Nursing Interventions and Principles of Care, Exams of Nursing

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Surgical Nursing Questions & Answers

List the sites for intramuscular injections (include name the muscles used). - ✔Ventrogluteal- 0-4mls Vastus lateratis- 5mls dorsogluteal- not used Deltoid- not over 4 mls The 3 principles of pain control are - ✔3 principles of chronic pain management Give the client as much control as possible Use a preventative approach, give before pain is bad Titrate to effect, desired effect with as few side effects as possible Intramuscular sites are - ✔Intramuscular Sites Ventrogluteal site- preferred site- has fewer blood vessels, even fat distribution and remains relaxed even if patient is tense. Location: Right palm over left greater trochlear, index finger over anterior superior iliac spine, middle finger spread dorsally over iliac crest. Injection site is in the middle of triangle created. Vastus lateralis site- preferred site for infants and children. Located in middle two thirds of thigh. Dorsogluteal Deltoid Sub cut sites are - ✔Abdomen, buttocks, front and side of thigh Out and upper arm Dysuria - ✔painful urination : Enteral Tubing - ✔Used when the patient is unable to ingest food but is still able to digest and absorb nutrients.

Feeding tubes can be inserted through: Nose (nasogastric or nasointestinal) Nasogastric- stomach nasointestinal -jejunum Short term - less than 4 weeks Dyspnea: - ✔shortness of breath or uncomfortable awareness of breathing Dysmenorrhea: - ✔Pain during menstruation that limits normal activity Nursing Interventions for nutrition - ✔Nursing Intervention's Help stimulate appetite: minimize Oduors, oral hygiene, position, manage symptoms i.e. antiemetic, analgesia Adhere to preferences or restrictions Replace % fluid loss via oral, IVT, SCT Assist: meals/drinks, use special aids Provide alternatives/varieties, small versus large Identify or eliminate food intolerance, allergy Ensure adequate intake with activity Monitor weight, food/fluid intake and output (FBC), BGL for diabetes Health promotion with education Enteral Tube Complications - ✔Aspiration - displacement, regurgitation or lying flat Diarrhea - change in diet, mal absorption, Constipation- lack of movement or fiber Tube occlusion, Tube displacement- blockage, kink Abdominal cramping/nausea/vomiting- delayed emptying, fast feeds, antibiotics or bacterial infection Care of Clients Stage 3 Students can give - ✔Oral care, Securing NGT, GT or PEG, Monitor bowel sounds Fluid Balance Chart (input/output) Monitor gastric drainage (color, consistency, Oduor and amount)

Skin integrity, Education and reassurance Peripheral IV Assessment Scale - ✔Pain, Redness, Swelling, Hardness, Discharge Hematoma- - ✔Localized collection of blood outside of a blood vessel Phlebitis - ✔inflammation of a vein Characterized by redness traveling along the vein, heat, pain, low grade fever Extravasation- - ✔leaking of medication into the surrounding tissues of a cannula site Pain, burning, stinging, heat, redness Infiltration - ✔accidental administration of IV fluid into the surrounding tissues Characterized by swelling, discomfort, tightness BODY FLUIDS (60 to 70%% body weight) (Average adult require 2.5 to 3L/day) - ✔Fluid Gains (mL) Fluid Losses(mL) Oral fluids 1100-1400 Kidneys 1200- Solid foods 800-1000 Skin 500- Metabolism 300 Lungs 400 GIT 100- Total Gains 2200-2700 Total Losses 2200- The Nursing Process - ✔Enables the nurse to organize and deliver individualized care successfully by identifying, diagnosing and treating human responses to health and illness. There are 5 steps: Assessment; Nursing diagnoses; Planning; Implementation; Evaluation Phases of Wound healing -

✔Inflammatory 0 to 6 days Proliferative 5 to 20 days Maturative 21 days - . Arterial Ulcers due to: - ✔Arteriosclerosis, diabetes, advanced age, hypertension, smoking. S&S: cool, thin, shiny, dry skin, absence of hair growth, thickened nails, pallor on elevation. Decreased/absent leg/pedal pulses, slow capillary refill, painful at rest relieved by lowering legs. Venous Ulcers due to - ✔h/o DVT, obesity, valvular incompetence in the vein’s r/t trauma, age, pregnancy, immobility S&S: oedema, red/brown pigmentation, evidence of healed ulcers, dilated veins, heat, mod to no pain relieved by elevation of leg, normal leg/pedal pulses Cellulitis- - ✔Inflammation of surrounding tissues Redness, swelling, tenderness What characteristics of a wound do you report - ✔Location Size: width, length, depth Appearance: granulating, epithelization, sloughy, necrotic, hyper-granulation Exudate: serous, purulent (pus), sanguineous and sero sanguineous Types: black, yellow, red, mixed Wound edges: red, pink, purple, blue, yellow, green, black, raised, cavity. Odour:? malodorou Faecal Characteristics that you would not - ✔-Colour - brown (alterations clay/white, pale, black or tarry, red) Pale- absence of bile, pale fatty, tarry blood in small intestine, red bleeding in large intestine -Odour- infection, malabsorption -Constituents- pus, mucous, blood, objects, undigested food -Frequency

-Amount -Shape -Consistency Urination the Process - ✔Bladder: stretch receptors (150 - 200mL), send messages to the micturition centre in spinal cord (SC) Parasympathetic impulses cause detrusor muscle to contract Internal sphincter relaxes, urine to urethra As bladder contracts, impulses travel up SC to Pons and cerebral cortex Conscious decision to void, external muscle relaxes (voluntary control). Over Flow Incontinence - ✔voluntary or involuntary loss of small amounts (20-30mL) -underactive detrusor: faecal impaction, DM, spinal cord injury, enlarged prostate glands Rx: Intermittent catheterisation, surgery, IDC Functional Incontinence - ✔involuntary, unpredictable - change in environment (sensory, cognitive or mobility deficit) Rx: environmental alterations, scheduled toileting, skin and perineal care Urge Incontinence - ✔involuntary passage of urine after a sense of urgency - decreased bladder capacity, irritation, infection, increased fluid intake Rx: Anti-cholinergic drug therapy, biofeedback, bladder training Others: : referral to Continence Advisory Service Stress Incontinence - ✔Leakage of small amounts, caused by sudden increase in intra-abdominal pressure - incompetent bladder outlet, weak pelvic muscles Rx: Pelvic floor exercise, surgery, biofeedback Reflex Incontinence - ✔Involuntary loss (large or small amounts) - spinal cord dysfunction Rx: Anti-cholinergic drug therapy, intermittent catheterisation, surgery, IDC. Urgency -

✔need to void immediately Dysuria: - ✔painful or difficult urination Nocturia: - ✔excessive at night Oliguria: - ✔< 500mL/24 hr Anuria: - ✔inability to produce urine Polyuria: - ✔large amounts of urine Incontinence - ✔involuntary loss of urine Residuel urine: - ✔volume remain after voiding (>100 ml) Frequency: - ✔< 2 hr intervals Nursing Interventions re incontinence - ✔-Patient education -Promoting normal micturition -Promote complete bladder emptying -Prevent infections Nursing interventions urination in acute care - ✔Maintain elimination habits -Medications -Catheterisation -Alternatives to urethral catheterisation -Nursing practice Neurovascular Observations -

✔Colour- pink, pale, mottled, flushed Temperature- hot, warm, cool, cold Movement- present, decreased, absent, active & passive Sensation- present, numb, tingling, absent Pain- mild, moderate, severe, absent, present, passive movement Pulses- strong, faint, absent Comparison- with unaffected limb Remarks i.e. swelling or oedema Post operative Care - ✔=Preparation: patient's room for return from theatre, post op bed, nbm/fasting sign, other equipment etc. =Ensure receive full handover for client from recovery staff =Psychological support: active listening, explanation, reassurance etc =Observation/documentation: pain, vital signs, medications, TPR, IVT, FBC, TEDS/neurovascular, nursing care plan etc. =Wound/s: check dressing/drains. =Oxygenation: suctioning (if applicable), breathing & leg exercises/coughing, O2 therapy (nasal/mask) incentive spirometry, pulse oximetry. =Hydration/nutrition: Water jug (if applicable), IVT and pole, NGT on drainage bag (if applicable) =Elimination: bed pan/urinals, vomit bowl, indwelling catheter to straight drainage or on hourly output measurement. =Hygiene: post op wash bowl, mouth care, dentures, hair etc. Catheter care - ✔- Check no tension, obstruction, kinks

• Maintain gravity,
• Drainage system: sealed
• Observe flow: note amount, colour, odour & abnormalities
• Report if < 30 mL/hr (0.5 mL/kg/day)
• Maintain catheter and perineal care

Promoting normal urination - ✔-Stimulating micturition reflex: relax, normal position (squat, sit) -Privacy -Sound of running water -Warm bed pan -Maintain adequate fluid intake -Monitor and record both intake and output (FBC) Report deficit -Promote and maintain effective elimination habits -Prevent infection: perineal hygiene, increase fluid intake -Others: medications (anticholinergic), bladder scan, catheterisation. Metabolism - ✔- all biochemical and physiologic processes involved in the growth and maintenance of the body

• Anabolic -construct molecules from smaller units
• Catabolic -large molecules to small Basal metabolic rate (BMR) - ✔- the rate at which the body metabolises food to maintain the energy requirements of a person at rest or awake Enteral Feeding- Care of Clients Stage 3 Students can give - ✔Oral care Securing NGT, GT or PEG Monitor bowel sounds Fluid Balance Chart (input/output) Monitor gastric drainage (colour, consistency, odour and amount) Skin integrity Education and reassurance Pressure Ulcer Risk - ✔=Sensory Impairment-Loss of protective reflexes- sensory deficit =Moisture- Incontinence g of urine or faeces Altered skin moisture: excessively dry/ excessively moist

=Mobility-Immobility-Prolonged pressure on tissue =Nutrition-Malnutrition =Friction- sheering forces, trauma Advanced age Orthopaedic devices Poor skin perfusion oedema Stages of Pressure Ulcers - ✔1: Epidermis - Intact skin with non-blanching erythema (redness) of a localised skin- 2: Partial thickness loss of dermis - shallow ulcer with red pink wound without slough 3: Full thickness tissue loss - epidermis, dermis subcutaneous fat may be visible, slough may be present but bone, muscle not exposed 4: Full thickness tissue loss with exposed bone, tendon or muscle; slough and eschar may be present Unstageable: full thickness tissue loss with slough, eschar or both in wound bed of ulcer. Wound Healing Complications - ✔-Haemorrhage: slipped suture, dislodged clot, FB -Infection (4th day post-op): fever, pain, redness, discharge, WBC, -Dehiscence (3 -4 days post): reopening of wound-strain/cough, increased exudate- -Evisceration: protrusion of visceral organ/s -Fistula: abnormal passage between organs, can be created -Delayed wound closure (third intention). Constipation - ✔-A symptom, not a disease. -Decrease in frequency of bowel movements, accompanied by prolonged or difficult passage of dry, hard stool. Impaction - ✔- Unrelieved constipation, hardened faeces collects & wedges in the rectum

• cannot be expelled Collecting MSU (mid-stream urine) - ✔Instruct - Clean external genitalia, void, stop, void

Collect 30 - 60 mL in sterile container and void Label and send Collecting CSU (catheter specimen urine) - ✔Clean straight from catherisation OR clamp for 30 minutes Don gloves Wipe & insert needle with syringe Withdraw Transfer specimen to sterile container Label and send. Basic Elements of Body mechanics - ✔=Body alignment & posture- relationship of body parts (horizontal & vertical) Good alignment allows good lung expansion, circulation, renal function Line of gravity, Centre of Gravity, base of support. =Joint mobility- extensors and flexors- extensor stronger than flexors. In resting position to stop permanent shortening of muscles. =Balance - proprioception, effective posture complex mechanism enhanced by effective body posture & proprioception =Coordinated movement - CNS. Consequences of Immobility - ✔Decreased respiratory movement Pooling of respiratory secretions Urinary stasis Urinary retention Urinary infection Constipation/impaction Reduced skin turgor Skin breakdown Decreased metabolic rate Nursing Intervention for mobilisation -

✔=Be aware of medical limitations, activity tolerance, non-wt bearing, RIB, effects of medications =Pre & post op education/expectations/exercises: deep breathing, coughing & legs, TED stockings =Ensure safety: pressure area care, use of walking aids =Pain relief prior to mobility =Position: comfort, body alignment/posture, support i.e. shoulder sling =Monitor/document/evaluate vital signs ,pre & post exercises (tolerance) =Consult: Dr, physiotherapist (PT), occupational therapist (OT) Pre op Checks - ✔Most patients are admitted to hospital on the day of surgery. Prior to admission patient will be instructed to : Fast Shower Remove make up, nail polish etc. May have additional instructions e.g. Bowel preparation Many hospitals have pre admission clinics for interview /assessment. Basic VS, weight, urinalysis, medications will be recorded. Procedures explained, consent gained, education provided Patients: may be anxious and fearful. Pre operatively the nurse should: Explore pt's feelings about admission/surgery and attempt to allay fears. Education should encompass physical and psychological care e.g. Psychological support, pain management information, prevention of respiratory problems, thrombi and emboli, promoting activity and exercise Provide anti-embolic stockings for all patients no matter how minor the surgery is Eupnoea - ✔Normal resps(16 to 20 normal ) Bradypnoea - ✔(<10 slow ) resps Apnoea - ✔cessation of resps (sleep)

Tachypnoea - ✔fasts resps (> 35 rapid) Kussmaul's - ✔resps (>35 may be slow or normal) Common Alterations in Breathing Patterns - ✔Altered breathing pattern Hypoxia Obstructed airway Dyspnoea: - ✔difficulty Use of accessory muscles: Orthopnoea: - ✔need to sit in upright or standing position Hypoxia Causes - ✔=Decreased haemoglobin level e.g. anaemia =Decreased concentration of inspired oxygen e.g. Sleep apnoea =Inability of tissues to extract O2 from blood e.g. Some congenital heart conditions, CAL =Decreased diffusion of O2 from alveoli e.g. Pulmonary fibrosis, sarcoidosis, lung cancer =Poor tissue perfusion e.g. Pulmonary oedema, pneumonia =Impaired ventilation, trauma, hyper/hypo ventilation, anaesthesia Interventions to maintain repspiratory function - ✔Facilitate respiratory health & oxygenation Prevent risk of CV & respiratory problems Monitor vital signs ECG blood studies PEFR

pulse-oximetry skin integrity e.g repositioning NV assessment Educate/promote: mobility, incentive spirometry, deep breathing/coughing & legs exercises, physio (percussion, vibration & postural changes), suction Increase hydration Oxygen therapy Medicate oxygen, nebulizers bronchodilators, expectorants Potential for Chest drains & artificial airways. Safety Issues when giving oxygen - ✔signs - flammable, no smoking flammable material fire extinguishers enough O2 in cylinder before transport educating patient and carers of safety issues Mobilising Respiratory Secretions - ✔Hydration- 1500- 2 L aday Humidification Nebulisation Coughing techniques Chest physiotherapy Indicators for Suctioning - ✔When patient is able to cough but not able to exporate it or swallow oropharyngeal or nasopharyngeal after cough Indicators for Neurovascular Obs - ✔-Post op- particularly cardiac patients

-Base line before surgery -Vascular or nerve supply at risk due to trauma or surgery -status over time to indentify indicators early of complications to intervene Oxygen therapy - ✔-Oxygen is a drug need a doctors order

• a nurse can give oxygen but needs to be followed up by a doctors order -Document- ammount, concetration, delivery and duration Respiratory assessment always done first. Indicators for Oxygen therapy - ✔Post-op Hypoxemia increased metabolic needs- i.e. fever trauma effecting lungs trachea etc Alterations in Cardiac Output - ✔Decreased cardiac output Impaired tissue perfusion Blood alterations Interventions to promote circulation - ✔Promoting circulation - preop education for post op - breathing & leg exercises and early mobilisation TED's Medications- to promote ciculation The aim is to preventing venous stasis Cardiopulmonary resuscitation may needed D R A B C Compartment Syndrome -

✔There are 4 compartment in each limb consisting of muscles separated by fascia. If the pressure in a compartment rises the blood supply to the nerves and tissues is compromised by compression on the blood vessels. Symptoms: Pain, pallor, parasethia, peripheral pulses, paralysis Complication: Hypoxemia of the tissues,permanate nerve and tissue damage, threatens patients limbs, sepsis. DVT - ✔Thrombos(clot) in a deep vein. Commonly occcurs in the legs. Symptoms- Pain, heat, swelling, impaired mobilisation, sometimes none. -Risk factors- obesity, immobility, Post op, trauma, clotting disorders. -Complications- embolus= MI, PE, CVA -Treatment- *Rest in Bed elevate legs, thrombolytic drugs to dissolve clot possibly anticoagulating drugs to prevent recurrance. *TED's stockings as prevention not when a clot is in situ we don't want to promote circulation Levels of Consciousness - ✔• Alertness -

• Confusion -
• Lethargy -
• Delirium -
• Stupor -
• Coma ACLDSC Glasgow Coma Scale (GCS) - ✔◦Eye opening, Best verbal response, Best motor response =Opens eyes: 4-spontaneous, 3 -To speech, 2- to pain, 1- none =Best verbal response: Orientated- answered questions regarding time place, birthdate etc 5

Confused, 4; inappropriate words, 3; incomprehensible sounds 2; none 1. =Best Motor Response:6- obeys commands, 5-Localise to pain, 4- withdraws from pain, 3- flexion to pain, 2-extension to pain, 1-none. ◦Score : 3 = lowest, less than 13 = neurological deficit or impairment. 3-8= usually coma. Neurological Checks - ✔Glasgow Coma Scale -Observe patient for eyes opening spontaneously, to speech, to pain or no response -Assess patient's orientation: Ask patient name What month, season, year Where they are -Assess motor response Single response command eg: touch your nose, wiggle your toes Increased ICP (intracranial pressure) :Neurological Assessment Charts Include -Level of consciousness -Pupillary check -Vital Signs -Movement and strength of extremities Process of working through grief - ✔TEAR-The Four Processes of Mourning (Grief Work) T = to accept the reality of the loss E = experience the pain of the loss A = adjust to an environment that no longer includes the lost person/object R = reinvest emotional energy into new relationships. Bereavement: -

✔subjective response that a person experiences, an actual process a person goes through following a significant loss. Grief: - ✔is part of the universal human experience, total response to the emotional experience related to loss: complex, evolutionally, multifaceted, price paid for love and for investing self in in others Mourning - ✔"grief work" - behavioural process required for healing, linked to culture, spirituality and custom, bereaved gradually incorporate the loss in their ongoing life