications such as perforation, plain tap water can cause fluid and electrolyte imbalances
ileal conduit urinary diversion; urinary drainage system made from a portion of small intestine,
complications of ileal conduit leakage of anastomosed ureters and intestinal segments, ureteral obstruction, separation of the stoma from surrounding tissue, infection, necrosis, paralytic ileus, gray or black means impaired circulation and notify provider immed., crystal formation, calculi, retraction, prolapse or hernia of stoma
postop care of pt with ileal conduit same as for other types of stomas; NG tube with suction to prevent abd distention and stress on resected bowel, mucus is normally present, catheter or stent may be in place to drain urine, attach pouch to a collection device at night
Koch or Indiana pouch postop care may have Penrose drain and clear tube for continuous urine drainage; irrigations may be ordered to remove mucus and blood clots, drain pouch q2-3 hrs after tube is removed,
postop care of cutaneous ureterostomy some blood in urine is normal at first, ureterostyomy drainage should not contain mucus
karaya products are used for intestinal ostomies but urine breaks down the product
impaired skin integrity cutaneous ureterostomy pouch is cleaned 1-2x per day, changed q4-6 days or when it leaks, change pouch in morning when urine production is lowest,
rash around ureter stoma yeast infection
vesicostomy or cystostomy opening into the urinary bladder
nephrostomy tube diverts urine directly from kidney through a tube in the skin
classification of fractures Grade I - least severe Grade II - moderate, skin and muscle contusions Grade III - severe, wound larger than 6-8 mc, skin, muscle, blood vessel and nerve damage pathological fx- tumor or disease process that causes a spontaneous break stress fx- repeated or prolonged stress, related to sports
most common cause of fx automobile accident and falls
most commonly fx bones in adults ribs
most commonly fx bones in young and middle aged adults femur
most commonly fx bones in elderly hip and wrist
when does a bone begin to heal as soon as the injury occurs
healing stage I hematoma formation, bleeding and edema, 48-72 hrs later a flot forms b/t two ends of broken bone
healing stage II fibrocartilage formation, hematoma does not completely reabsorb, granulation tissue forms replacing clot, forms a collar around each end of bone, becomes firm and forms a bridge
healing stage III callus formation, 1-4 weeks post, made up of cartilage, osteoblasts, calcium, phosphorus, serves as temp splint
healing stage IV ossification, 3 weeks to 6 months post, perm bone callus known as woven bone, ends begin to knit
healing stage V consolidation and remodeling, distance b/t bone ends decreases and closes, excess bone is chiseled away by motion, exercise and weight bearing
osteomyelitis infection in bone, from contamination of open wound or from indwelling hardware,
iatrogenic health care associated infection
s&s and tx of osteomyelitis local pain, redness, purulent wound drainage, chills, fever, radiographic changes are not usually seen until 10-14 days after onset of infection, IV antibiotics for 4-8 weeks followed by 4-8 weeks of oral antibiotics
fat embolism fat globules released from marrow into blood stream, migrate to the lungs, breakdown into fatty acids which inflame pulmonary blood vessels, pulmonary edema; long bones, multiple fx, severe trauma; 24-48 hrs post injury, most often seen in young men 20-40 yo and older adults 70-80 yo, older pt with hip fx is most at risk
s&s and tx of fat embolism resp distress, tachycardia, tachypnea, fever, confusion, LOC, petechiae; bed rest gentle handling, O2, vent support, fluid restriction, diuretic agents, can be fatal
compartment syndrome internal or external pressure on affected area; 4-6 hrs after onset irreversible muscle damage may occur, paresis(partial paralysis) can result if not treated within 24 hrs; in 24-48 hrs the limb can become useless
s&s and tx of compartment syndrome pain with touch or movement that can not be relieved with opioids, edema, pallor, weak or unequal pulses, cyanosis, tingling, numbness, paresthesia, severe pain; relieve pressure by surgical fasciotomy (linear incisions in fascia), cast or dressing removed for external syndrome
malunion healing time is appropriate but alignment of bone is off, results in deformity and dysfunction
nonunion fracture never heals
delayed union failure of fx to heal in expected time; inadequate immobilization or excess movement, poor alignment, infection or poor nutrition
osteogenic method of healing bone grafts
osteoconductive method of healing synthetic materials used to provide a matrix for bone growth
osteoinduction the use of substances such as platelet derived growth factor
posttraumatic arthritis can result from non union of fx
avascular necrosis deprived of O2 and nutrients the cells die and collapse; s&s: increasing pain, instability, decreased function; tx: relief of weight bearing, removal of part of the bone, amputation
complex regional pain syndrome (CRPS)type I reflex sympathetic dystrophy, symptoms persist longer than expected with the type of injury sustained, no detectable nerve damage or other symptoms tx: nerve blocks, PT, TENS, drugs, antidepressants,
CRPS type II (causalgia) same as type I but nerve damage can be detected
tx of fx goal: realign bone fragments, establish sturdy union b/t ends of bone, restore function
reduction process of bringing the ends of the bones into proper alignment; closed = non surgical, open = surgical,
fixation when reduction alone is not feasible b/c of extent or type of break, internal- use of pins, rods, nails, screws, metal plates, promotes early immobilization; external- pins are inserted directly into the bone above and below a fx, a frame is attached
external vs internal fixation external fixation allows easier access to the site and facilitates wound care
petaling of cast short pieces of tape placed over edges of cast to prevent skin irritation and to protect the cast from moisture and soiling
univalved cast split down the front to allow casting material and padding to spread
bivalved cast cut down both sides so that front portion can be removed while back portion maintains immobiliization
windowed cast save the cut out b/c it might be reinserted later
arm cast keep arm elevated above heart when lying in bed to prevent swelling
leg cast elevated leg on several pillow during the first few days
cast brace supports affected part while allowing knee to bend
body or spica cast fx is in the trunk, body cast encircles the trunk, spica cast encases the trunk plus one or two extremities; never use the bar on spica cast for turning pt.,
cast syndrome compression of a portion of the duodenum b/t superior mesenteric artery and aorta and vertebral column; s&s: nausea, abd distention
traction to provide alignment, correct a deformity, decrease muscle spasm, promote rest, maintain position of the diseased or injured part
skin traction Buck traction, for hip and knee contractures, no more than 5-10 ob to prevent injury to the skin
skeletal traction pins are inserted into the the skull on either side, 15-30 lb weights,
traction nursing considerations weights must hang freely, correct weight is used, good body alignment, use padding, assess temp, pain, sensation, cap refill time, and pulses, assess pin sites for infection
crutches requires good upper body strength
crutch fit PT does proper fitting, nurse reinforces; 3-4 fingerbreadths below axilla, elbow flexed no more than 30 degrees
two point gait crutch on one side and the oposite foot are advanced at the same time; used with partial weight bearing and bilateral prostheses
three point gait both crutches and the affected extremity are advanced together, requires strength and balance, partial or no weight bearing,
four point gait right, left, right, left, used if weight bearing is allowed
swing to gait both crutches advance together then both legs placed down behind crutches; tripod
swing through gait both crutches are advanced together then both legs are lifted through and beyond crutches; used when adequate muscle power and balance in the arms and legs exist
goal of nursing care for pt with fx preventing complications and restoring the pt to independent function
neurovascular checks pulse, skin color, cap refill time, sensation
a good indication of circulation skin color
determine sensation by pinprick, especially b/t web space on hand and foot
pain control analgesics, muscle relaxants, cold therapy, positioning, massage, diversion
evidence of impaired circulation abnormal coolness or warmth, weak or absent pulses, pale or bluish skin color, sluggish cap refill, immediately report to provider
standard infection control for signs of infection
periodic elevation of the affected limb promotes venous return and reduces swelling
by age 90 17% of men and 30% of women sustain hip fx
most hip fx are in the femoral neck and intertrochanteric regions
3-5% of all falls result in fx in older adults
s&s of hip fx hx of fall, severe pain, tenderness, evidence of soft tissue trauma, affected leg is shorter, hip is rotated externally
pt begin PT as early as 1 day postop for surgical repair; begin by sitting in chair and then progress to walking with a walker, weight bearing can begin almost immediately after total hip replacement
delirium after hip fx due to anesthesia during surgery
post total hip replacement care hip must not be adducted and must not be flexed more than 90 degrees or dislocation of the prosthesis can occur
colles fx older women, fall with outstretched hand, dinner fork appearance
pelvic fx 2nd leading cause of death from trauma after head injury, internal trauma such as lac of colon, hemorrhage, rupture of urethra or bladder, heal within 6-8 weeks; monitor pt for blood in urine and stool and watch for abd rigidity and swelling
disarticulation amputation through a joint
traumatic amputation accidents: motorcyles, cars, farm machinery, firearms, explosives, electrical equip, power tools, frostbite; most common reason for upper extremity amputation; young men b/c of occupational hazards
disease amputation vascular disease major reason for lower extremity amputation, PVD, DM, arteriosclerosis
auto amputation a limb, most often a toe, self-amputates itself without surgery
amputation due to tumor large or invasive, frequently in adolescents but can occur at any age, 1/3 of these indiv are 11-20 yo
amputation due to congenital defects absent or deformed limb at birth; surgery can be performed to convert a deformed limb to a more functional one that can be fitted with prosthetic device
pulse volume recording volume of blood flow to an extremity; aka plethysmography
surgical management of the pt aims for amputation at the lowest level that will still preserve healthy tissue and favor wound healing
closed amputation to create a weight bearing residual limb or stump; a long skin flap with soft tissue and muscle is positioned over the severed end of the bone and sutured in place
open amputation severed bone or joint is left uncovered; actual or potential infection exists; left open for 5-10 days; staged or guillotine amp
when can amputee bear weight on prostheses approx 3 months after amputation
preop nursing care of amputee routine: see chapter 17
preop assessment of amputee determine if the pt has ever had phlebitis, varicosities, thromboses, emboli or stasis ulcers in either the affected of unaffected extremities;
poor blood supply is indicated by cool, cold, clammy, mottled skin that is pale or cyanotic
postop care of amputee priorities: pain relief, restored mobilization, avoidance of complications; most common postop problems: hemorrhage, edema, infection, pain
hemorrhage is greatest danger early postop; early signs are restlessness and increasing pulse and resp; late signs are hypotension and cyanosis
bright, red bleeding after amputation is not normal; if observed apply pressure over existing dressing, elevate residual limb and notify surgeon immed.; a large BP cuff may be placed at the bedside for use as a tourniquet
sympathectomy done to relieve pain of amputation
neuroma severed nerve endings attempt to regenerate
incision should appear dry, intact and only slightly red
the residual limb is bandaged to promote healing, shrink and shape residual limb to a tapered, round smooth end that will fit the prosthesis
shrinker socks maintain compression but they are expensive and it is difficult to find the right size and length
pillows can be placed under BKA but not continuous b/c it can cause contractures of the hip; use low rather than high fowlers
massage residual limb after the 5-7th postop day to promote circulation
position after lower extremity amp prone with head turned away from affected side, if allowed for part of the day, prevents hip contractures
phantom limb pain described as burning, crushing, stinging pain; tx: TENS, diversion, massage, anesthetic, properly fitting dressing, beta-blockers, benzos, antidepressants,
after lower extremity amp safe mobility is a priority goal: prevention of contractures
a typical activity order for amp pt to be assisted out of bed two or three times per day for one hour at a time
disturbed body image emphasize ways to adapt to the loss and, if the pt wishes, to conceal it; counsel family and friends to support the pt and not to encourage excessive dependence
consideration for older adult amputee high calorie, high protein intake; empathy, patience and respect are essential in approaching older adults
reanastomose reconnect
amputations above the wrist not usually feasible b/c of the extensive tissue, muscle, and bone damage accompanying the injury
the greater the muscle mass injury the less likely that replantation will be possible
signs of arterial occlusion pale or blue color, slow cap refill, shriveled appearance, coolness
signs of venous congestion cyanosis, rapid cap refill, edema, warmth
massive edema accompanies replantation
measures to promote circulation elevation of limb, do not elevate above the level of the heart b/c this might impair arterial flow;
microvascular precautions avoid substances and conditions that contribute to blood vessel spasm or constriction; abstain from caffeine and nicotine for 7-10 days, maintain room temp at 80 degrees to prevent compensatory vasoconstriction of peripheral tissue, loosen tight or restrictive gowns or pjs
if evidence of inadequate arterial circulation to replanted limb medical emergency; notify provider and prepare pt for surgery
leeches saliva contains anticoagulant, local vasodilator and local anesthetic agent
pulmonary toilet attempts to clear mucus and secretions from the trachea and bronchial tree by deep breathing, incentive spirometry, postural drainage, and percussion; same thing as physiotherapy
0.45% NS is given for a pt that has experienced excessive water loss
advantage of PICC over other central catheters easier insertion cost savings reduced risk of infection less traumatic to vein no restriction of arm movement
opening created to drain contents of an organ stoma
surgical procedure to creates an opening into the body structure ostomy
which gait is used with a walker modified swing to
type of gait pattern used with bilateral lower extremity prostheses two point
canes should be held on the unaffected side
Created by: nursingTSJC2013