Abdominal Exam - o 1. Position client supine o 2. Inspection o 3...

Fundamentals 21 Abdominal Exam • Order of Abdominal Exam

• Position client supine
• Inspection
• Auscultation

▪ Before the stomach is messed with

• Percussion
• Palpation

▪ Last so it doesn’t interfere with assessment

Aphasia

• Definition: impaired communication due to a neurological condition

• Expressive Aphasia (B):

o Cause: Injury to Broca Area

o Speech: Sparse and Non-Fluent

▪ Trouble speaking and writing ▪ Speaks in short phrases and struggles with word choice

o Comprehension: Relatively Preserved

o Nursing Interventions:

▪ Listen without interrupting and give the client time to form words

• Receptive Aphasia (W):

o Cause: Injury to Wernicke Area

o Speech: Voluminous and Fluent but Lacks Meaning

o Comprehension: Greatly Diminished

▪ Trouble understanding both speech and writing

o Nursing Interventions:

▪ Speak clearly and ask simple “yes” or “no” question ▪ Use gestures

Arterial Lines • Phlebostatic Axis: this is how the height of the transducer is determined (zero point)

• 4

th intercostal space midaxillary line

Fundamentals 22 Barium Enema

• Purpose:

• Uses fluoroscopy to visualize the colon with contrast

▪ Can detect polyps, ulcers, tumors, and diverticula

• Contraindications:

• Acute Diverticulitis

▪ Risk of Rupture

• Side Effects:

• Abdominal Cramping
• Urge to Defecate

• Pre-Op Teaching:

• Take a cathartic to empty stool from the colon

▪ Magnesium Citrate or Polyethylene Glycol

• Clear Liquid Diet the day before
• NPO 8 hours before

• Post-Op Teaching:

• Expect passage of chalky, white stool from barium contrast
• Take a laxative to help expel the barium and prevent fecal impaction

▪ Magnesium Hydroxide

• Drink lots of fluid to promote hydrate and eat high-fiber diet

Beck’s Triad

• Cardiac Tamponade (Three Most Prominent Signs):

• Hypotension / Narrow Pulse Pressure
• Muffled Heart Sounds
• Neck Vein Distension

Blood Products

• Nursing Considerations:

• Ensure that the blood isn’t more than a week old
• Two RN’s must verify compatibility
• Use filtered Y tubing for blood transfusions (infuse one unit at a time)
• Prime tubing with 0.9% sodium chloride

▪ Clamp this side of the tubing during the infusion, open to flush after

• The RN must take the first vital signs after 15 minutes
• The blood must be started in 30 minutes, or it should be returned to the bank

• Transfusion Reaction

o Manifestations:

Fundamentals 23 ▪ Shortness of Breath ▪ Chest Tightness ▪ Fever ▪ Lower Back Pain ▪ Anxiety ▪ Tachycardia and Hypotension

o Treatment:

▪ Discontinue Blood Products and Call HCP ▪ Administer 0.9% NS through a different port ▪ Monitor Breath Sounds

Brachytherapy • Definition: Internal radiation treatment that is ingested, injected, or implanted

• Indications: Cancer treatment

• Permanent Brachytherapy: Only emits low doses of radiation that does not affect others • Temporary Brachytherapy: Require safety precautions because it poses a risk to other

o Example: Sealed Cervical Radium Implants

o Nursing Care:

▪ Use Appropriate Shielding to Limit Exposure • Place client in a lead room and use lead shields / aprons ▪ Limit Each Person’s Exposure to the Client • Cluster care to limit exposure to 30 minutes per shift ▪ All Assigned Staff Need a Dosimeter Badge • This measures the radiation exposure ▪ Place Client on Bedrest and Prevent Repositioning • Necessary to avoid device dislodgement ▪ Maximize Distance from Client • 6 feet is recommended Bronchoscopy

• Purpose: used to visualize larynx, trachea, bronchi, obtain tissue biopsy

• Indications:

• Diagnosis
• Remove Foreign Object

• Nursing Considerations:

• Requires informed consent
• Provide local anesthetic throat spray

o Administer medications as prescribed:

Fundamentals 24 ▪ Atropine to reduce oral secretions ▪ Sedation or Anti-Anxiety medications

• Keep patient upright for procedure

• Patient Education:

• Remain NPO 8-12 hours beforehand

▪ To reduce risk of aspiration

• Post-Procedure Care:

• Assess for Return of Gag Reflex

▪ This is a priority to decrease the risk of aspiration

• Monitor for Bleeding
• Monitor Respiratory Status, Vital Signs, and LOC

Cane

• Cane Size:

• From greater trochanter to the floor (wearing shoes)

• Cane Positioning:

• Always hold cane on the stronger side
• 6-10 inches to the side of the body

• Cane Advancing:

• Move cane forward 6-10 inches forward, then move affected leg
• Last, move stronger leg PAST the cane
• May also have the client move the affected leg and cane at the SAME TIME

▪ This is for clients needing minimal support

• Climbing Stairs with Cane:

• First, step with stronger leg
• Next, move the cane while bearing weight on strong leg
• Last, bring up the weaker leg

• Descending Stairs with Cane:

• First, lead with the cane
• Next, bring down the weaker leg
• Last, step down the stronger leg

• Pneumonic: “up with the good and down with the bad”

• The cane always moves before the weaker leg

Cardiac Catheterization

• Definition: a catheter is advanced to the heart through a vein

• Indications:

• Diagnosis of Coronary Artery Disease
• Treatment of Aortic Stenosis