1) Recognizing stool characteristics of IBD (Assessment, 1 MC)

Crohns Disease Ulcerative Colitis

- diarrhea - BLOODY diarrhea
- 5-6 liquid to semiformed stools/day - moderate disease- up to 10 stools/day, bleeding
WITHOUT mucus or blood -severe disease- bloody diarrhea containing mucus, 10-20 stools/day.
- rectal bleeding

2) Client teaching for ostomy care (Implementation, 1 MC) 7) Delegation decisions for ostomy care (SATA)
- remove old skin barriercleanse skin (washed with plain
water/mild soap, rinsed with WARM water, dried
thoroughly)correctly apply new skin barrier.
- pouch must fit snugly to prevent leakage around stoma.
inch bigger than exact stoma size to provide sealprevents
skin breakdown.
- ostomy bags should be emptied when full to prevent
leakage.
- burp the bag- let gas/flatus out.
5) Expected stool output for each type of ostomy
The more distal the ostomy, the more the intestinal contents
resemble feces. Ileostomy- liquid to semiliquid.
Sigmoid colostomy- normal formed stool.
6) Dietary teaching for clients with ostomy
- well balanced diet & dietary supps to prevent nutritional
deficiencies.
- promote fluid intake of at least 3000 mL/day to prevent
dehydration.
- diet mods to gas and odor. No beans, broccoli, garlic,
onions, cheese, cabbage, beer/carbonated bev, spinach.
4) Stoma assessment
Color Edema Bleeding
Assess stoma color q4h to ensure that it remains Mild to mod- normal in initial Small amount- oozing from
pink with no excessive bleeding. postop period. Trauma to stoma. stoma mucosa when
Rose/pink to brick red- viable stoma mucosa. Mild to mod swelling of stoma in touched is normal b/c of its
Pale- anemia. first 2-3wks after surgery. high vascularity.
Blanching, dark red to purple- ERnotify MD. Mod to severe- obstruction, allergic Mod to large amount- lower
Inadequate blood supply to stoma. rxn. GI bleed.
3) S/S of complications of IBD, Diverticulitis
IBD Diverticulitis
- iron-deficiency anemia from blood loss - LLQ ab pain
- hemorrhage, strictures, perforation, fistulas, colonic - fever, leukocytosis, palpable ab mass.
dilation (toxic megacolon). - perforation w/ peritonitis, abscess and fistula formation,
obstruction, and bleeding.

8) Client teaching for constipation mgt

- Laxatives may be used to treat acute constipation but overuse/chronic use leads to chronic constipation,
dependence, and pt cant defecate without the laxative (unable to have a bowel movement w/o them)SS.
- Increase intake of dietary fiber (20-30g/day, beans, oatmeal) and fluids (3 quarts/day).
- exercise regularly
- establish regular time to defecate. Do not delay defecation or else hard stools and decreased urge to defecate.
9-10) Recognizing S/S of appendicitis/peritonitis
Appendicitis Peritonitis
- periumbilical painanorexianv. - abdominal pain
- RLQ pain and localizing at McBurneys point (b/w umbilicus - tenderness over involved area.
and R iliac crest) - rebound tenderness, muscular rigidity/spasm.
- localized tenderness, rebound tenderness, muscle guarding. - ab distention/ascites, fever, tachyC, tachypnea, n, v,
- coughing magnifies pain. altered bowel habits.
- pt prefers to lie still, with R leg flexed. - shallow resps

11) Action of each drug for diarrhea & constipation

DIARRHEA DRUGS
Bismuth Dries up GI tract. secretions, has weak antibacterial activity. Prevents travelers diarrhea.
subsalicylate
Loperamide Inhibits peristalsis, delays transit, absorption of fluid from stools. SE= constipation.
Diphenoxylate with Opiod (slows GI motility) and anticholinergic (dry mouth), peristalsis and intestinal motility
atropine may increase.
CONSTIPATION DRUGS
Bulk forming Absorbs water, increases bulkstimulate peristalsis, acts within Methylcellulose (mostly
24h. Safe- can take everyday. fiber)- not many SE.
Stool Softeners & Lubricate intestinal tract and soften feces, makes hard stools Softener- docusate
Lubricants easier to pass, do not affect peristalsis. Draws water into stool
Softeners- soften only new food, not old constipation probs. Lubricants- mineral oil
Lubricants- for old stool constipation.
Stimulants Promote GI peristalsis by irritating colon wall and stimulating Bisacodyl
enteric nerves
Intestinal fluid secretion and accelerates intestinal transit. Linaclotide
secretagogue

12-13) Dietary teaching for IBD, Diverticulitis (oses)

IBD Diverticulitis
- high calorie, high vitamin, high protein - HIGH FIBER diet (from fruits/veg)- to
- LOW RESIDUE (NO FIBER, nuts, seeds corn, wheat bread) prevent disease.
- BRAT Diet- diarrhea mgmt- forms stool- bananas, rice, - once dischargedlow residue.
applesauce, toast. - low fat and red meat intake.
- lactose free (if lactase deficiency) - acute exacerbation- NPO.
- Good- MEATS. - clear liquid dietsemisolids.

14) Drug therapy teaching for IBD (SATA)

5-Aminosalicylates (5ASA)
***Sulfasalazine***
Meslamine
Antimicrobials
Metronidaole, ciprofloxacin
***Corticosteroids***
Immunosuppressants
***cyclosporine***
Decrease GI inflammation
through direct contact with
bowel mucosa.
Prevent/treat 2ndary
infection
Decrease inflammation
Can suppress bone marrow
and lead to inflammation
of pancreas or gallbladder.
***DRUG ALERT***- may cause YELLOWISH/
ORANGE discoloration of skin/urine.
Avoid exposure to sunlight and UV light until
photosensitivity is determined.
Cant be stopped abruptly. Must taper off.
Nephrotoxicity, toxic to kidneys so need baseline kidney
function. Teaching- Grapefruit juice prevents metabolism
of drugs. NO GRAPEFRUIT JUICE. Consuming
grapefruit juiceincrease toxicity

15) Evaluating effectiveness of IBD therapy

- pt experiences decrease in # of diarrhea stools. Stools are soft and formed.
- consumes adequate calories and nutrients. Maintains body weight. Increased muscle tone/strength.
16) Client teaching for GERD /// 22) Dietary teaching for GERD
1) Lifestyle modification
NO SMOKING/ALCOHOL (acid secretion).
Pt teaching- ***eat small, frequent meals to prevent gastric distention.
Explain rationale for avoiding alcohol, smoking, caffeine (they all LES Pweaker).
DO NOT LIE DOWN 2-3h after eating, NO TIGHT CLOTHING around waist (or else ab
pressure), or bend over (esp after eating).
Encourage pt to sleep w/ HEAD OF BED ELEVATED as long as upper extremity is higher than
trunk/rest of body.
2) Nutritional
avoid foods that LES P- chocolate, peppermint, tomatoes, fatty foods, coffee, caffeine, alcohol, tea.
acid in stomachirritate esophagustomato products, OJ, cola, red wine. Small, frequent
mealsprevent overdistention of stomach. Avoid late evening meals/nocturnal snacking. ***TAKE
FLUIDS BETWEEN MEALS, AFTER MEALS, never with meals.
INCREASES PRESSURE (Makes LES STRONGER) DECREASES PRESSURE- AVOID
- bethanechol - alcohol, chocolate, peppermint, tea, coffee, caffeine
- metoclopramide - ANTICHOLINERGICS, NICOTINE

17-19) Complications & mgt of Bilroth I & II surgery

Surgical
gastroduodenostomy/Billroth I- gastric stump to duodenum.
Gastrojejunostomy/Billroth II- gastric stump to jejnum. Prone to dumping syndrome.
Postop comps- DUMPING SYNDROME- Billroth II tx of duodenal ulcer pts prone to this.
Mgmt of Dumping Syndrome- ***1) LIE DOWN 30 MINS AFTER EATING. 2) DECREASE FLUID
INTAKE WITH MEALSrisk for D.S. If pt doesnt lie downonset of S/S occurs within 15-30 mins after
eating***generalized weakness, palpitations, dizzinessall due to sudden decrease in plasma volume.
Dumping syndrome diet mgmt- 6 small meals, sweets avoided, protein/fats intake.
Postop care- pt may require COBALAMIN (Vit B12) replacement therapy for PERNICIOUS ANEMIA
(due to LOSS of INTRINSIC FACTOR). Stomach cutno intrinsic factorno Vit B12 absorptionprone to
pernicious anemiaNeed cobalamin replacement. ***Health teaching- teach pt about VITAMIN
SUPPLEMENTS via INJECTIONS and NASAL SPRAY.

20-21) Drug therapy mgt & teaching for GERD /// 24) Drug therapy for GERD
Drug- decrease volume and acidity of reflux, improve LES fxn (strength), esophageal clearance/emptying,
protecting esophageal mucosa/lining (SUCRALFATE- cytoprotective medsprotect lining, NEED TO
TAKE 15-30 MINS BEORE MEALS). Goal of HCl acid suppression tx- to reduce acidity of gastric refluxate.
Proton Pump Inhibitors (PPIs) Decrease incidence of esophageal strictures (chronic GERD comp).
***OMEPRAZOLE- Rx. PRILOSEC- OTC.
***Nurse teaching/ed- DO NOT CRUSH/CHEW, TAKEN WHOLE, DO
NOT OPEN CAPSULE or DO NOT DISSOLVE IN LIQUID. Not a long
term regimen or elseC diff infectiondiarrhea.
TAKE BEFORE 1st MEAL OF DAY.
Histamine (H2) Receptor Blockers Reduce symptoms, promote esophageal healing. FAMOTIDINE.
Other Meds ***SUCRALFATE- CYTOPROTECTIVE- protects esophagus lining. Taken
15-30 mins before meals.
Cholinergics BETHANECHOL- increases LES pressure, gastric emptying. HOWEVER,
increases HCl acid secretion= disadvantage.
Prokinetic METOCLOPRAMIDE (Reglan)- motility enhancing drugsgastric
emptyingstomach content.
Antacids Neutralizes acidity. Taken 1-3hr AFTER MEALS and at BEDTIME.
23) Recognizing risk factors for GI bleeding
Stomach and Duodenal Origin- drugs are major cause of Upper GI bleeding: NSAIDs (ibuprofen), Aspirin,
Corticosteroidsall causes irritation and disruption of gastroduodenal mucosa.

25) Hiatal hernia client teaching

Teach pt to reduce intraab P- eliminating constricting garments, avoiding lifting, Valsalva, and straining.
Eliminating alcohol and smoking, elevating head of bed, lose weight if overweight.

26) Contrast duodenal vs gastric ulcer

Etiology/Patho- PUD develop ONLY IN ACIDIC ENVIRONMENT.
Medication-induced injury: ulcerogenic drugs (ASPIRIN- blood thinner, NSAIDs)gastric acid
secretionsrisk of PUD development. Corticosteroids, anticoagulants, SSRIall risk of PUD dev.
Lifestyle factors- high alcohol intakeacid. Psychological distress, stress. Smoking.

DUODENAL GASTRIC
In 1st part of SI. H PYLORI (bacteria)= most common factor for PUD In stomach- most commonly found in
development. Associated with high HCl acid secretion: alcohol + ANTRUM (bottom part of stomach).
smokingboth are stimulants of acid secretion. More likely than duodenal ulcers to
S/S of DUODENAL ulcers- MIDepigastric region, occurs 2-5h AFTER result in obstruction.
MEALS. Burning + cramplike pain. *****FOOD ALLEVIATE painfood S/S of GASTRIC ulcers- discomfort
helps buffer the acid. located HIGH in epigastrium, occurs
1) Heliobacter Pylori- H Pylori colonizes areaduodenal ulcer. *****H Pylori 1-2h AFTER MEALS. Burning +
infection: 1) common precursor of gastritis and PUD. 2) organism synthesize gaseous pain. *****Intake of FOOD
UREASE=ureaproduces AMMONIAdamages gastric mucosa. AGGRAVATE pain.
***AMMONIA NEUTRALIZES pHallows microorganism to live in
stomach.
27) Drug therapy for PUD /// 28) Client teaching for PUD drug therapy
H pylori infection treated with 2 antibiotics + 1 PPI- TRIPLE DRUG THERAPY (OAC): 1)
AMOXICILLIN, 2) CLARITHROMYCIN, 3) OMEPRAZOLE. Antacids- neutralizing effect (if taken on
EMPTY STOMACH)last only 20-30 MINS. When TAKEN AFTER MEALSeffects last 3-4 HRS.
Drug Class Action Example RN Consideration
H2 Blockers - Promote ulcer healing ***Famotidine- prevents dev Oral or IV
- secretion of gastric acid of stress ulcer. Effects last up to 12hrs
Ranitidine= Zantac, for GI
bleed caused by PUD.
PPIs More effective than H2 OMEPRAZOLE Used in combo w/ antibiotics to
blockers in gastric acid and Also available in OTC treat ulcers caused by H pylori
promoting ulcer healing TAKEN WHOLE before
meals
Antibiotics Tx of pt with PUD + for H *Triple Drug Therapy*- Given in 7-14 days duration
pylori infection omeprazole (PPI), amoxicillin,
clarithromycin.
Antacid gastric pH by neutralizing HCl Sodium bicarbonate Taken 1-3hrs AFTER MEALS
acid. and at BEDTIME.
Cytoprotective Cytoprotection for esophagus, SUCRALFATE- ***action is Taken 15-30 mins before
stomach, and duodenum. most effective at low meals.
pH(acidic). Carafate

29) Client teaching for clients receiving steroids (SATA)

***Corticosteroids*** Decrease inflammation Cant be stopped abruptly. Must taper off.
If stopped abruptlyresult in adrenal insufficiency.
High protein, high calcium diet, high K diet (pt at risk for
hypokalemia), low fat. Restrict sodium intake.
Diabetic pts- monitor blood sugar for hyperglycemia

30) DKA prevention

DIABETIC KEOTACIDOSIS (DKA)
- Type 1 DM, ketone in urine. Caused by profound deficiency of insulin.
- take meds and insulin as directed.
- careful monitoring of blood glucose levels (especially when ill or stressed). Check 3-4 times/day.
- adjust insulin dosage as needed (depending on exercise, illness, blood sugar level, and what pt eats).
- test urine for ketone level. If highcall MD. If low- may need to take more insulin.
- be prepared with insulin at all times and act quickly.
- precipitating factors- illness, infection, traumaall factorsblood glucose & insulin requirement.

31) RN responsibilities post thyroidectomy

Postop complications- hypothyroidism- give thyroid hormones (LEVOTHYROXINE). Hemorrhage.
Recurrent laryngeal nerve damage (MED ER)vocal cord paralysis. Place by bedside (SCOT): 1) Suction
apparatus, 2) Calcium gluconatecalcium, 3) Oxygen, 4) Tracheostomy. SCOT should be readily available in
pts room. Laryngeal stridor (harsh, vibratory sound) is a NURSING ER- prepare to assist with ER intubation
and tracheostomy while notifying MD and RRT (rapid response team). Laryngeal stridor may also be related to
TETANY (s/s of HYPOcalcemia), S/S of tetany: 1) Chvostek (cheek), 2) Trousseau (BP cuffcarpopedal
spasm). ***Treat tetanyIV calcium salts (Ca gluconate/gluceptate) should be available.
Assess for signs of hemorrhage/tracheal compression: neck swelling (blood may pool behind neck, palpate with
gloved hand), frequent swallowing, sensations of fullness at incision site. ***Stridor on exhalation is a
hallmark of resp distress caused by obstruction resulting from edema. Place pt in SEMI-FOWLERS
position and support head with pillows. Monitor vitals and Ca levels. S/S of HYPOCa that can lead to seizure
activity and tetany (muscle spasms): tingling in toes, fingers, around mouth, Trousseau & Chvoskennotify
MD if (+) signs.
32) Hearing loss prevention - teaching
- reduce music level when using headphones.
- avoidance of continued exposure to high noise levels.
- wear ear protection when firing gun or around high noise level environments.
- periodic audiometric screening is important to detect loss before it progresses.
- monitor s/s of ototoxic drug effectsif tinnitus or diminished hearingimmediately stop meds.
- MMR vaccinations.

33) Drug therapy for glaucoma

Meds to treat glaucoma- all aqueous humor production: all are CHOLINERGICS- helps contract the iris
dilator muscle and outflow. Contraindication- anticholinergics.
Beta blockers (timoptic) BPrisk fall. Monitor BP, inform pt to perform ***occlude nasal puncta (put
pressure on nose) 2-5 mins.
Alpha-adrenergic agonist Decrease aqueous humor production and IOP.
Carbonic anhydrase inhibitor Acetazolamide (DIAMOX)
Miotics and oral/IV hyperosmotic agents decrease IOP. DRUG ALERT: warn pt about decreased visual acuity,
especially in dim light
GIVE CHOLINERGICS DONT GIVE
Miotic Pilocarpine (PILOCAR) Anticholinergics
Prostaglandin agonist Latanoprost (XALATAN) Atrophine outflow of aqueous
Carbonic anhydrase inhibitor Acetazolamide (DIAMOX) Epinephrine humorIOP.
Beta blocker Timolol (TIMOPTIC)

34) Interventions for hyper vs hypokalemia (SATA)

HYPOkalemia
1) mild/mod low K- immediate effectgive
oral K supplementsDO NOT CRUSH
MEDS. If pt cant tolerate, ask MD for liquid
form. Give with food/water to prevent GI
upset.
2) severe low K- give diluted KCl IV. DO
NOT IV PUSH K- illegal. 10 mEq/hr in
normal saline, 2 hrs minimum. NEVER add
KCl to hanging IV vag. Use IV pump, cardiac
monitor, monitor IV site.
3) K rich foods- bananas, oranges,
cantaloupes, dried fruits, vegetables, milk
products.
HYPERkalemia
NEVER USE SALT SUBSTITUTES. Attach pt to cardiac monitor.
Force K from ECF (blood)ICF (cells): fastest ways:
1) calcium gluconate- emergency meds, prevent cardiac arrest but
doesnt lower K.
2) give regular insulin 10 units with D50=dextrose/glucose- prevent
hypoglycemia. Insulin pushes K back into cells.
3)Sodium bicarbonate to counteract acidosis.
4) Albuterol x 2pushes K back into cells.
5) KAYEXALATE- sodium polystyrene sulfonate. Given oral, NGT,
rectally. Causes diarrhealoose stoolslose K. #1 pt teaching- loose
stools. Counterinteraction- bowel obstruction, stomach distention. Before
give medsassess bowel sounds for good GI movement. This txt takes
time.

35) Assessment & Interventions for clients with COPD/ oxygenation problems

Assessment findings:

Over age 40 w/ 10 + packs years of smoking

Cough, sputum production, and/ or hx of exposure of risk factors for the disease

Dyspnea is progressive usually upon exertion & present everyday

Pt complaint of not being able to deep breath, heaviness in chest, gasping inc. effort to breath, air hunger
 o Pt typically says Im getting older or Im out of shape

Difficulty with ADLs

Feeling of fatigue, weight loss & anorexia

During exam, prolonged expiratory respiratory phase, wheezes/rhonchi/crackles or decreased breath

sounds noted in all lung fields

Chronic intermittent cough (may be unproductive)

Barrel chest, cyanosis, tripod position, pursed lips,

Use of accessory muscles such as those in the neck

Peripheral edema (clue to right sided heart failure)

Intervention:

Give O2 ALARA (As Low As Reasonably Achievable) via nasal

cannula (hydration of 3 L/day)

Bronchiodilators

Cessation of smoking

Treatment of exacerbation

Drug therapy

Breathing exercises retraining

Airway clearance techniques

Flu & PN vaccine

Exercise regimen e.g. walking

Nutritional supplementation if low BMI

Surgery

o Lung volume reduction

o Lung transplant
36) Recognizing complications of COPD
Classification of COPD Severity (golden initiative for chronic obstructive lung disease=GOLD)
Classification Level of Severity FEV1 Results
GOLD 1 Mild FEV 80% predicted
GOLD 2 Moderate FEV 50-80% predicted
GOLD 3 Severe FEV 30-50% predicted
GOLD 4 Very Severe FEV <30% predicted

COPD COMPLICATION RN intervention to manage s/s

Cor Pulmonale pulmonary hypertension Oxygen therapy Bronchodilators Diuretics
LowSodium Diet VasodilatorsCalcium channel
caused by diseases affecting the lungs e.g.
blockers Inotropic agents
COPD
Right-side Heart Failure
Dyspnea
Large Pulmonary Vessels on XRay

COPD Exacerbations Bronchodilators

Increased dyspnea Corticosteroids
Increased sputum volume/ purulence Antibiotics
Malaise/ Fever without other known cause Oxygen Therapy
Insomnia Anti-cholinergics
Fatigue
Depression
Confusion
Decreased exercise tolerance
Increased wheezing

* Assess ABGs for s/s of respiratory acidosis

or further hypoxia/ respiratory failure;
Determine # of previous exacerbations in the
previous yr; Presence of comorbidities; Signs
of use of accessory muscles for breathing;
Central cyanosis; Lower extremity edema;
Unstable BP; Right-side heart failure; Altered
alertness
 Acute Respiratory Failure Promote preoperative teaching
Use of sedatives, benzodiazepines,
opioids can depress the respiratory system
Ineffective ventilation due to incorrect
splinting in postop patients

37) Recognizing S/S of hypoxia

Hypoxia- when PaO2 falls sufficiently (normal= 80-100 mmHg).
Early stages of Hypoxia:
o Change in mental status/ restlessness
o ABGs (PaO2)
o Vital Signs (Increased HR, RR, BP)
o Lung Sounds (cough)
o Dyspnea
Late Stages of hypoxia:
o Decreased LOC
o Decreased activity level
o Hypotension
o Bradycardia
o Metabolic acidosis
o Cyanosis
Chronic S/S:
o Clubbing of the fingers & toes
o Peripheral edema
o Right-sided heart failure
o Respiratory acidosis
o O2 sat, 87
38-39) Diagnostic testing for Pulmonary TB
History & physical exam
Tuberculin skin test (TST/Mantoux test/ PPD)
o Cannot distinguish active or LTBI
QuantiFERON TB test (blood assay)
o Cannot distinguish active or LTBI
Chest x-ray
o Finding are suggestive of TB include upper lobe infiltrates, cavitary infiltrates, & lymph
node involvement
Bacteriologic studies
o Sputum culture to test for tubercle bacilli
o Sputum smear for acid fast bacilli (AFB)
o Sputum culture

40) Interpreting PPD results

A.K.A Tuberculin Skin Test (TST) (Mantoux Test)
PPD (purified protein derivative) screens people for M. Tuberculosis
The test is read by inspection & palpitation 48 to 72 hours later for presence or absence of
induration
o Induration (not redness) at the injection site means the person has been exposed to TB
and has developed antibodies
o The induration area is measured & recorded in millimeters
o Based on interpretation of induration size & risk factors a determination will be made for
positive test reactions
Immunocompromised patients may have decreased response to PPD
o They have smaller induration reactions of 5mm or larger and are considered positive
Previously infected pt with TB may have a waning immune response resulting in a false-negative
 o Repeated TST is recommended to prevent misinterpretation

41-44) Drug therapy for tuberculosis

isoniazid (INH)
o S/E: monitor liver function test monthly
rifampin (Rifadin)
o S/E: orange discoloration of bodily fluids
pyrazinamide (PZA)
o Contraindicated on pt with liver disease & prego women
ethambutol (Myambutol)
o Monitor visual acuity & color discrimination
Drug therapy is divided into 2 phases: Initial and Continuation phase
Regimen for treating TB disease has an intensive phase of 2 months, followed by a continuation
phase of 4-7 months (total of 6-9 months of treatment)
Preferred Regimen:
o Initial Phases: take all 4 drugs for 56 doses (8 weeks)
o Continuation Phase: take INH & rifampin for 126 doses (18 weeks) OR 5 days/week
DOT for 90 doses (18 weeks)
45) Promoting drug compliance in TB
Non-adherence is a major factor in the emergence of multidrug resistance & treatment failures. DOT
(directly observed therapy, involves providing the anti-tuberculous drugs directly to pts & watching as
they swallow the med) is an expensive but essential public health measure. The risk for reactivation of
TB & MDR-TB is increased in pts who do not complete the full course of therapy. When DOT is not
used, fixed-dose combo drugs may enhance adherence.
46) Recognizing S/S of TB

47) Purpose of Flu & PN vaccination in COPD

Flu & Pneumonia shots help people with COPD prevent COPD exacerbation.
The primary causes of exacerbations are from bacterial or viral infections. Repeated episodes of COPD
exacerbation may cause lung function decline to progress more rapidly & shorten life expectancy. It is
signaled by an acute change in the pts usual dyspnea, cough, and/or sputum.

48) Delegation decisions when caring for COPD client

Role of the RN Role of the LPN/LVN Role of the UAP
Assess need for For STABLE pts ONLY, Use pulse ox to measure
adjustment In O2 flow adjust O2 flow rate O2 sat
rate depending on desired O2 Report O2 sat level to RN
Evaluate response to O2 sat level Assist pt w/ adjustment of
therapy O2 delivery devices (e.g.,
Monitor pt for signs of nasal cannula, face mask)
adverse effects of O2 Report to RN any changes
therapy in pt LOC or complaints
In many cases, chose the of SOB
optimal O2 delivery
device (e.g., a nasal
cannula or simple face
mask
Teach pt & caregivers
 about home O2 use

49) ABG interpretation

pH 7.35-7.45 Low pH- acidic. High pH- alkaline. Midpoint range= 7.4
PaCO2 35-45 High CO2- low pH, acidic. Low CO2- high pH, basic. RESPIRATORY.
HCO3 22-26 High- alkaline. Low- acidic. METABOLIC.

a. pH ( Acidic 7.35- 7.45 Alkalotic)

b. PaCO2 (Alkalotic 35-45 Acidic)
c. HCO3 (Acidic 22-26 Alkalotic)
d. Fully compensated- 2 systems off, pH normal
e. Partially compensated- 2 systems off, pH off
f. Uncompensated- 1 system normal

50-51) Client teaching for using DPI & MDI (MC/SATA)

DPI
(Dry Powder Inhaler)
Remove mouthpiece cap/open the device
according to mftr. Instructions. Check for
dust/dirt. If there is an external counter, note
the # of doses remaining
Load the med into the inhaler/engage the lever
to allow the med to become avail. Some DPIs
should be held upright while loading. Others
should be held sideways or in a horizontal
position
Do not shake medicine
Tilt your head back slightly & breathe out,
getting as much air out of your lungs as you
can. Do not breathe into your inhaler bc this
could affect the dose
Close your lips tightly around the mouthpiece
of the inhaler
Breathe in deeply & quickly. This will ensure
that the medicine moves down deeply into
your lungs. You may not taste or sense the
medicine going into your lungs
Hold your breath for 10 secs or as long as you
can to disperse the medicine into your lungs
If there is an external counter, note the # of
doses remaining. It should be one less than the
# in step 1 above
Do not keep your DPI in a humid place such
as a shower room bc the med may clump
MDI
(Metered Dose Inhaler)
Start by removing cap & SHAKE the
inhaler
Breathe out all the way
Hold inhaler as per DR either 1 or 2 inches
from mouth (about the width of 2 fingers);
or by using a spare/holding chamber; or
just put inhaler in mouth
Than breathe IN slowly through mouth,
press down on inhaler ONE time (if
holding the chamber, first press down &
within 5 seconds begin to breathe slowly)
Keep breathing in slowly, as deeply as you
can
Hold your breath as you count to 10
slowly, if you can
For inhaled quick relief med (B2-agonist),
wait about 1 min btwn puffs,. There is no
need to wait between puffs for other meds.
Remember to clean inhaler especially if
you see powder residue
Clean by removing metal canister & rinse
only the mouthpiece & cap in warm water
& let dry overnight
Remember to know when to replace
inhaler
52-53) Performing neurovascular assessment (Implementation 2 MC)
The neurovascular assessment should consist of a peripheral vascular assessment (color,
temperature, capillary refill, peripheral pulses, and edema) and a peripheral neurologic
assessment (sensation, motor function, and pain). Throughout the neurovascular assessment,
compare both extremities to obtain an accurate assessment.

Assess an extremitys color (pink, pale, cyanotic) and temperature (hot, warm, cool, cold) in the
area of the injury. Pallor or a cool to cold extremity below the injury could indicate arterial
insufficiency. A warm, cyanotic extremity could indicate poor venous return. Next assess capillary
refill (blanching of the nail bed). The standard for a compressed nail bed to return to its original
color is within 3 seconds.

Compare pulses on both the unaffected and injured extremity to identify differences in rate or
quality. Pulses are described as strong, diminished, audible by Doppler, or absent. A diminished
or absent pulse distal to the injury can indicate vascular dysfunction and insufficiency. Also
assess peripheral edema. Pitting edema may be present with severe injury.

Evaluate the ulnar, median, and radial nerves by assessing sensation and motor innervation in
the upper extremity. Assess neurovascular status by abduction and adduction of the fingers,
opposition of the fingers, and supination and pronation of the hand. In the lower extremity,
dorsiflexion and plantar flexion indicate motor function of the peroneal and tibial nerves. Sensory
innervation is evaluated for the peroneal nerve on the dorsal part of the foot between the web
space of the great and second toes. Tibial nerve assessment is performed by stroking the plantar
surface (sole) of the foot. Contralateral evaluation is critical.

Paresthesia (abnormal sensation [e.g., numbness, tingling]) and hypersensation or hyperesthesia

may be reported by the patient. Partial or full loss of sensation (paresis or paralysis) may be a
late sign of neurovascular damage. Instruct patients to report any changes in their neurovascular
status.
54) Nursing responsibilities for diagnostic testing (Implementation 1 MC)
 55) Stages of fracture healing (Planning 1 MC)
1. Fracture hematoma: When a fracture occurs, bleeding creates a hematoma, which surrounds the ends of the
fragments. The hematoma is extravasated blood that changes from a liquid to a semisolid clot. is occurs in the
initial 72 hours after injury.

U 2. Granulation tissue: During this stage, active phagocytosis absorbs the products of local necrosis. The
hematoma converts to granulation tissue. Granulation tissue (consisting of new blood vessels, fibroblasts, and
osteoblasts) produces the basis for new bone substance called osteoid during days 3 to 14 post injury.

U 3. Callus formation: As minerals (calcium, phosphorus, and magnesium) and new bone matrix are deposited in
the osteoid, an unorganized network of bone is formed that is woven about the fracture parts. Callus is primarily
composed of cartilage, osteoblasts, calcium, and phosphorus. It usually appears by the end of the second week
after injury. Evidence of callus formation can be verified by x-ray.

U 4. Ossification: Ossification of the callus occurs from 3 weeks to 6 months after the fracture and continues until
the fracture has healed. Callus ossification is sufficient to prevent movement at the fracture site when the bones
are gently stressed. However, the fracture is still evident on x-ray. During this stage of clinical union, the patient
may be allowed limited mobility or the cast may be removed.

U 5. Consolidation: As callus continues to develop, the distance between bone fragments diminishes and
eventually closes. During this stage ossification continues. It can be equated with radiologic union, which
occurs when there is x-ray evidence of complete bony union. is phase can occur up to 1 year after injury.

U 6. Remodeling: Excess bone tissue is resorbed in the final stage of bone healing, and union is complete. Gradual
return of the injured bone to its preinjury structural strength and shape occurs. Bone remodels in response to
physical loading stress or Wolfs law. Initially, stress is provided through exercise. Weight bearing is gradually
introduced. New bone is deposited in sites subjected to stress and resorbed at areas where there is little stress.

U
56) Nursing responsibilities after surgical procedures (Implementation 1 MC)
Postoperative Management. In general, postoperative nursing care and management are directed toward
monitoring vital signs and applying the general principles of postoperative nursing care.

Frequent neurovascular assessments of the affected extremity are necessary to detect early and subtle
neurovascular changes.
Closely monitor any limitations of movement or activity related to turning, positioning, and extremity
support.
Pain and discomfort can be minimized through proper alignment and positioning.
Carefully observe dressings or casts for any signs of bleeding or drainage.
o Report a significant increase in size of the drainage area.
o If a wound drainage system is in place, regularly measure the volume of drainage and assess the
patency of the system, using aseptic technique to avoid contamination.

Other Measures.

Patients often have reduced mobility as a result of the fracture.

Plan care to prevent the many complications associated with immobility.
Prevent constipation by increased patient activity and maintenance of a high fluid intake (more than
2500 mL/day unless contraindicated by the patients health status) and a diet high in bulk and roughage
(fresh fruits and vegetables).
If these measures are not effective in maintaining the patients normal bowel pattern, warm fluids, stool
softeners, laxatives, or suppositories may be necessary.
Maintain a regular time for elimination to promote bowel regularity.
Renal calculi can develop as a result of bone demineralization.
The hypercalcemia from demineralization causes a rise in urine pH and stone formation from the
precipitation of calcium.
o Unless contraindicated, a fluid intake of 2500 mL/day is recommended.
Rapid deconditioning of the cardiopulmonary system can occur as a result of prolonged bed rest,
resulting in orthostatic hypotension and decreased lung capacity.
o Unless contraindicated, these effects can be diminished by having the patient sit on the side of
the bed, allowing the patients lower limbs to dangle over the bedside, and having the patient
perform standing transfers.
o When the patient is allowed to increase activity, assess for orthostatic hypotension.
Also assess patients for deep vein thrombosis (DVT) and pulmonary emboli.

57-59) Cast care & client teaching (Implementation 3 MC)

60) Recognizing S/S of compartment syndrome (Assessment 1 MC)
Compartment syndrome is usually associated with trauma, fractures (especially the long bones), extensive soft
tissue damage, and crush injury. Fractures of the distal humerus and proximal tibia are the most common
fractures associated with compartment syndrome. Compartment injury can also occur after knee or leg surgery.
Prolonged pressure on a muscle compartment may result when someone is trapped under a heavy object or a
persons limb is trapped beneath the body because of an obtunded state such as drug or alcohol overdose.

Compartment syndrome may occur initially from the bodys physiologic response to the injury, or it may be
delayed for several days after the original insult or injury. Ischemia can occur within 4 to 8 hours after the onset
of compartment syndrome.

One or more of the following six Ps are characteristic of compartment syndrome:

(1) pain distal to the injury that is not relieved by opioid analgesics and pain on passive stretch of muscle
traveling through the compartment
(2) increasing pressure in the compartment

(3) paresthesia (numbness and tingling)

(4) pallor, coolness, and loss of normal color of the extremity

(5) paralysis or loss of function

(6) pulselessness, or diminished or absent peripheral pulses.

61-63) Principles of proper skeletal & skin traction use (Implementation 3 MC)
When slings are used with traction, inspect exposed skin areas regularly. Pressure over a bony prominence
created by the wrinkling of sheets or bedclothes may cause pressure necrosis. Persistent skin pressure may
impair blood flow and cause injury to the peripheral neurovascular structures. Observe skeletal traction pin sites
for signs of infection. Pin site care varies but usually includes regularly removing exudate with half-strength
hydrogen peroxide, rinsing pin sites with sterile saline, and drying the area with sterile gauze.

External rotation of the hip can occur when skin traction is used on the lower extremity. Correct this position by
placing a pillow or rolled-up towels along the greater trochanter of the femur. Generally, the patient should be in
the center of the bed in a supine position. Incorrect alignment can result in increased pain and nonunion or
malunion.

To off set some of the problems associated with prolonged immobility, discuss specific patient activity with the
health care provider. If exercise is permitted, encourage patient participation in a simple exercise regimen based
on activity restrictions. Activities that the patient should participate in include frequent position changes, ROM
exercises of unaffected joints, deep- breathing exercises, isometric exercises, and use of the trapeze bar (if
permitted) to raise the body off the bed for linen changes and use of the bedpan. These activities should be
performed several times each day. Encourage and help the hospitalized patient to stay connected with friends
and family through social media resources.

Traction is the application of a pulling force to an injured or diseased part of the body or an extremity.
Counter- traction pulls in the opposite direction. Traction is used to (1) prevent or reduce pain and muscle
spasm associated with low back pain or cervical sprain (e.g., whiplash), (2) immobilize a joint or part of the
body, (3) reduce a fracture or dislocation, and (4) treat a pathologic joint condition (e.g., tumor, infection).
Traction is also indicated to (1) provide immobilization to prevent so tissue damage, (2) promote active and
passive exercise, (3) expand a joint space during arthroscopic procedures, and (4) expand a joint space before
major joint reconstruction.

Traction devices apply a pulling force on a fractured extremity to attain realignment while countertraction pulls
in the opposite direction. The two most common types of traction are skin traction and skeletal traction. Skin
traction is generally used for short-term treatment (48 to 72 hours) until skeletal traction or surgery is possible.
Tape, boots, or splints are applied directly to the skin to maintain alignment, assist in reduction, and help
diminish muscle spasms in the injured extremity. The traction weights are usually limited to 5 to 10 lb (2.3 to
4.5 kg). A Bucks traction boot is a type of skin traction used to immobilize a fracture, prevent hip flexion
contractures, and reduce muscle spasms. Pelvic or cervical skin traction may require heavier weights applied
intermittently. In skin traction, assessment of the skin is a priority, since pressure points and skin breakdown
may develop quickly. Assess key pressure points every 2 to 4 hours.

Skeletal traction, generally in place for longer periods than skin traction, is used to align injured bones and
joints or to treat joint contractures and congenital hip dysplasia. It provides a long-term pull that keeps the
injured bones and joints aligned. To apply skeletal traction, the physician inserts a pin or wire into the bone,
either partially or completely, to align and immobilize the injured body part. Weight for skeletal traction ranges
from 5 to 45 lb (2.3 to 20.4 kg). The use of too much weight can result in delayed union or nonunion. The major
complications of skeletal traction are infection in the area of the bone where the skeletal pin is inserted and the
consequences of prolonged immobility.

When traction is used to treat fractures, the forces are usually exerted on the distal fragment to align it with the
proximal fragment. Several types of traction are used for this purpose. One of the more common types of
skeletal traction is balanced suspension traction. Fracture alignment depends on the correct positioning and
alignment of the patient while the traction forces remain constant. For extremity traction to be effective, forces
must be pulling in the opposite direction (countertraction). Countertraction is commonly supplied by the
patients body weight or by weights pulling in the opposite direction, and it may be augmented by elevating the
end of the bed. It is imperative to maintain traction continuously and to keep the weights of the floor and
moving freely through the pulleys.

64-66) RN responsibilities post hip replacement surgery (Implementation 3 MC)

In the early postoperative period there is a potential for neurovascular impairment. Assess the patients
extremity for (1) color, (2) temperature, (3) capillary refill, (4) distal pulses, (5) edema, (6) sensation, (7) motor
function, and (8) pain. Edema is alleviated by elevating the leg whenever the patient is in a chair. The pain
resulting from poor alignment of the affected extremity can be reduced by keeping pillows (or an abductor
pillow) between the knees when the patient is turning to either side.

If the hip fracture has been treated by insertion of a prosthesis with a posterior approach (accessing the hip joint
from the back), measures to prevent dislocation must be used. Inform the patient and caregiver about positions
and activities that predispose the patient to dislocation (more than 90 degrees of flexion, adduction across the
midline [crossing of legs and ankles], internal rotation). Many daily activities may reproduce these positions,
including putting on shoes and socks; crossing the legs or feet while seated; assuming the side- lying position
incorrectly; standing up or sitting down while the body is flexed more than 90 degrees relative to the chair; and
sitting on low seats, especially low toilet seats. Until the so tissue capsule surrounding the hip has healed
sufficiently to stabilize the prosthesis, teach the patient to avoid these activities (usually for at least 6 weeks).

Elevated toilet seats and chair alterations (e.g., raising the seat with pillows, maintaining a straight back) are
necessary. Towel rolls (i.e., a trochanter roll) or pillows placed on the lateral side of the leg are also used to
prevent external rotation. If a foam abduction pillow is used, it should be placed between the legs to prevent
dislocation of the new joint. Ensure that the top straps are above the knee to avoid placing pressure on the
peroneal nerve at the lateral tibial tubercle.

In addition to teaching the patient and caregiver how to prevent prosthesis dislocation, you should also (1) place
an abductor pillow or several pillows between the patients legs when turning and (2) avoid turning the patient
on the affected side until approved by the surgeon. In addition, some health care providers prefer that the patient
keep the leg abductor pillow on except when bathing.

Taking a tub bath and driving a car are not allowed for 4 to 6 weeks. An occupational therapist may teach the
patient to use assistive devices, such as reachers or grabbers to avoid bending over to pick something of the
floor, long-handled shoehorns, or sock assists. The knees must be kept apart. Instruct the patient to never cross
the legs or twist to reach behind.

If the hip fracture has been treated by insertion of a prosthesis with an anterior approach (joint reached from
front of body), the hip muscles are left intact. This approach generally results in a more stable hip in the
postoperative period with a lower rate of complications. Patient precautions related to motion and weight
bearing are few and may include instructions to avoid hyperextension.

The physical therapist usually supervises exercises for the affected extremity and ambulation when the surgeon
permits it. The patient is usually out of bed on the first postoperative day. In collaboration with the physical
therapist, monitor the patients ambulation status for proper use of crutches or a walker. For the patient to be
discharged home, have the patient demonstrate the proper use of crutches or a walker, the ability to transfer into
and from a chair and bed, and the ability to ascend and descend stairs.

Weight bearing on the involved extremity varies. Weight bearing of especially fragile fractures may be restricted
until x-ray examination indicates adequate healing, usually 6 to 12 weeks.

Complications associated with femoral neck fracture include nonunion, avascular necrosis, dislocation, and
degenerative arthritis. As a result of an intertrochanteric fracture, the affected leg may be shortened. A cane or
built-up shoe may be required for safe ambulation.

Sudden severe pain, a lump in the buttock, limb shortening, and external rotation indicate prosthesis dislocation.
is requires a closed reduction with conscious sedation or open reduction to realign the femoral head in the
acetabulum. If this occurs (regardless of the setting), keep the patient on nothing- by-mouth (NPO) status in
anticipation of a possible surgical intervention.

Assist both the patient and caregiver in adjusting to the restrictions and dependence imposed by the hip fracture.
Anxiety and depression can easily occur, but creative nursing care and awareness of potential problems can help
to prevent them. Inform the patient and caregiver about community referral services that can assist in the
postdischarge rehabilitation phase.

67-68) Collaborative care for osteoporosis (Implementation 2 MC)

69) Risk factors for osteomyelitis (Assessment 1 MC)

The infecting microorganisms can invade by indirect or direct entry. The indirect entry (hematogenous) of
microorganisms most frequently affects growing bone in boys younger than 12 years old, and is associated with
their higher incidence of blunt trauma. Adults with vascular insufficiency disorders (e.g., diabetes mellitus) and
genitourinary and respiratory tract infections are at higher risk for a primary infection to spread via the blood to
the bone. The pelvis, tibia, and vertebrae, which are vascular-rich sites of bone, are the most common sites of
infection.

Direct entry osteomyelitis can occur at any age when there is an open wound (e.g., penetrating wounds,
fractures) and microorganisms gain entry to the body. Osteomyelitis may also occur in the presence of a foreign
body such as an implant or an orthopedic prosthetic device (e.g., plate, total joint prosthesis).
70) Preventing complications of amputation (Implementation 1 MC)
Flexion contractures may delay the rehabilitation process. The most common and debilitating contracture is hip
flexion. Hip adduction contracture is rare. To prevent flexion contractures, have patients avoid sitting in a chair
for more than 1 hour with hips flexed or having pillows under the surgical extremity. Unless specifically
contraindicated, patients should lie on their abdomen for 30 minutes three or four times each day and position
the hip in extension while prone.

Proper residual limb bandaging fosters shaping and molding for eventual prosthesis fitting. The physician
usually orders a compression bandage to be applied immediately after surgery to support the soft tissues, reduce
edema, hasten healing, minimize pain, and promote residual limb shrinkage and maturation. This bandage may
be an elastic roll applied to the residual limb or a residual limb shrinker, which is an elastic stocking that fits
tightly over the residual limb and lower trunk area.