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2011-03-18 15:31:25

Nursing 102 Exam 3
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    • C = Character
    • O = Onset
    • L = Location
    • D = Duration
    • E = Exacerbation
    • R = Relief
    • R = Radiation
    • AS = Associated Symptoms
  2. morphine (Avinza, Kadian, MS Contin, MSIR, Oramorph SR, Roxanol)
    in a group of drugs called narcotic pain relievers.Morphine is used to treat moderate to severe pain. It works by dulling the pain perception center in the brain.

    may be habit-forming; do not stop taking morphine suddenly; not take morphine if you are having an asthma attack or if you have a bowel obstruction called paralytic ileus.

    serious side effects: shallow breathing, slow heartbeat;seizure (convulsions);cold, clammy skin;confusion;severe weakness or dizziness; orfeeling light-headed, fainting.

    Less serious side effects are more likely to occur, such as:constipation;warmth, tingling, or redness under your skin;nausea, vomiting, stomach pain, diarrhea, loss of appetite;dizziness, headache, anxiety;memory problems; orsleep problems (insomnia).
  3. fentanyl (Fentora, Onsolis)
    a narcotic (opioid) pain medicine; indicated for cancer patients who are tolerant to opioid therapy

    ADVERSE EFFECTS: mental and respiratory depression (particularly in the elderly), stupor, delirium, somnolence, and dysphoria; potential for abuse; nausea, vomiting, and constipation
  4. Versed (midazolam )
    given before medical procedures or before anesthesia for surgery to cause drowsiness, relieve anxiety, and prevent any memory of the event. Midazolam is in a class of medications called benzodiazepines. It works by slowing activity in the brain to allow relaxation and sleep.

    ADVERSE EFFECTS: cardiorespiratory depression, apnea, and respiratory arrest; alterations in blood pressure, arrhythmias, and ventricular irritability; Hypotension and decreases in systemic vascular resistance; nausea, vomiting, and hiccups

    Midazolam may cause some people to feel drowsy, tired, or weak for 1 or 2 days after it has been given. It may also cause problems with coordination and one's ability to think. Therefore, do not drive, use machines, or do anything else that could be dangerous if you are not alert until the effects of the medicine have disappeared or until the day after you receive midazolam, whichever period of time is longer.

    Do not drink alcoholic beverages or take other CNS depressants (medicines that slow down the nervous system, possibly causing drowsiness) for about 24 hours after you have received midazolam, unless otherwise directed by your doctor. To do so may add to the effects of the medicine. Some examples of CNS depressants are antihistamines or medicine for hay fever, other allergies, or colds; other sedatives, tranquilizers, or sleeping medicine; prescription pain medicine or narcotics; medicine for seizures; and muscle relaxants.

    Do not drink grapefruit juice or eat grapefruit while you are using this medicine. Also, do not take this medicine if you have allergies to cherries.Do not take other medicines unless they have been discussed with your doctor. This includes prescription or nonprescription (over-the-counter [OTC]) medicines and herbal or vitamin supplements.
  5. Rebound Tenderness
    pain upon removal of pressure application
  6. PERRL
    pupils equal, round, reactive to light
  7. Urine Specific Gravity
    1.010 - 1.025

    If greater than normal limits, sign of dehydration.
  8. PACU admission
    Report from ACP (Anesthesia Care Provider) to PACU (Post Anesthesia Care Unit) nurse.

    • General Info
    • patient name, age, ACP, surgeon, surgical procedure

    • Patient History
    • Indication for surgery
    • Medical HX, medications, allergies

    • Intraoperative Management
    • Anesthetic meds
    • Other meds received pre/intra-operatively
    • Blood loss
    • Fluid replacement totals, including blood transfusions
    • Urine Output

    • Intraoperative Course
    • Unexpected anesthesia events or reactions
    • Unexpected surgical events
    • VS and monitoring trends
    • Results of intraoperative lab tests

    • Initial PACU Assessment
    • Airway - patency
    • Breathing - rate and quality, auscultated breath sounds, pulse oximetry, supplemental oxygen
    • Circulation - BP, temp, color of skin, peripheral pulses
    • Neurologic - Level of consciousness, Orientation, Sensory and motor status
    • Genitourinary - Intake (fluids, irrigations); Output (urine, drains)
    • Surgical Site - dressings/drainage
    • Pain - incision / other
  9. Dyspepsia
    upset stomach or indigestion
  10. Melena
    black, tarry stools
  11. Hematemesis
    stark red bloody vomit
  12. Biliary Colic
    Severe pain produced when gallbladder spasms in response to gallstone; pain is rarely colicky but rather steady

    can be excruciating and accompanied by tachycardia, diaphoresis and prostration
  13. Steatorrhea
    the presence of excess fat in feces. Stools may also float due to excess lipid, have an oily appearance and be especially foul-smelling. An oily anal leakage or some level of fecal incontinence may occur. There is increased fatexcretion
  14. Hypothermia (intraoperative)
    Deliberate lowering of body temperature to decrease metabolism

    Reduces demand for O2 and anesthesia
  15. Malignant Hyperthermia
    Rare metabolic disease; inherited hypermetabolism of skeletal muscles resulting in altered control of intracellular calcium. Hyperthermia with rigidity of skeletal muscles

    Often occurs in exposure to succinylcholine, especially in conjunction with inhalation agents. Usually occurs under general anesthesia but may also occur in recovery

    Manifestations: tachycardia, tachypnea, hypercarbia, ventricular dysrhythmias. Rise in body temperature (1oF / 5 minutes) NOT an early sign.

    Can result in cardiac arrest and death
  16. PreOp Medications / Day of Surgery Medications
    A variety of preoperative medications may be used, either alone or in combination, depending on the patient and the type of surgery.

    These include benzodiazepines for sedation and amnesia, anticholinergics to reduce secretions, and opioids to decrease pain and intraoperative anesthetic requirements.

    Additional drugs include antiemetics, antibiotics (prophylactically), insulin, histamine-receptor antagonists, eye drops, and regular prescription drugs.

    Clarify with MD on day of surgery to administer: cardiac, insulin, antihypertensive and asthma drugs.
  17. Time Out / Universal Protocol
    Preventing wrong site, wrong procedure and wrong surgery is known as universal protocol.

    Time out: all members of surgical team stop what they are doing just before the procedure is started to verify patient identification, surgical procedure, and surgical site.
  18. Therapeutic Diets
    • Clear liquid diet
    • a. A clear liquid diet provides adequate fluid/water, 50-1,000 kcal of simple sugars, electrolytes, and is fiber free and fat free
    • b. It requires minimal digestion, as there is no residue, fiber, or fat
    • c. It is recommended for short-term use (3-5 days), can be used both before and after surgery or diagnostic procedures and during acute stages of illness
    • d. It consists of "see-through" foods that are liquid at body ternperature — tea, coffee, broth, or frozen ice, pops, gelatin.

    • Full liquid diet
    • a. A full liquid diet provides water, calories, protein, vitamins and minerals, and dairy products (contains lactose); because milk is allowed, it contains residue
    • b. It may be indicated for some clients who have difficulty chewing or swallowing but may not be indicated for a client following CVA
    • c. It can be considered to be a transition diet (moving from one diet to another as the client's clinical status improves) as the client progresses postoperatively or post-procedure from liquid to solids
    • d. It consists of all foods found on a clear liquid diet, plus milk, pudding, ice cream, soups, yogurts, and all prepared liquid formulas; is contraindicated with severe lactose intolerance; may have increased cholesterol content
    • e. Clients who are lactose intolerant may require lactose-free supplements to prevent clinical symptoms

    • Pureed diet
    • a. A pureed diet provides essential nutrients in a pureed (blenderized) form for clients who are unable to chew or swallow
    • b. It can be used as a long-term diet—the preparation of the food items is the deciding factor
    • c. The use of seasoning depends on individual client preferences
    • d. A blender or food processor is used to change foods into pureed or blended form for use in the diet
    • e. Certain foods such as raw eggs, nuts, whole breads, raw fruits or vegetables, and foods containing seeds are not included in this type of diet

    • Dysphagia diet
    • a. A dysphagia diet consists of chopped, ground, or pureed foods and liquids that may be thickened; provided to clients who have swallowing problems
    • and are at risk for aspiration (such as those post-CVA)
    • b. Thickening agents can be added to liquids to maximize texture and help facilitate the swallowing process
    • c. This diet is a modification of the soft- with increased attention to the liquid component due to possible aspiration concerns
    • d. Stringy, raw, dry, and fried foods are not allowed on this type of diet due to potential aspiration
    • e. Foods that are considered to be small in size or handheld, such as nuts, and popcorn, small candies, should be avoided due to risk of aspiration
    • f. positioning of the client to at least 30-45 degrees of higher and monitoring of feedings are critical
    • during meals in order to decrease risk of aspiration and evaluate client's attempts at eating

    • Mechanical soft diet or mechanically altered diet
    • a. This diet is used for clients who have problems with chewing; focuses on including all foods and seasonings in a form that is easily handled by the client
    • b. Foods with soft textures, those that are
    • tender, and chopped food items are included
    • in the diet
    • c. It can be used as either a long-term diet or a
    • transition diet
    • d. This diet is a modification of the regular diet with attention to texture
    • e. Foods that are tough in nature —containing seeds, nuts, raw eggs, and fruits with pits—are not included
    • in this diet
    • Soft diet (also called bland diet)
    • a. This diet includes food items that contain small amounts of seasoning and moderate fiber content but are easy to chew, digest, and absorb
    • b. Foods that are highly seasoned, fried, high in fiber, nuts, coconuts, and foods that contain seeds are not included in the diet as they could cause GI symptom upset.
    • c. It can be used as a progressive or
    • transition diet and is a modification of a regular
    • diet

    • a. The diabetic diet includes a controlled complex carbohydrate (CHO) source of 55-60%/day of total calories, protein source of 10-20%/day of total calo­ries, a lipid source of < 30%/day of total calories, and a recommended fiber intake of 20-35 grams/day; the relationship among glucose levels, serum lipids, kilocalories, diet therapy, and insulin/medication is evaluated in re­sponse to hemoglobin Al, and serum blood glucose monitoring
    • b. The gestational diabetes diet provides
    • adequate calories based on prepreg­nant weight status and frequent small feedings and snacks throughout the day to normalize postprandial glucose levels, maintain normal (euglycemic) levels throughout the pregnancy, and prevent ketosis
    • c. A hypoglycemic diet consists of small feedings at frequent intervals to help normalize blood glucose levels; the 15-15 rule is used to treat glucose levels <
    • 60 mg/dL

    • Gastric bypass diet
    • a. A gastric bypass diet consists of small meals eaten several times a day, drinking liquids between meals and taking multivitamin supplements with an emphasis on nutrient-dense foods
    • b. The diet is low in fat and high inprotein
    • c. The use of carbonated beverages, simple CHOs, and foods with a high content of fiber and residue are restricted

    • Low-residue diet
    • a. A low-residue diet consists of food items that minimize elimination patterns by reducing fecal
    • volume
    • b. High-fiber food sources are restricted in this diet along with milk and milk products
  19. Pulmonary Embolism
    • shortness of breath
    • tachypnea
    • temperature elevation of 101.6
    • tachycardia with cough

    • start oxygen
    • begin heparin/Coumadin therapy
    • take vitals
    • remain with patient
  20. T-tube
    to drain bile from common bile duct and keep duct patent until edema subsides

    • Expect 300-500mL of thick, blood-tinged, bright yellow to dark green bile drainage the first 24H after surgery.
    • Report drainage greater than 500mL/day.
    • After 4 days, amount will be < 200mL/day
  21. Hemovac and Jackson Pratt (JP/grenade)
    suction devices that are used postop to drain wound exudates
  22. Hemorrhage
    • Nursing Actions
    • assess vitals and wound dressing q4hours
    • monitor mental states changes
    • monitor hgb and hct, platelets and coagulation function tests
  23. Pyridium
    relieves urinary tract pain, burning, irritation, and discomfort, as well as urgent and frequent urination caused by urinary tract infections, surgery, injury, or examination procedures. However, phenazopyridine is not an antibiotic; it does not cure infections.

    turns urine reddish orange
  24. Shigella and Salmonella infection symptoms
    • Manifestations:
    • Shigella: Watery stools containing blood and mucus, tenesmus (straining at stool or urine), urgency, severe cramping, fever: onset 24 hrs, duration-7 days

    Salmonella: Watery diarrhea, nausea, vomiting, abdominal cramps, fever; onset 6-48 hrs, duration 2-5 days

    Both: dry mucous membranes; malnutrition; poor skin turgor; perianal irritation; sunken eyeballs; lethargy; decreased output concentrated urine; leukocytosis;


    • Gatorade; Pedialyte (adequate but not excessive)
    • IV fluids with electrolytes,
    • Vitamins
    • Antidiarrheal agent: to coat and protect mucous membranes; absorb irritating substances; inhibit GI motility; decrease intestinal secretions, and decrease CNS stimulation of the GI tract


    Antibiotics reserved for treating specific bacterial organism; can cause a secondary infection by altering the intestinal flora; Clindamycin leaves patients susceptible to C. difficile infection

    • Record I/O
    • Infection Control - Follow contact isolation procedures; gloves on entering room whenever
    • providing direct patient care or having hand contact with potentially contaminated surfaces and gowns when substantial contact is anticipated
    • Monitor vitals
    • Administer antiinfective and antidiarrheals
    • Assess skin turgor, sunken eyes, rapid pulse, and anorexia
    • Monitor K+ and Na+ (fluid and electrolytes)
    • Weigh daily (fluid balance indicator)
    • Administer IV
    • Increase fluid intake: to at least 3,000 cc/day
    • Assess mouth and requests for liquids (thirst)
    • Assess perianal area
    • Cleanse perianal area with warm water after each bowel movement
    • Apply ordered ointment to perianal area
    • Teach about recurrence of diarrhea; avoidance of recurrence-cooking, proper handling and storage of food


    Room assignments: All cases of acute diarrhea should be considered infectious until the cause is determined
  25. PCA use postop
    • PCA attempts to administer low doses of analgesic at
    • frequent intervals to deliver a more continuous level of pain control. A loading dose is delivered initially to raise the blood level to an effective range. The patient then self-administers to maintain the blood level within an effective range, based on his or her perception of the pain.
    • The type of medication, amount of medication delivered with each dose, and time interval between doses may need to be adjusted to achieve the greatest effectiveness. Sometimes the additional administration of PO NSAIDs or other PO analgesics may prove effective when used in conjunction with PCA.

    Remember, no single drug is effective for everyone.
  26. Hyperkalemia
    • greater than K+ normal range: 3.5-5.0
    • manifestations: abdominal cramps, tachycardia, numbness or tingling, oliguria

    causes: kidney disease, rapid administration of K, K+ sparing diuretics (Aldactone

    • treatment:
    • Kayexalate
    • decrease K+ intake
    • IV Sodium Bicarbonate
    • 10% calcium gluconate
    • insulin and glucose
  27. hypokalemia
    less than K+ normal range: 3.5-5.0

    • manifestations:
    • decreased peristalsis, abdominal distention, paralytic ileus (hypoactive bowel sounds), nausea, vomiting, dizziness, confusion, soft flabby muscles "like half filled water bottles," polyuria

    • causes:
    • vomiting, diarrhea, gastric suction, laxative abuse, dehydration, anorexia, starvation, steroids, diuretics, trauma, surgery

    • treatment:
    • dietary sources: bananas, OJ
    • oral K+ supplement: K-Dur, K-lyte
  28. Hyponatremia
    Less than Na+ normal range 136-145 mEq/L

    • manifestations:
    • mental status change (confusion, headache, lassitude); weight changes, BP changes, dry mucous membranes, coma, seizures, muscle weakness

    • causes:
    • vomiting, sweating, fever, muscular exercise, diarrhea, tap water enema, burns, surgery, gastric suction, potent diuretics, hormonal insufficiency, kidney-heart-circulatory dysfunction; hypotonic solutions

    • treatment:
    • fluid restriction
    • 3% NaCl -- correct slowly to prevent neurlogic damage
  29. Hypernatremia
    Greater than Na+ normal range 136-145 mEq/L

    • manifestations:
    • INTENSE THIRST, flushed skin, increased temperature, dry tongue, weight gain, peripheral and pulmonary edema, increased blood pressure, coma, seizures, restlessness, agitation, tachycardia

    • causes:
    • vomiting, diarrhea, decreased water intake, too much sodium intake, excessive adrenal hormone production (Cushing's syndrome), kidney-heart-circulatory dysfunction, increased water loss from perspiration or fever, too little water intake

    • treatment:
    • give oral or IV fluids for water loss
  30. Indicators of gastrointestinal hemorrhage
    • Hypotension, tachycardia
    • bloody emesis
    • occult blood in stools
    • decreasing hgb and hct
    • increasing abd girth
    • vertigo and nausea
    • dsypnea
  31. NG tube postop management
    • tape and tube at nares should be checked regularly for sign of ischemia
    • notify physician immediately if find bright red drainage, excessive drainage
    • do NOT irrigate or reposition NGT; sutures are very delicate and can be easily broken -- contributing to hemorrhage if broken.
  32. Surgical wound dehiscence
    • have client lie in bed with HOB raised to take pressure off abd cavity
    • cover wound with NS-soaked gauze
    • give client call light and instruct NOT to get out of bed while call physician
  33. Call physician for these warning signs for postop ABD surgical client
    any increased redness in/around wound, increased pain, any increase of temperature >101degF, any drainage from wound including clear drainage. and swelling of wound, or any separation of wound edges
  34. Simethicone
    anti-flatulent drug