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NSG-430 EXAM 4 Review
Adult Health Nursing II (NSG-430)
Grand Canyon University
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Abdominal Pain – Understand what organs are in each quadrant and what could be causing the pain
Blood Transfusions & Transfusion Reactions
- Types of transfusions: Autologous blood transfusion Blood collected from a client for re-transfusion at a later date into the same individual.
Allogeneic blood transfusion The transfusion of blood originating from a donor of the same species.
Massive transfusion Refers to the number of units transfused in a 24 hour period that exceeds the recipient's blood volume.
Fresh transfusion Refers to blood less than 24 hours since time of collection.
- Types of transfusion reactions: Type of reaction Cause Signs and symptoms Acute Hemolytic Reaction
Wrong blood type (ABO- incompatibility)
Reactions develop within 15 minutes
Fever, chills, back/abdominal/chest/flank pain, infusion site pain, tachycardia, dyspnea, tachypnea, hypotension, dark urine
Febrile, nonhemolytic reaction
Sensitization to donor WBCs (most common),
Sudden chills, rigors, and fever (rise in temperature of
platelets, or plasma proteins.
>1°C), headache, vomiting.
Mild allergic reaction Sensitivity to foreign plasma proteins.
More common in people with history of allergies.
Flushing, itching, pruritus, urticaria (hives).
Anaphylactic and Severe Allergic Reaction
Sensitivity to donor plasma proteins.
Infusion of IgA proteins to IgA-deficient recipient who has developed IgA antibody.
Anxiety, abdominal pain, urticaria, dyspnea, wheezing, progressing to cyanosis, bronchospasm, hypotension, shock, and possible cardiac arrest.
- Explore More Notes:
- NS is the only fluid compatible with blood products
- If a reaction is suspected: STOP the blood, THEN assess the client
- Anaphylactic reaction: Stop, hang NS, then give EPI
- Febrile non-hemolytic: Stop, give acetaminophen, reassess patient Most common type of reaction
- Acute hemolytic: Wrong blood type
- Bacterial: Out of the fridge for too long or hanging too long
- TRALI: Slow down the blood 1-6 hours post-life threatening LEUKOCYTE REDUCED BLOOD
Bowel Obstruction
Types of Shock Type of Shock How they get it Signs and Symptoms Interventions Cardiogenic Shock Anything related to cardiac: MI, arrythmia, valvular
Hypotension Tachycardia Weak thready pulse Cool, pale, moist skin UO < 30 ml/hr Crackles in lungs Tachypnea
Support BP for better perfusion
Distributive Shock Neurogenic, anaphylactic (direct result of allergy), Septic
Neurogenic: hypotension, BRADYCARDIA, WARM DRY SKIN
Anaphylactic: Hypotension
Continuum of Sepsis (SIRS, Sepsis, Severe Sepsis, Septic Shock)
- SIRS > Sepsis > Severe Sepsis > Septic Shock
- SIRS Criteria: T: >100 or <96 RR > HR > WBC >12,000 or <4,000 or 10% bands PCO2 <32 mmHg
- Sepsis criteria: SIRS + confirmed or suspected infection TX: Fluid resuscitation (NS) bolus, Broad-spectrum antibiotics (Vancomycin)
- Severe Sepsis Sepsis + signs of organ damage, hypotension (<90), Lactate > 4 mmol Organ damage: decreased UO
- Septic Shock Severe sepsis + persistent hypotension, signs of organ damage, lactate > 4 mmol Decrease in UO and Decrease in cognitive function
- Explore More Notes: Volume expansion for septic, hypovolemic, anaphylactic shock One or two large bore IV, intraosseous access device, or central venous catheter Isotonic crystalloids (normal saline, lactated ringers), and colloids (albumin) Fluid responsiveness determined by: VS, cerebral and abdominal pressures, cap refill, skin temp, UO
- MODS: 2 or more organ systems
DIC
- Can be caused by numerous conditions including cancer and shock
- Extreme clotting all over the body, once clotting factors are depleted, there is extreme bleeding.
SICKLE CELL DISEASE
- RBCs are misshapen and cannot carry O2 adequately = no perfusion
- Decrease in perfusion presents as pain a. Always assess O2 first and then pain
LEUKEMIA 1. Risk for: neutropenia, thrombocytopenia, anemia 2. Treatment: Chemo, radiation, surgery a. Chemo side effects: weight loss, anorexia, weak immune system
HODGKINS VS NONHODGKINS 1. Hodgkin’s = Move its way down (predictable), Sternberg, alcohol-induced pain 2. Non-Hodgkin’s = Everywhere at once
SHORT BOWEL SYNDROME
- Can occur from any obesity/gastric surgery
- Dumping syndrome interventions: a. More protein type foods b. Snacks (6 small meals) instead of one big meal c. No fluids 30-60 minutes before and after they eat d. Lay down after eating
GI BLEED 1. Keep NPO and insert 2 large bore IVs 2. Take BP – hypotensive if bleeding 3. Color and consistency of blood depends on the location of the bleed a. Frank (bright red) – the brighter, the closer the bleed is to opening (mouth or anus) b. Coffee grind vomit – deeper in GI 4. The closer the bleed is to the airway = risk for aspiration (especially if it’s upper GI) 5. Rigid abdomen = bleeding in the abdomen = medical emergency 6. Labs to monitor: H&H
ALL/AML ALL: MC in CHILDREN, usually B-cells 1. Immature lymphocyte proliferation in bone marrow 2. Fever @ dx 3. s/sx: bleeding, fever (abrupt onset); gradual → progressive weakness, fatigue, bone and/or joint pain, and bleeding tendencies 4. CNS manifestations: arachnoid infiltration → Leukemic Meningitis AML 1. Neutropenia and thrombocytopenia
LABS
- WBC = <12,000 or >4,
- Platelet = 150,000–400,000/mm
- PT = 11–12 seconds; 85%–100%
- INR = 0–1.
- aPTT = 30–40 seconds
- Fibrinogen = 200–400 mg/dL or 2–4 g/L (SI units)
- D-Dimer = < 500 ng/mL fibrinogen equivalent units (FEU) or < 0 mg/L FEU
- Formula to monitor urine output : 0/kg/hr
Esophagectomy 1. First s/sx: progressive dysphagia + substernal feeling of food blockage (meat→ soft foods→ fluid 2. Late s/sx: pain (epigastric, substernal, back) ↑ w/ swallowing 3. Radiates → neck, jaw, ears, shoulders
Platelet count? Fresh frozen plasma is indicated for an elevated PT/INR. Albumin is indicated for hypovolemic shock or hypo-albuminia. TRALI is caused by a reaction between donor and the client leukocytes that causes pulmonary inflammation and capillary leaking. o One way to prevent: Transfuse leukocyte reduced packed red blood cells. Dumping syndrome: The client should lay down for about 30 minutes after eating. The other choices will add to the dumping syndrome. The nurse is educating the client about what to expect post-op from esophageal/gastric surgery. Included in this education, the client should expect: o Indwelling urinary catheter o IV Fluids o NGT to LIWS o Chest tubes The nurse is providing discharge instructions about dumping syndrome to a client after abdominal surgery. The nurse knows the client understands when the following is said: o "I will lay down after meals for 30 minutes." o "I will eat 6 small meals instead of 3 large meals." o "I will restrict fluid intake during meals." o "I will restrict intake of carbohydrates and sugars." S/S of neurogenic shock??? After a patient who has septic shock receives 2 L of normal saline intravenously, the central venous pressure is 10 mm Hg and the blood pressure is 82/40 mm Hg. What medication should the nurse anticipate? o Norepinephrine Which finding is the best indicator that the fluid resuscitation for a 90-kg patient with hypovolemic shock has been effective? o Urine output 65 mL over the past hour Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock? o Monitor breath sounds frequently A nurse is assessing a patient who is receiving a nitroprusside infusion to treat cardiogenic shock. Which finding indicates that the drug is effective? o Skin is warm and pink Which assessment information is most important for the nurse to obtain when evaluating whether treatment of a patient with anaphylactic shock has been effective? o O2 sat Which data collected by the nurse caring for a patient who has cardiogenic shock indicate that the patient may be developing multiple organ dysfunction syndrome (MODS)? o Serum creatinine is high Septic shock: o First intervention is push fluids (NS @ 500 mL/hr) When the nurse educator is evaluating the skills of a new registered nurse (RN) caring for patients with shock, which action by the new RN indicates a need for more education? o Maintaining a cool room temperature for a patient with neurogenic shock
A patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 4 days. Which finding is most important for the nurse to report to the health care provider? o New onset of confusion Which preventive actions by the nurse will help limit the development of systemic inflammatory response syndrome (SIRS) in patients admitted to the hospital? o Ambulate postoperative patients as soon as possible after surgery. o Use aseptic technique when manipulating invasive lines or devices. o Remove indwelling urinary catheters as soon as possible after surgery. o Administer prescribed antibiotics within 1 hour for patients with possible sepsis A young adult patient is admitted to the hospital for evaluation of right lower quadrant abdominal pain with nausea and vomiting. Which action should the nurse take? o Suggest the patient lie on the side, flexing the right leg. What should the nurse admitting a patient with acute abdominal pain plan for initial care? o Administer IV fluids and keep NPO The nurse is assessing a patient with abdominal pain. How will the nurse document ecchymosis around the area of umbilicus? o Cullen sign A patient is admitted to the emergency department with severe abdominal pain and rebound tenderness. Vital signs include temperature 102° F (38° C), pulse 120 beats/min, respirations 32 breaths/min, and blood pressure (BP) 82/54 mm Hg. Which prescribed intervention should the nurse implement first? o Infuse a liter of lactated Ringer’s solution over 30 minutes. A patient is awaiting surgery for acute peritonitis. Which action will the nurse plan to include in the preoperative care? o Position patient with the knees flexed o N/v, distended rigid abdomen, abdominal pain, tachycardia, dec UO, fever Which prescribed intervention for a patient with chronic short bowel syndrome should the nurse question? o Senna 1 tablet Which assessment should the nurse perform first for a patient who just vomited bright red blood? o Taking BP and pulse Which information will the nurse include when teaching a patient with peptic ulcer disease about the effect of ranitidine (Zantac)? o Ranitidine decreases gastric acid secretion
NSG-430 EXAM 4 Review
Course: Adult Health Nursing II (NSG-430)
University: Grand Canyon University
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