Nursing Interventions for Postoperative Patients, Exams of Nursing

Download Nursing Interventions for Postoperative Patients and more Exams Nursing in PDF only on Docsity!

NUR 351 - Acute Med SURG Final

What is the priority of a professional nurse? - Answer-SAFETY Step 1 of Nursing Process - Answer-Assessment Nursing Assessment - Answer-systematic and continuous collection and analysis of information about the client

• Construct database o Mental Status Exam o Psychosocial assessment o Physical exam o History o Interviews - assessment interview requires culturally effective communication skills and encompasses a large database o Standardized rating scales
• Verify the data SBAR communication - Answer-(Situation, Background, Assessment, Recommendation) - framework for communication between members of the healthcare team about a patient's condition.

SBAR: Situation - Answer-What is the situation you are calling about?

• Identify self, unit, patient, room number.
• Briefly state the problem, what is happening at the time, when it happened or started, and how severe. SBAR: Background - Answer-Pertinent background information related to the situation could include the following:
• The admitting diagnosis and date of admission
• List of current medications, allergies, IV fluids, and labs
• Most recent vital signs
• Lab results: provide the date and time test was done and results of previous tests for comparison
• Other clinical information
• Code status SBAR: Assessment - Answer-What is the nurse's assessment of the situation? Provide an analysis of the problem or pt. need based on assessment data collected SBAR: Recommendation - Answer-What is the nurse's recommendation or what does he/she want? Desired outcome Examples:
• Notification that patient has been admitted
• Patient needs to be seen now
• Order change

goal of safety - Answer-the ability to keep the patient and staff free from harm and minimize errors in care Errors in health care can lead to: - Answer-- pt injury

• pt death
• increased health care costs Best safety practices reduce error and harm through: - Answer-- established protocols
• memory checklists
• bar code medication administration National Patient Safety Goals (NPSGs) - Answer-areas of patient safety concern identified annually by the Joint Commission that, if rectified, may have the most positive impact on improving patient care and outcomes sentinel event - Answer-a serious variation in the standard of care that is caused by huan or system error and results in an avoidable pt death or major harm. Failure to rescue - Answer-the inability to recognize a patient's negative change in status in a timely manner in order to prevent patient complications and to prevent major disability or death What have most hospitals implemented in order to improve pt. safety and prevent failure to rescue? - Answer-a Rapid Response Team Goal of Rapid Response Team - Answer-To save lives and decrease the risk for harm by providing better care before a medical emergency occurs. They intervene rapidly when needed for pts. who are beginning to rapidly decline

Members of the rapid response team are critical care experts who are on-site and available at any time. May consist of: - Answer-- ICU nurse

• Respiratory therapist -Intensivist and/or hospitalist
• Acute care NPs
• Medical residents The American Nurses Association (ANA) standard related to ___________ ___________ demands skill in teaching clients. - Answer-Promoting Health ; teaching clients is a part of health promotion Why do nurses need teaching skills? - Answer-- Patients participate in healthcare decisions. - It is important that pts and families obtain info so they can make informed decisions. Help them with answers to their questions, find resources, recognize problems, and help them develop self care behaviors Hospital stays are brief. - Since hospital stays are brief it is important to teach family members how to care for the pt. and to teach pt's to care for themselves as much as possible Healthcare is expensive.- Pt education can help reduce overall cost of health care Three domains of learning - Answer-1. Cognitive

2. Psychomotor
3. Affective Cognitive Domain of Learning - Answer-Includes storing and recalling information in the brain. Ranging from simple to complex processes, it encompasses six levels of behavior: memorization, recall, comprehension and analysis, synthesis, application, and evaluation of ideas. Strategies and tools to support teaching cognitive-type content include lectures, reading materials, panel discussions, audiovisual materials, programmed instruction, computer-assisted instruction (CAI), and problem-based learning (e.g., case studies and care plans).

Psychomotor Domain of Learning - Answer-"Hands-on" skill: Psychomotor learning involves learning a skill that requires both mental and physical activity. It requires the learner to accept and value the skill (the affective domain) as well as know about the skill (the cognitive domain). Strategies and tools used to teach psychomotor skills include demonstration and return demonstration, simulation models, audiovisual materials (e.g., DVDs, streaming video), journaling and self-reflection, and printed materials (especially with photographs and illustrations). affective domain of learning - Answer-Changing feelings, beliefs, and attitudes. Strategies and tools for promoting affective learning include role modeling, group work, panel discussion, role playing, mentoring, one-to-one counseling and discussion, audiovisual materials (e.g., DVDs, streaming video, interactive computer-based modules, movies), and printed materials. Evaluating learning - Teach back Method - Answer-Teach back method also called the "show-me" method, is a communication confirmation method used by healthcare providers to confirm whether a patient (or care takers) understands what is being explained to them. If a patient understands, they are able to "teach-back" the information accurately. Nurses must possess the knowledge and skills needed for patient teaching so that... A. They can complete the documentation forms related to client teaching accurately. B. They can help the hospital meet The Joint Commission standards requiring client teaching. C. They can promote the health, safety, and rights of clients through education. D. They can meet the patient rights delineated in the "Patient Care Partnership." - Answer-C. They can promote the health, safety, and rights of clients through education. The nurse is monitoring the patient who is 24 hours post-opt from surgery. Which finding requires intervention? A. BP 100/ B. 24-hour urine output of 300 ml C. Pain rating of 4 on 1-10 scale D. Temperature of 99.3' F - Answer-B. 24-hour urine output of 300 ml

The nurse needs to watch the patient's urinary output closely. Urinary output within a 24-hour period should be at least 30 ml/hr. In this case, the patient is only urinating 12.5 ml/hr. A patient reports he hasn't had a bowel movement or passed gas since surgery. On assessment, you note the abdomen is distended and no bowel sounds are noted in the four quadrants. You notify the MD. What non-invasive nursing interventions can you perform without a MD order? A. Insert a nasogastric attached to intermittent suction B. Administer IV fluids C. Encourage ambulation, maintain NPO status, and monitor intake & output D. Encourage at least 3000 ml of fluids per day - Answer-C. Encourage ambulation, maintain NPO status, and monitor intake & output This patient is most likely experiencing a paralytic ileus which is failure for the bowels to move its contents. The only correct non-invasive option is to encourage ambulation, maintain NPO status, and monitor intake & output. Inserting a NG tube or administering IV fluids is invasive and requires a MD order. Patients with potential paralytic ileus are to be NPO (nothing by mouth) so encouraging fluid intake is incorrect. What is a potential postoperative concern regarding a patient who has already resumed a solid diet? A. Failure to pass stool within 12 hours of eating solid foods B. Failure to pass stool within 48 hours of eating solid foods C. Passage of excessive flatus D. Patient reports a decreased appetite - Answer-B. Failure to pass stool within 48 hours of eating solid foods After a patient resumes solid food, they should have a bowel movement within 48 hours. The patient may be experiencing constipation and appropriate interventions must be followed. A nurse is developing a care plan for a patient who is at risk for developing pneumonia after surgery. Which of the following is not an appropriate nursing intervention?

A. Encourage patient intake of 3000 ml/day of fluids if not contraindicated B. Encourage patient to use the incentive spirometer device 10 times every 1-2 hours while awake C. Encourage early ambulation and patient to eat meals in beside chair D. Repositioning every 3-4 hours - Answer-D. Repositioning every 3-4 hours The answer is D. All options are correct expect for repositioning every 3-4 hours. If the patient is unable to reposition themselves or ambulate, they must be repositioned every 1 to 2 hours minimally. When assessing your patient who is post-opt, you notice that the patient's right calf vein feels hard, cord-like, and is tender to the touch. The patient reports it is aching and painful. What would NOT be an appropriate nursing intervention for this patient? A. Allow the patient to dangle the legs to help increase circulation and alleviate pain B. Instruct the patient to not sit in one position for a long period of time C. Elevate the extremity 30 degrees without allowing any pressure on affected area D. Administer anticoagulants as ordered by MD - Answer-A. Allow the patient to dangle the legs to help increase circulation and alleviate pain All options are correct except for "Allow the patient to dangle the legs to help increase circulation and alleviate pain". The patient should NOT dangle the legs because this causes blood to pool in the lower extremities which will put the patient at risk for another blood clot formation. A patient is recovering from surgery. The patient is very restless, heart rate is 120 bpm and blood pressure is 70/53, skin is cool/clammy. As the nurse you would? A. Continue to monitor the patient B. Notify the MD C. Obtain an EKG D. Check the patient's blood glucose - Answer-B. Notify the MD

This is an emergency situation. The patient is more than likely experiencing a hemorrhage of some type. Notifying the MD would be the first line of action and then you could check the patient's blood glucose and obtain an EKG. This patient is probably going to need a surgical intervention. A patient is taking Aspirin 325 mg PO by mouth daily. The patient is scheduled for surgery in a week. What education do you provide the patient with before surgery? A. Educate the patient to take the scheduled dose of Aspirin the day of surgery to help prevent blood clots B. To hold his morning dose of Aspirin because the nurse will give it to him before surgery C. None of the above are correct D. The medication should be discontinued for 48 hours prior to the scheduled surgery date - Answer-D. The medication should be discontinued for 48 hours prior to the scheduled surgery date Aspirin alters the normal clotting factors and increases the patient's chances of hemorrhaging. Therefore, it should be held for at least 48 hours prior to surgery as specified by the surgeon. You are observing your patient use the incentive spirometry. What demonstration by the patient lets you know the patient understands how to use the device properly? A. The patient inhales slowly on the device and maintains the flow indicator between 600 to 900 level B. The patient blows on the mouthpiece rapidly. C. The patient uses the incentive spirometry once a day D. The patient rapidly inhales on the devices and exhales - Answer-A. The patient inhales slowly on the device and maintains the flow indicator between 600 to 900 level All of the options are wrong expect for "The patient inhales slowly on the device and maintains the flow indicator between 600 to 900 level". The other options do not demonstrate how to properly use the incentive spirometry.78*- As the nurse you are getting the patient ready for surgery. You are completing the preoperative checklist. Which of the following is not part of the preoperative checklist?

A. Assess for allergies B. Conducting the Time Out C. Informed consent is signed D. Ensuring that the history and physical examination has been completed - Answer-B. Conducting the Time Out The answer is B. The time out is conducted by the OR nurse prior to surgery. All of the other options are conducted by the nurse getting the patient ready for surgery. As a nurse, which statement is incorrect regarding an informed consent signed by a patient? A. The nurse is responsible for obtaining the consent for surgery B. Patients under 18 years of age may need a parent or legal guardian to sign a consent form C. The nurse can witness the client signing the consent form D. It is the nurse's responsibility to ensure the patient has been educated by the physician about the procedure before informed consent is obtained - Answer-A. The nurse is responsible for obtaining the consent for surgery The answer is A. All statements are correct except that it's the nurse's responsibility for obtaining the consent for surgery. It is the surgeon's responsibility. Ethical Principle of Nursing: Autonomy - Answer-a.ka. self-determination or self-management --> when a pt. is not capable of self-determination, you are ethically obligated to protect him or her as an advocate within the professional scope of practice Ethical Principle of Nursing: Beneficence - Answer-Promotes positive actions to help others. It encourages the nurse to do good for the patient Ethical Principle of Nursing: Nonmaleficence - Answer-Emphasizes the importance of preventing harm and ensuring the pt's well-being. Harm can be avoided only if its cause or possible causes are identified.

Ethical Principle of Nursing: Veracity - Answer-Nurse is obligated to tell the truth to the best of his/her knowledge Ethical Principle of Nursing: Fidelity - Answer-Refers to the agreement that nurses will keep their obligations or promises to pts to follow through with care Ethical Principle of Nursing: Social Justice - Answer-Refers to equality and fairness; that is all patients should be treated equally and fairly, regardless of age, gender, identity, sexual orientation, religion, race, ethnicity, or education Teaching Strategy: Demonstration/Return - Answer-The teacher explains and demonstrates a skill or task. The learner then demonstrates comprehension by returning the demonstration. Return demonstrations should be scheduled close to the initial teaching of the skill. This format allows for targeted questions and answers and practical matters, rather than theory. This method requires the demonstrator to have specialized expertise if highly technical tasks are involved. Primary Prevention - Answer-Prevent/slow onset of disease - eating healthy foods, immunizations, exercise Secondary Prevention - Answer-Screening; Detect & treat illnesses in early stages; breast self exam, physical exam, BP and DM screenings, TSE Tertiary Prevention - Answer-Stop disease progression; return to pre-illness state; rehabilitation is the main intervention Nursing Assessment - Health History - Answer-family hx, various health disorders ,COD of various family members

Nursing Assessment - Physical Exam - Answer-Level of detail of physical exam depends on the health hx. At min will include VS, Weight, BMI, auscultation and palpation of the chest and abdomen, palpation of the peripheral pulses, inspection of skin. Exam may be accompanied by labs and disease specific studies Nursing Assessment - Physical Fitness (3 Types) - Answer-1. Cardiorespiratory Fitness

2. Muscular Fitness
3. Flexibility cardiorespiratory fitness - Answer-The ability of the circulatory and respiratory systems to supply oxygen-rich blood to skeletal muscles during sustained physical activity. Reflected in the ability to perform large muscle moderate to high intensity exercise for an extended period of time; different modes of testing: field test (walking and running), treadmill, stationary bikes; results depend on age and gender Muscular Fitness - Answer-refers to both muscle strength and endurance. Muscle strength - a measure of the amount of weight a muscle or a group of muscles can move at one time. Muscle endurance - refers to the ability of a muscle to perform repeated motions Flexibility - Answer-the ability to move a joint through its ROM. Mode of testing: ROM. Most common assessment is to evaluate low back and hip trunk flexion Health risk assessment (HRA) - Answer-a tool to assess a patient's health status, risk of negative health outcomes, and readiness to change behaviors. Some factors assessed: Personal responsibility for health Physical activity Nutrition Interpersonal relations Spiritual growth Stress management

Hans Selye's General Adaptation Syndrome - Answer-Selye's concept of the body's adaptive response to stress in three phases—alarm, resistance, exhaustion. Nutritional assessment includes - Answer-Body mass Dietary patterns Health Screening includes - Answer-BP screening Cancer screening tests Lab studies (e.g. lipid levels, PSA) What is the most accurate noninvasive indicator of fluid status? - Answer-Weight The parents of a 3 year old bring their child to the ER. The parents report the child suddenly developed a fever overnight and has had issues swallowing, which has led to excessive drooling. In addition, the parents explain that the child complains of sore throat, and it is hard to understand the child's speech because her voice is muffled. Based on this information, your next nursing actions will be? Select all that apply: A. Assess the child's temperature orally B. Obtain a throat culture C. Count the patient's respirations D. Assess the child's throat for tonsillar exudate E. Keep the child NPO - Answer-C. Count the patient's respirations E. Keep the child NPO Older adults are at Increased Risk for Cognitive Health Problems. What are the 3 D's? - Answer-1. Depression

2. Delirium

3. Dementia Depression in Geriatrics - Answer--Mood disorder having cognitive, affective, physical manifestations Primary (lack of neurotransmitters) Secondary or situational (illness or loss) Geriatric Depression Scale - Short Form (GDS-SF) used for assessment Treatment includes drug therapy, psychotherapy Reminiscence or reflective therapies useful with older adults Dementia in Geriatrics - Answer-Syndrome involving slow, progressive cognitive decline (also known as chronic confusion) Global impairment of intellectual function; generally chronic & progressive Delirium in Geriatrics - Answer-Acute state of confusion Usually short-term; reversible within 1 month or less Often experienced by older adults in unfamiliar settings Can include physical & emotional manifestations of change Most common accident in older adults? - Answer-Falls Some common home modifications that can be instituted to assist with falls? - Answer-handrails, slip- proof pads for rugs and adequate lighting are essential Risk factors risk for falls is related to: - Answer-decreased mobility and changes in sensory perception may make walking more difficult - person is less aware of the location of each step, chronic disease and peripheral neuropathy, and arthritis- common in diabetes, disorders that affect visual acuity such as macular degeneration, cataracts, glaucoma, or diabetic retinopathy, reduced sense of touch decreases the awareness of body orientation

What is the symptom that dying patients fear most? - Answer-Pain; Schedule pain medications to prevent recurrence of pain Some CAM that can be used for pain managemen? - Answer-Massage Music therapy Therapeutic touch Aromatherapy Doctors are required by law to initiate CPR for a pt that is not breathing or is pulseless unless what exists? - Answer-A DNR Priority treatment for a patient in anaphylaxis - Answer-Epinephrine signs of anaphylaxis - Answer-Widespread hives Respiratory distress Dyspnea Bronchospasms Swelling of lips Wheezing/Stridor (be very concerned if pt is exhibiting stridor, they may need to be intubated) Hypotension Incontinence Hypotonia What therapies does the nurse anticipate the provider will order for a patient exhibiting anaphylaxis? (Select all that apply.)

A. Epinephrine (Adrenaline) B. Diphenhydramine (Benadryl) C. Acetaminophen (Tylenol) D. IV fluids = E. Oxygen - Answer-A. Epinephrine (Adrenaline) B. Diphenhydramine (Benadryl) D. IV fluids E. Oxygen During Medication administration: always ask patient's about ________ to drugs or other substances - Answer-allergies Injection with bee venom is what type of Hypersensitivity Reaction? - Answer-Type 1 Hypersensitivity reaction meaning it is immediate Some interventions to teach pt with Type 1 Hypersensitivity - Answer-Avoidance therapy Environmental changes Air-conditioning, air-cleaning units Cloth drapes Upholstered furniture Carpeting Pet interventions Five cardinal signs of inflammation - Answer-redness, swelling, heat, pain, loss of function normal potassium levels - Answer-3.5-5.0 mEq/L

normal sodium levels - Answer-135-145 mEq/L Hemoglobin levels - Answer-12-17.5 mg/dL Creatinine levels - Answer-0.5-1.2 mg/dL Preoperative - Answer-begins when patient decides to have surgery, ends when patient is entering OR Intra-operative - Answer-begins at the OR table, ends when pt is in the PACU Postoperative - Answer-PACU through healing Things that are decreased in older adults that cause increased risk during surgery: - Answer-- Cardiac output, peripheral circulation

• Vital capacity (lung elasticity) therefore less blood oxygenation
• Blood flow to kidneys, glomerular filtration rate Things that are increased in older adults that cause increased risk during surgery: - Answer-- Blood pressure
• Risk for skin damage, infection
• Sensory deficits
• Deformities related to osteoporosis/arthritis Nurses role during preoperative period - Answer-Nurse functions as educator, advocate, promoter of health and safety

During the pre-op assessment of the patient, you are obtaining what? Focusing on what? And reporting what? - Answer-Obtaining - baseline VS Focusing on -Focus on problem areas identified in hx; all body systems affected by surgery Reporting - Report abnormal assessment finding to Surgeon/anesthesiologist Some labs/assessments that may be completed pre-op - Answer-Urinalysis Blood type and crossmatch CBC or hemoglobin level and hematocrit Clotting studies (PT, INR, aPTT) Electrolyte levels Serum creatinine level Pregnancy test Chest x-ray ECG Informed consent - Answer-Surgeon obtains signed consent before sedation and/or surgery

• Nurse clarifies facts and dispels myths about surgery
• Nurse not responsible for providing detailed information about procedure! Some pre-operative meds - Answer-Reduce anxiety (anxiolytics) Promote relaxation (sedatives, hypnotics) Reduce nasal and oral secretions (anticholinergic agents) Prevent laryngospasm Reduce vagal-induced bradycardia Inhibit gastric secretion (H2 histamine blockers) Decrease amount of anesthetic needed for induction and maintenance (opioids)

Pre-operative chart review - Answer-- Ensure all documentation, preoperative procedures, orders are complete

• Check surgical consent form and others for completeness
• Inform patient that area will be marked before procedure begins
• Document allergies, height, and weight
• Ensure all laboratory and diagnostic test results are in chart and abnormal results noted Pre-operative patient preparation - Answer-Remove most clothing; provide gown Leave valuables with family member or lock up Tape rings in place if cannot be removed Ensure patient is wearing ID band Remove: -Dentures -Prosthetic devices -Hearing aids -Contact lenses -Fingernail polish -Artificial nails -Pierced jewelry During post- operative period, what is priority? - Answer-Airway management is priority

Patient teaching post-operatively - Answer-- Patient teaching

• Incentive spirometry (IS)
• Turn, cough, deep breath (TCDB)
• Deep vein thrombosis (DVT) prevention: Sequential compression devices (SCDs)
• Early ambulation
• Void/urine output -Report urine output of <30 mL/hr GI - post op - Answer-a sign of bowel waking up/ coming back is passing gas, ambulation will help How to reduce pain of abdominal surgery? - Answer-splint incision to reduce pain after abdominal surgery Priority goals related to a patient with a post-op drain - Answer-(no redness, warmth, drainage at insertion site) no s/s infection Pain Interventions: CAM - Answer-Positioning Massage Relaxation/diversion techniques Because of the high potential for hypoxemia post-op, what are some interventions the nurse can implement? - Answer-- Airway maintenance
• Monitor (Spo2)
• Semi-Fowler's position
• Oxygen therapy, breathing exercises
• Mobilization as soon as possible

The nurse knows that the most important reason for controlling postoperative nausea/vomiting in the PACU is to A. Prevent the patient from becoming dehydrated. B. Prevent potential airway issues. C. Prevent the surgical dressing from becoming soiled. D. Prevent the patient from becoming upset. - Answer-B. Prevent potential airway issues. - Aspiration is a concern When positioning to decrease pain in the postoperative patient, which nursing intervention is most appropriate? A. Raise the knee gatch of the bed. B. Place pillows under the patient's knees. C. Reposition the patient at least every 2 hours. D. Allow the patient to get out of bed as soon as possible. - Answer-C. Reposition the patient at least every 2 hours. When assessing NGT and bowel sounds, what is the nurse's first action? - Answer-turn off the suction BEFORE assessing bowel sounds Respiratory assessment in the PACU - Answer-- Patent airway, adequate gas exchange

• Rate, pattern, depth of breathing
• Breath sounds
• Accessory muscle use
• Snoring and stridor
• Respiratory depression or hypoxemia

before administering first shock of defibirllation, must say... - Answer-"ALL CLEAR" Topical administration of nitroglycerin - Answer-Measure ointment as you squeeze the prescribed amount from the tube (2 inches is 30 mg), apply to dry skin. Cover with plastic wrap Potential complication of MI - Answer-cardiogenic shock cardiogenic shock - Answer-A state in which not enough oxygen is delivered to the tissues of the body, caused by low output of blood from the heart. It can be a severe complication of a large acute myocardial infarction, as well as other conditions. Signs of cardiogenic shock - Answer--elevated pulse rate -rapid and shallow breathing -naseau and vomiting -decrease in temp -Low bp is late finding that indicates decompensated shock Cold, clammy skin Poor peripheral pulses Agitation, restlessness, confusion Pulmonary congestion Tachypnea Continuing chest discomfort Ischemic Stroke - Answer-a type of stroke that occurs when the flow of blood to the brain is blocked embolic stroke - Answer-a type of ischemic stroke that causes a clot to travel to the brain, mostly from the left side of the heart

thrombotic stroke - Answer-Arterial occlusions caused by thrombi formed in arteries supplying the brain or in the intracranial vessels hemorrhagic stroke - Answer-floods the brain with blood (often a result of trauma) when a brain artery leaks or ruptures, can be caused by accident or weakening of the vessels such as an aneurysm, high risk of seizures (vs. ischemic), normally neurologic damage is at its peak at the time of the stroke Major pre-disposing factors of hemorrhagic stroke - Answer-- HTN

• Anti-coagulant therapy
• Cerebral aneurysm Major pre-disposing factors of ischemic stroke - Answer-- A-fib
• Carotic Stenosis
• Cerebral arteriosclerosis signs of stoke - Answer-weakness or numbness, slurred speech, vision changes, memory loss thrombolytic therapy - Answer-Dissolves clot 4-5 hour time window - this is why time of onset is so important May reverse symptoms and pt may regain mobility TIME LOST IS BRAIN LOSS! Emotional lability is most often seen with which sided stroke? - Answer-Right Hemispheric stroke Some interventions for nutritional balance risk after stroke - Answer-Keep NPO until swallowing evaluated - at risk for aspiration

Perform dysphagia screen Try sip of water Request ST (speech therapy) swallowing evaluation ataxia - Answer-the loss of full control of bodily movements Nursing interventions post CVA - ataxia - Answer-Refer to PT, OT Maintain good body alignment Perform ROM exercises Mobilize: chair or ambulate Turn q 2 hours what to do if chest tube becomes disconnected - Answer-DO NOT CLAMP!!!! Immediately - Place the end of the tube in a container of sterile saline or water until a new drainage system can be connected If the chest tube is accidently removed from the patient - apply pressure with an occlusive dressing and Notify MD!!! How much chest tube drainage is concern to notify the physician? - Answer-report >70 ml/hr drainage or change to bright red drainage Chest tubes are placed - Answer-intrapleural space Why are chest tubes inserted? - Answer-- Improve impaired gas exchange

• restore negative intrapleural pressure (it has become positive)
• drainage of fluid, blood, air

Indications for Chest tube placement - Answer-- Pneumothorax

• Hemothorax
• Pleural Effusion
• Empyema Signs and symptoms of tension pneumothorax - Answer---cyanosis --unequal movement of the chest --distended neck veins --diminished lung sounds to one side. --tracheal deviation Therefore, the rate of pneumonia is higher among: - Answer-older adults nursing home residents hospitalized patients pts with neurological problems or difficulty swallowing those being mechanically ventilated Community- Acquired - Pneumonia - Answer-more common than health-care acquired and most often occurs in late fall and winter and is a complication of flu Populations at higher risk for community-acquired pneumonia - Answer-Never received pneumococcal vaccine Did not receive the flu vaccine Chronic health problem Recently exposed to respiratory viral or flu infection Uses tobacco or alcohol or is exposed to a lot of second hand smoke

Hospital acquired pneumonia - Answer-pneumonia occurring 48 hours or longer after hospital admission and not incubating at the time of hospitalization. Populations at higher risk for hospital-acquired pneumonia - Answer-Chronic lung disease Altered LOC Recent aspiration event Poor nutritional status Endo, trach, or NG tube Chest x-ray of a patient with pneurmonia will show... - Answer-patchy , white infiltrates and consolidation (solidification, lack of air spaces) What nursing intervention will help to facilitate secretions in a pt with pneumonia? - Answer-Increased fluid intake; unless contraindicated Acute Kidney Injury (AKI) - Answer-rapid-onset disease of the kidneys resulting in a failure to produce urine Prerenal AKI - Answer-Cause is "before" Glomerular Apparatus; MOST COMMON AKI *Reduced renal artery blood flow Hypotension, Hypo-perfusion, Cardiogenic Shock, Sepsis, Shock Renal vascular obstruction Shock Decreased cardiac output causing decreased renal perfusion