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NR 142 adult health exam 1 Veach

Identify nursing interventions for the client with hiatal hernia Frequent small feedings that pass thru esophagus, No reclining 1 hour after eating to prevent reflux/movement of hernia, Elevate HOB 4 to 8 inch blocks,Drugs: antacids, H2 antagonist, PPI, No spicy food, no eating b4 bed, No lifting/ straining, Exercise
Identify treatments for oral Candida related to chemotherapy for oral cancer Antifungal medications such as nystatin (Mycostatin) amphotericin B, clotrimazole, ketoconazole taken in pill or suspension. When used as suspensions have patient swish vigorously for at least 1 minute then swallow.
Identify characteristics of squamous cell carcinoma Oral lesions that won’t heal, red- erythroplakia;white leukoplakia), Erythroplakia–50% areSCC, Characteristics of SCC-epidermis or mucous memb, invasive&metastasis by blood or lymph;rough thick scaly tumor(asympt or bleeding) Border wider, inflammatory;
Identify nursing interventions for the client post-radical neck dissection part 1 Watch for infection and bleeding,fowler’s position for breathing and comfort, Assess for respiratory distress, dyspnea, cyanosis, mental status, VS, edema, hemorrhage, inadequate oxygenation, or drainage, Encourage coughing/deep breathing, Pain mgt
Identify nursing interventions for the client post-radical neck dissection part 2 Empty suction device for 1st 24 hrs, excessive drainage indicate hemorrhage), Reinforce&assess dressing for blood,graft-assess color, temp and pulse. sh/be pale pink &warm to touch,Assess for infection ,nutrition,Assess chewing ability,oral care
Identify nursing interventions for the client post-radical neck dissection part 3 Support patient who has had a change in body image or has concerns about prognosis (reassure that adjusting to the results of surgery will take time), Provide help resources, no tobacco or alcohol, Communication methods for patient
Identify nursing assessments for the client with GERD HX, Pyrosis(burning sensation in esophagus), dyspepsia,Dysphagia or odynophagia(painful swallowing),hypersalivation,esophagitis,24 hour pH monitoring (degree of acid reflux),EGD,barium (damage to mucosa), Bilirubin monitoring (Bilitec)measure bile reflux,
Identify education measures related to GERD Avoid eating or drinking 2 hours b4bedtime, Maintain normal body weight, no tight fitting clothes, Elevate HOB 6 to 8 inch blocks & elevate upper body w/pillows,Sleep left side, no smoking &alcohol,no lifting heavy objects,straining,or bent-over posture
Identify appropriate dietary education related to GERD Low fat diet, Avoid caffeine (coffee, tea), tobacco, beer, milk, foods containing peppermint or spearmint, and carbonated beverages, chocolate, tomatoes, Can have fruit/gelatin,
Identify treatments related to GERD Nutrition Therapy – no chocolate, peppermint, tomatoes, coffee, tea, milk. Yes- fruits, gelatins, easy to digest low fat foods. Lifestyle changes – HOB elevated 6”, sleep in direction of stomach (left side
Identify nursing assessments for the client post-surgery for hiatal hernia Bowel Sounds, Swallow with gag reflex. What other infections is the client at risk for by virtue of lying in bed after surgery
Identify nursing interventions for a client after esophageal surgery Watch for bleeding, infection, hypovolemic or hemorrhagic shock, hepatic encephalopathy, electrolyte imbalance, metabolic and respiratory alkalosis, alcohol withdrawal syndrome, and seizures
Identify nursing assessments related to gastritis (weakens protective stomach coating) Abd discomfort, HA, Lassitude, N/V, anorexia, hiccupping, Complaints of anorexia, heartburn, belching or sour taste in mouth, N/V after eating. Clinical manifestations: abdominal tenderness, bloating, hematemesis, Melena, intravascular depletion & shock
Identify nursing interventions for the client with chronic gastritis Diet therapy – limit foods and spices that cause distress such as chocolate, coffee, alcohol, tea, sodas, mustard, paprika, cloves, and pepper. (Reduces pain), Limit tobacco & alcohol, Reduce stress, Promote Fluid balance, Medications
Identify indications for the use of Pepcid (Famotidine) H2 receptor antagonist Peptic Ulcer Disease & gastritis; Decreases acid produced by stomach, Best choice for critically ill patients d/t low drug-drug reactions, doesn’t alter liver metabolism, Short term relief for GERD
Identify common drug treatment for the client with H. Pylori.(Pg 1049) Combination of antibiotics, proton pump inhibitors, and bismuth salts for 10-14 days
Identify nursing assessments for the client with peritonitis (pg 1081) pain,rebound tenderness,abd distention,rigid board-like abd, fever,decrease or absent bowel sounds, n/v,decrease in BP &increase in HR, incr WBC, Labs/CBC WBC increased, serum electrolyte studies, abdominal x-ray, CT, MRI, abdominal ultrasound
Identify priority nursing interventions for the client with peritonitis Rebound tenderness, board like abdomen (rigidity), fever, n/v, anorexia, BP down, HR up, abd distention, bowel sounds, dehydration
How are going to know if the patient is getting septic Low blood pressure,Lack of oxygen, Cardiac arrest,Cool Clammy & Pale skin,Rapid weak pulse,Rapid,Shallow breathing,Weak, Confusion,Anxiety,Restless,Altered LOC, Rapid HR,Hypothermia, Thirst,Dry mouth, Fatigue, huge bacterial infection,Fever,
Identify education measures following gastrectomy and continued care Part/full surgical removal of stomach, low fowlers position during mealtime & for 30 minutes after to prevent dumping syndrome, Antispasmodics, No fluid during meals or 1 hr before &after meals; dry meal, Low carb diet(fat ok), Vitamin iron, B12 (lifetime
Identify desired outcomes for a client following a gastrectomy What would you want for your patient that has just had their stomach removed- We would want them to still receive proper nutrition and maintain or gain weight. We would also want them to maintain fluid and electrolyte balance, and avoid potential complica
Identify interventions for dumping syndrome small frequent meals, lay down for 30 minutes. ***No fluids with meals limit drinking to one hour before and one hour after meals. Stay in low fowlers during meal and 30 min after. Eat high protein/low carb foods. Administer antispasmodics, as prescribed,
Identify education measure for the administration of antacids and sulcralfate (Carafate) Take before meals & at bedtime, Take on an empty stomach, take full course of therapy, avoid smoking, avoid antacid used within ½ hour of taking before or after.
Identify interventions for the client with Clostridium Difficile Wash hands! Spores are resistant to alcohol so waterless hand products not effective. Contact precautions including gloves & gowns. Bleach based solutions for cleaning & clean frequently touched equipment
Identify education measures related to administration of bulk laxatives Take with full glass of water, Have bathroom facilities readily available, Safety measures for dizziness, Importance of daily activity such as exercise to promote bowel function, High fiber diet & adequate fluid intake, Avoid overuse to prevent long term
Identify nursing interventions for the client with abdominal trauma Maintain effective airway, avoid excessive fluid intake prior to surgery as it may cause hemorrhage, sit patient up to decrease tension, and watch for signs and symptoms of peritonitis. Depending on trauma may need to prepare patient for surgery.
Identify nursing interventions for the client with appendicitis Non surgical – NPO, iv fluids & antibiotics, semi fowlers position, no Analgesics (will mask signs), no laxatives or enemas, no heat. Post surgical – Bleeding!, VS., reduce tension via positioning in high fowlers, monitor for infection
Identify indications for the use of Azulfidine Broad spectrum antibiotic – anti-inflammatory reduces lymphocyte response & inhibits angiogenesis. in the treatment of mild to moderate ulcerative colitis, and as adjunctive therapy in severe ulcerative colitis; for the prolongation of the remission perio
Identify nursing interventions related to impaired skin integrity from prolonged diarrhea Perianal care, skin protectants, Prevent by cleansing with a wet wipe, dry skin and apply a barrier cream (Vaseline) and also use pressure relieving devices. The skin of an older person is more sensitive because of decrease turgor and less subcutaneous f
Identify nursing assessments for the client with malnutrition part 1 Low serum albumin levels (less than 3.4 grams per deciliter), Eyes: dry, pale conjunctiva, Bitot's spots (vitamin A), periorbital edema, Mouth: angular stomatitis, cheilitis, glossitis, spongy bleedng gums (vitamin C), parotid enlargement. Teeth: enamel
Identify nursing assessments for the client with malnutrition (part2) Skin- loose and wrinkled (marasmus), shiny and edematous (kwashiorkor), dry, follicular hyperkeratosis, patchy hyper- and hypopigmentation, erosions, poor wound healing, Nail: thin and soft nail plates, fissures or ridges. Musculature: muscles wasting,
Identify complications of N/G suctioning page (1026) Fluid volume deficit, Pulmonary complications (aspiration), Tube related irritations, Electrolyte imbalance,
Identify signs and symptoms of (small) bowel obstruction Crampy pain wavelike and colicky, Stool blood and mucous ( no fecal matter), Vomiting, Peristaltic waves become extremely vigorous and a reverse direction with intestinal content propelled toward mouth, If ileum obstructed, fecal vomiting take place, Dehy
Identify signs and symptoms of (small) bowel obstruction Large bowel obstruction- symptoms develop slower than Small, Sigmoid colon- constipation may be the only symptom for months, shape may be altered as obstruction increasing in size, Blood loss in stool, may lead to anemia, Weakness, weight loss, anorexia,
Identify nursing assessments related to colonoscopy BEFORE-Cannot be performed if colon perforation, acute severe diverticulitis, fulminant colitis, Prophylactic antibiotics for prosthetic heart valves or endocarditis, Assess for implantable defibrillators and pacemakers,Informed consent
Identify nursing assessments related to colonoscopy DURING - Changes in oxygen , cardiac dysrhythmias, respiration, Vs., color and temp of skin, level of consciousness, abdominal distention, vagal response, circulation overload, hypotension, pain intensity
Identify nursing assessments related to colonoscopy AFTER-bowel perforation ( rectal bleeding, abdominal pain or distention, fever, focal peritoneal signs)
Identify indications for carcinoembryonic antigen (CEA) Testing for cancer ( GI and colorectal cancer) It is a protein that is detected in the blood of patients with cancer, indicates that cancer is present, not what type. does not stage the cancer; . Usually done for a baseline and then to monitor after surge
Identify normal characteristics of stomas It is red, which means it has a good blood supply and is healthy, It is moist to the touch, It can bleed easily (small amounts are usual and common) , It has no feeling , It has no sphincter (no voluntary control) . Also: The stoma will usually start out
Identify education measures related to care of a stoma Wash daily with soap and water and rinse well and pat it dry, Remove any encrustation, Evaluate for breakdown, irritation, excoriation, drainage or gastric leakage, Measure. Quite often it's more comfortable to wear a skin barrier that is closer to the a
Identify purpose of a double barrel stoma Double-barrel stoma is one that is temporary to rest the bowel. The proximal end is the functioning end, while the distal end is the nonfunctioning stoma. Temporary stomas can be placed for multiple reasons including draining fistula, trauma to the intes
Identify post-op complications of colostomy surgery Paralytic ileus, Mechanical obstruction, Peritonitis, Abscess formation, Infection, Wound disruption, Intraperitoneal infection and abdominal wound infection, Dehiscence of anastomosis , Fistulas
Identify therapeutic response to treatments for pancreatitis Priority is supportive by reducing pain, complications or inflammation. Anticipate and treat complications; comfort measures, Relieve pain and decrease secretion of pancreatic enzymes (parenteral opioids, morphine hydromorphone, fentanyl via patient-contr
Identify education measures for the client with chronic pancreatitis It is important to stay away from alcohol, caffeine, tea. Avoid fatty foods, eat small frequent meals full of protein and fiber and low fat. Increase the amount of fluids. Have them take extra vitamins and calcium. Pain medications will be given to help w
Identify nursing assessments related to liver failure Early stages include: fatigue, significant weight gain, GI symptoms, abdominal pain and liver tenderness in right quadrant, pruritus. Late stages: Jaundice and yellowing of the sclera, dry skin, rashes, petechiae, warm bright red palms of the hands, spid
Identify monitoring for the client with cirrhosis Bleeding, Fluid volume changes, Hepatic Encephalopathy (LOC) and lab data. Look for blood in the NG drainage, and stool, fruity musty breath, amenorrhea, bruising, petechiae, enlarged spleen, neuro changes, asterixis (flapping of the hands) indicates incr
Identify indications for lactulose Used for hepatic encephalopathy- reduces serum ammonia levels; Also used to treat constipation
Identify priority care for the client with esophageal varices The main concern in the event of esophageal varices is rupture and bleeding so the priority is to monitor the patients AIRWAY. Give vasopressin
Identify nursing monitoring related to balloon tamponade treatment Monitor that the patient does not pull on or inadvertently displace the tube, Monitor airway and lungs to make sure balloon has not ruptured, Monitor and record the pressure within the esophageal balloon every 2-4 hours, Once balloon is deflated still mon
Identify lab findings for the client with cirrhosis Elevated Serum levels of Aminotransferase, Lactate dehydrogenase, Alkaline Phosphatase, Total bilirubin and urobilinogen. Decreased Total serum protein and albumin, Prolonged Prothrombin time (PT), Decreased Serum levels of WBC, H/H, Plt, Increased Serum
Identify nursing assessments for the client with cholelithiasis Respiratory status/risk factors, Nutritional status, Monitor for potential bleeding, GI symptoms,
Identify complications related to paracentesis Bleeding, oozing from the insertion site, shock (symptoms include decreased BP, increased HR, LOC changes).Fluid and electrolyte disturbance because of n/v, movement of fluid from vascular compartment to peritoneal cavity, diaphoresis, fever, and the use
Identify assessments related to administration of parenteral nutrition Check blood glucose every 6 hours, daily weights , Hydration status, Electrolyte levels and calorie intake, Persistent vomiting and diarrhea, Hydration status, Electrolyte levels and calorie intake
Identify dietary restrictions for the client with end-stage liver failure Low fat, high protein (unless encephalopathy occurs in which case protein should be restricted) high carbohydrate (help with glucose production and are easier to break down). Low sodium
Identify education measures following anorectal surgery Keep perianal area clean by gently cleansing with warm water and then drying with absorbent cotton wipes, No rubbing with toilet tissue, Use sitz bath 3 or 4 times a day, 24 hours after surgery painful spasms of sphincter and perineal muscles may occur, I
Created by: rivabard