Author Archives: Bherulal

Obstetrical Nursing- MCQs

1. Contains FSH to stimulate the ovaries to perform oogenesis or gametogenesis?
a. MOM               c. Syntocinon
b. Clomid            d. Methergin

2. This is given to contract uterus and remove retained secundines to prevent bleeding and infection?
a. Yutopar                                        c. Prednisone
b. Methylergonovine maleate     d. Tamoxifen

3. One of this medication counteracts oxytocin to stop preterm labor?
a. Pitocin            c. Methergin
b. Syntocinon     d. Terbutaline

4. Anti-estrogen helps suppress growth of breast tumor that is supported by estrogen?
a. Teslac             c. Nolvadex
b. Halostiten     d. Methergix

5. Helps relieve severe labor pain, best given at 6-7 cm cervical dilatation or at active phase of the 1st stage of labor?
a. Allopurinol    c. Dolfenal
b. Demerol       d. Indomethacin

6. Sim’s Hunher test is ordered after a normal semen analysis. Which two of the following results are normal?
I. 15-20 live motile sperm per hpf
II. Mucus stretches 8-10 cms per hpf
III. Less than 15 live motile sperm per hpf
IV. Mucus stretches 5-7 cms

  1. II and III
  2. I and II
  3. I and IV
  4. II and IV

7. What method of delivery is based on the theory of stimulus-response conditioning to reduce pain sensation during labor?
a. Lamaze        c. Leboyer
b. Bradley        d. Natural childbirth

8. Which of the following is not observed in Leboyer method?
a. Birth occurs in a well-lighted and quiet room
b. The cord is cut after the pulsation ceases
c. Neonate is placed immediately on the mother’s abdomen
d. Neonate is emerged in a tub of warm water

9. Jenny, a severe pre-eclamptic, has been on IV magnesium sulfate for 12 hours. Which of the following is not a sign overdose?
a. Absence of deep tendon reflexes
b. Respiration rate slower than 12 per minute
c. Urinary output less than 30 cc per hour
d. Decrease BP

10. Ritodrine hydrochloride has been infusing IV for several hours to stop Jane’s preterm labor. Since there are no contraindications for inhibiting labor and Jane is 30 weeks gestation, what other standard tocolytic therapy might the nurse use in place of ritodrine?
a. Indomethacin
b. Demerol and Vistaril IM
c. Magnesium sulfate
d. Morphine sulfate

11. Pat has a history of genital herpes during pregnancy. She is now term, in labor. Her cervical cultures for the last 2 months were negative. She delivers vaginally. The day after delivery, Pat has lesion on her labia majora. What medication can the nurse use to help alleviate the pain.
a. Acyclovir
b. T-stat (erythromycin lotion)
c. Hydrocortisone cream
d. Ampicillin

12. During labor a client who has been receiving epidural anesthesia has a sudden episode of severe nausea and her skin becomes pale and clammy. The nurse’s immediate reaction is to:
a. Notify the physician
b. Elevate the client’s legs
c. Check for vaginal bleeding
d. Monitor the FHR every 3 minutes

13. A client who was admitted inactive labor has only progressed from 2-3 cm in 8 hours. She is diagnosed having hypotonic dystocia and is given oxytocin (Pitocin) to augment her contractions. The most important aspect of nursing at this time is to:
a. Monitor the FHR
b. Check the perineum for bulging
c. Time and record length of contractions
d. Preparing for an emergency ceasarian delivery

14. A client in the midphase of labor becomes very uncomfortable and asks for medication. Meperidine (Demerol) 50 mg and Phenergan 50mg are ordered. These medications:
a. Act to produce anesthesia
b. Act as preliminary anesthetics
c. Induce sleep until the time of delivery
d. Increase the client’s pain threshold, resulting in relaxation

15. Overstretching of perineal supporting tissues as a result of childbirth can bring about a rectocele. The most common symptom is:
a. Crampy abdominal pain
b. A bearing down sensation
c. Urinary stress incontinence
d. Recurrent urinary tract infection

16. During pregnancy, the uterine musculature hypertrophies and is greatly stretched as the fetus grows. This stretching:
a. By itself inhibits uterine contraction until oxytocin stimulates the birth process
b. Is prevented from stimulating uterine contraction by high levels of estrogen during late pregnancy
c. Inhibits uterine contraction along with combined inhibitory effects of estrogen and progesterone
d. Would ordinarily stimulate contraction but is prevented by high levels of progesterone during pregnancy

17. The nurse would suspect an ectopic pregnancy if the client complained of:
a. An adherent painful ovarian mass
b. Sharp lower left abdominal pain radiating to the shoulder
c. Leukorrhea and dysuria a few days after the first missed period
d. Sharp lower left or right abdominal pain radiating to the shoulder

18. When obtaining the nursing history from a client with diagnosis of ruptured tubal pregnancy, the nurse should expect the client to indicate that her symptoms of pain in the lower abdomen and vaginal bleeding started:
a. About 6th week of pregnancy
b. At the beginning of the last trimester
c. Midway through the second trimester
d. Immediately after implantation

19. A client is on magnesium sulfate therapy for severe preeclampsia. The nurse must be alert for the first sign of an excessive blood magnesium level, which is:
a. Change in level of consciousness
b. Severe persistent headache
c. Epigastric pain
d. Disappearance of the knee-jerk reflex

20. A client with preeclampsia with two preschool children is prescribed bed rest at home. To help stimulate compliance plans for the client’s care should include:
a. A suggestion to find a housekeeper
b. An explanation as to why bed rest is necessary
c. A warning of the risks involved in non-compliance
d. A contract that 4 hours of nap time will neet the requirement

21. A post partum mother with diagnosis of thrombophlebitis has been placed on Coumadin therapy. The nurse knows the client understands teaching about Coumadin when she states:
a. “If I miss a dose, I will double the next dose.”
b. “I should eat plenty of green leafy vegetables.”
c. “If my arthritis flares up again, I’ll take only 2 aspirins every 6 hours.”
d. “I will use a soft toothbrush and stop flossing my teeth.”

22. Warfarin sodium (Coumadin) is ordered for a client along with the medications listed below. Which of the following medications should the nurse question before administering the drug?
a. Ascorbic acid (Vitamin C)      c. Cimetidine
b. Secobarbital (Seconal)          d. Psyllium

23. Which nursing care measure is not appropriate for client with thrombophlebitis?
a. Careful leg massages     c. Elevating the legs
b. Elastic stockings             d. Leg exercises

24. Which of the following the postpartum mother with diagnosis of thrombophlebitis should avoid?
a. Helping the client avoid straining at stool
b. Telling the client to avoid sudden movements
c. Assisting the client to dangle on the side of the bed 3 times a day
d. Teaching the client to avoid bumping the legs against other objects

25. A client with deep vein thrombosis is started on Heparin therapy. Which nursing action is not indicated during heparin administration?
a. Having vitamin K available if bleeding occurs
b. Observing for hematoma at IV puncture site
c. Suggesting that the client use a soft bristled toothbrush
d. Using an IV control device for drug administration

26. A client has thrombophlebitis. Heparin SC q 8hrs is prescribed. Nursing interventions related to the administration of heparin include:
a. Monitoring the client’s UO
b. Checking the client’s INR before administration
c. Checking the client for ecchymosis
d. Informing the client that NSAIDS may be taken for discomfort

27. The patient who has a deep vein thrombosis has been receiving heparin sodium. Which of these findings will evidence the desired effect of heparin therapy?
a. A reduction of pedal edema
b. A rapid capillary refill after squeezing the big toe
c. An increase in blood sedimentation rate
d. An elevation of the prothrombin time

28. Which statement by the client with thrombophlebitis indicates a need for further instructions?
a. I can cross my legs at the knee but not the ankle
b. I need to elevate the foot of the bed during sleep
c. I need to avoid prolonged sitting or standing
d. I should continue to wear elastic hose for at least 6-8 weeks

29. All of the following measures may be performed when a patient with diagnosis of previa is being admitted to the labor room except:
a. Auscultating the FHT with a fetoscope
b. Performing Leopold maneuvers
c. Determined cervical dilatation
d. Checking the vaginal discharge with nitrazine paper

30. Which of these comments, if made by the woman would indicate accurate knowledge of the non stress test?
a. “I know that I can’t eat anything after midnight on the day of the test.”
b. “I hope that they can find a vein for the test. Often my veins seem to disappear.”
c. “I hope that my baby is active when I come to the clinic for the test.”
d. “I’ll have to drink about 4 glasses of water within the hour before the test.”

31. Which sign helped confirm the diagnosisof severe PIH?
a. Proteinuria +3 on reagent strip
b. Elevated BP 155/98
c. Marked edema of lower extremities (+2)
d. Deep tendon hyperreflexia (+3)

32. During labor the woman is receiving magnesium sulfate IV. It is essential the nurse have which of the following drugs available to counteract the potential adverse effect?
a. Oxytocin (Pitocin)
b. Sodium bicarbonate
c. Phenytoin sodium (Dilantin)
d. Calcium gluconate

33. Which of the following position is best indicated in woman with diagnosis of PIH?
a. Semi-fowler’s, alternating sides
b. Left lateral position
c. Supine with head elevated on a small pillow
d. Right lateral Sim’s

34. A woman with diagnosis of PIH tells the nurse that she has severe headache and asks for medication to relieve it. The nurse should:
a. Notify the physician immediately
b. Explain that headaches are common in PIH
c. Offer some tea and toast
d. Administer prescribed prn pain medications

35. Twenty-fours after delivery the woman with history of PIH has BP of 150/100mmhg. The nurse should recognize that:
a. PIH can continue for 48 hours after delivery
b. This may be precursor of chronic hypertension
c. Kidney damage has probably occurred
d. There is no longer a danger of a convulsion

36. A woman who has PIH is receiving magnesium sulfate therapy. Which of the following manifestations would the nurse expect the woman to have if the magnesium sulfate is having the desired effect?
a. Reduction in patellar reflex response from +4 to +2
b. Decreased in urine output from 100ml/hr to 50 ml/hr
c. Increase in frequency of contractions from every 5 minutes to every 3 minutes
d. Increase in respiratory rate from 12/minute to 18/minute

37. A 26 year old woman is brought to the emergency room, complaining of severe left lower quadrant pain. She tells the nurse that she performed a home pregnancy test and believes that she is 8 weeks pregnant. On the admission the patient’s v/s are: pulse 90, BP 110/70, respirations 20. a half hour later her v/s are pulse 120, BP 85/50, respirations 26. The nurse interprets the change in the patient’s v/s to mean that:
a. The patient’s pain may have increased
b. The patient may be bleeding internally
c. The patient may be frightened
d. The patient may have an infection

38. A 23 year old woman comes to the clinic at 32 weeks gestation. A diagnosis of PIH is made. The nurse performs teaching. Which of the following statements made by the patient indicates to the nurse that further teaching is required?
a. “Lying in bed on my left side is likely to increase my urinary output.”
b. “If the bed rest works. I may lose a pound of two in the next few days.”
c. “I should be sure to maintain a diet that has a good amount of protein.”
d. “I will have to keep my room darkened and not watch much television.”

39. A 30 week pregnant attending the prenatal clinic has symptoms of PIH. Which of the following findings is indicative of this condition?
a. The woman has been getting short of breath when climbing the second flight of stairs in the family’s apartment
b. The woman has a craving for salty foods lately
c. The woman has a BP of 124/80mmhg, compared with 90/60mmhg a month ago
d. The woman has gained 3 lbs (1.4kgs) during the past month

40. At 33 weeks gestation, a woman who has been treated for PIH is admitted to the hospital because her condition has not improved. She is placed on bed rest and started on magnesium sulfate therapy. Which of the following assessment is essential for the nurse to make?
a. Obtaining the woman’s weight daily
b. Assessing the woman’s abdominal circumference daily
c. Observing the woman for jaundice
d. Checking the equality of the woman’s femoral pulse

41. A patient with history of abruptio placenta bleeds continuously after delivery. A diagnosis of Couvelaire uterus is mad. The nurse should:
a. Prepare the client for a uterine examination and insertion of vaginal packing.
b. Return the client to the DR for curettage
c. Add 10U of oxytocin (Pitocin) to the IV infusion
d. Ask the client to sign consent for a hysterectomy

42. While in the recovery room a patient with history of abruptio placenta begins to hemorrhage after delivery. Which is the most likely cause of hemorrhage?
a. Her uterus was not massaged adequately
b. She developed hypofibrinogenemia, a coagulation defect
c. Her rigid abdomen resulted in atony of the uterine muscles
d. Placental fragments remained in her uterus

43. A 34 yearl old G4P2 is admitted in active labor. She complains of severe pain that does not subside between contractions and her abdomen has become rigid. A diagnosis of abruption placenta is made. The priority nursing actions for the patient is/are to prepare for a blood transfusion and:
a. Observe for changes in her v/s and skin color
b. Obtain a clean catch urine specimen for culture and sensitivity
c. Prepare a solution of calcium gluconate for IV infusion
d. Maintain her in supine position

44. A woman who is hospitalized because of abruptio placenta would be carefully monitored for which of the following complications?
a. Toxic shock syndrome
b. Pulmonary embolism
c. Cerebrovascular accident
d. Disseminated intravascular coagulation

45. In which type of high risk pregnancy would abruptio placenta most likely occur?
a. Cardiac disease                    c. Drug addiction
b. Chronic hypertension         d. Hyperthyroidism

46. The fetal monitoring strip shows an FHR deceleration occurring midway during contraction; the FHR return to baseline midway between contractions. With this type of deceleration; the nurse’s first action should be to:
a. Place the woman in trendelenburg or knee-chest position
b. Call the physician
c. Position the woman in labor on the left side
d. Stop infusion of oxytocin

47. A woman in labor with complete cervical dilatation begins pushing during contractions, the FHR drops to approximately 90 BPM and then quickly returns to the baseline when she stops pushing. This sudden change is probably the result of:
a. Maternal position
b. Decreased utero-placental perfusion
c. Fetal distress
d. Umbilical cord compression

48. The fetal monitor strips shows an FHR deceleration occurring during the increment of a contraction, reaching its lowest point at the acme of the contraction, and returning to baseline during the decrement of the contraction. This type of deceleration indicates:
a. Fetal distress
b. Uteroplacental perfusion
c. Fetal vagal nerve stimulation
d. Umbilical cord compression

49. The fetal monitor strips shows an FHR deceleration occurring during the increment of contraction, reaching its lowest point at the acme of the contraction, and returning to baseline during the decrement of the contraction. This type of deceleration indicates:
a. Maternal hypoxia                c. Fetal movement
b. Fetal lung maturity             d. Fetal well-being

50. The electric monitor tracing shows the FHR is not smooth and straight between contractions. This indicates that:
a. The monitor cannot record the FHR accurately
b. The fetus is jumpy between contractions
c. The healthy FHR has beat to beat variability and should be not smooth
d. Application of internal monitor is necessary

51. Which of the following FHR patterns would indicate to the nurse that the fetus may be experiencing distress?
a. A baseline rate of 140-150 between contractions with moderate variability.
b. Consistent heart rate accelerations that coincide with the fetal movements
c. A heart rate that slows midway during contraction and returns to baseline 30 seconds after the contraction ends
d. Gradual slowing of the heart rate that begins with the onset of the contraction and return quickly to the baseline

52. An electronic fetal monitor is attached. The fetal monitoring strip shows an FHR deceleration occurring about 30 seconds after each contraction begins and the FHR return to baseline after the contraction is over. This type of deceleration is caused by:
a. Fetal head compression
b. Umbilical cord compression
c. Uteroplacental insufficiency
d. Cardiac anomalies

53. Which one would clue the nurse to suspect pregnancy in a woman with history of diabetes mellitus since she was 10 years old and hospitalization for DKA?
a. Nausea and vomiting             c. Listless and fatigue
b. Urinary frequency                  d. Breast sensitivity

54. A woman who is 20 weeks pregnant has history IDDM. The nurse understands that her insulin dosage has been increased to her prepregnant dose and will probably be further increased as her pregnancy progresses in order to:
a. Utilize the increase caloric intake of the second half of pregnancy
b. Limit the total pregnancy weight gain to 12.5 kg (27.5 lbs)
c. Meet the increasing glucose demands of the rapidly growing fetus
d. Counteract the effects of insulin antagonists produced by the placenta

55. When discussing diet with a newly diagnosed pregnant woman who is diabetic and taking insulin, the nurse should:
a. Emphasize the normalcy of pregnancy and the fact that her prescribed pregnancy diet will be suitable
b. Explain that pregnancy increases the need for protein and calcium but that will be the only needed diet adjustment
c. Confirm that dietary and insulin needs may vary throughout the pregnancy thus requiring close follow-up
d. Instruct her to self-regulate her diet and insulin based on daily urine tests for glucose

56. The woman is 6 weeks pregnant. She has history of IDDM. Her insulin dosage has been lowered at this time because:
a. Fetal insulin crosses the immature placent and enters maternal circulation
b. Increasing fetal demands deplete maternal blood glucose levels
c. Diabetic dietary needs decrease and less insulin is required
d. Maternal glucose levels decrease in direct proportion to increased maternal metabolism

57. Before amniocentesis, the amniotic sac should be located with the aid of:
a. Ultrasonography          c. Amniography
b. X-ray photography      d. Fetoscopy

58. Physical preparation for the amniocentesis includes:
a. No solid food between the previous midnight and the time of the procedure
b. Ingestion of 8 glasses of water 2 hours before the procedure
c. An enema on the morning of the procedure
d. Emptying the bladder just before the procedure

59. The woman is admitted with diagnosis of placenta previa. She is taken to the delivery room for a double set-up examination. Nursing responsibilities include preparing the woman for regional or inhalation anesthesia and:
a. vaginal or rectal examination
b. vaginal delivery or ceasarian section
c. ceasarian section
d. hysterectomy

60. Which ultrasound finding helped confirm the diagnosis of H-mole?
a. Multiple gestation of at least 4 fetuses
b. No discernible fetal skeleton or soft parts
c. Fetal anencephaly with hydrocephalus
d. Large fetal meningomyelocele

61. After removal of H-mole by D&C, which of the following finding would indicate that it would be safe to start another pregnancy?
a. Albumin/globulin ratio of 2:1
b. Negative HCG
c. Blood urea nitrogen of 18 mg/dl
d. Negative-C reactive protein

62. Fifteen minutes after the administration of epidural anesthesia the nurse observes decelerations of the FHR midway during contractions. The nurse should first:
a. Notify the physician
b. Administer O2
c. Record the findings q 5mins
d. Assess the maternal BP

63. In the patient’s chart, the nurse notes doctor’s order of Ergonovine maleate (Ergotrate) 0.4mg 4 x a day. The primary reason for the nurse to question the order of Ergonovine maleate to the post partum with history of RHD is that Ergotrate:
a. Can be administered either by oral or IM route
b. Is rarely ordered more than 2 days with a maximum of 1 week
c. Is usually prescribed in a dosage of 0.2 mg 4 x a day
d. Is usually contraindicated for cardiac clients

64. A teenager who is 4 months pregnant verbalizes that she has herpes genitalis. She asks if her baby will have the virus. The best response by the nurse should be:
a. If treatment is started during pregnancy, her baby will probably protected
b. That is one of the few vaginal diseases that does no affect the baby before, during or after delivery
c. If she has an active infection at term, a CS will probably protect her baby
d. Her baby will be protected by vaccine that will be administered immediately after delivery

65. A woman with diagnosis of PIH is placed on bed rest. An IV of LR has been started. The nurse has started an indwelling catheter to measure urine output because:
a. Incontinence may occur if preeclampsia progresses to eclampsia
b. Some urine may be lost when voiding on a bedpan
c. UO should be measured hourly to detect increasing oliguria
d. A 24hour urine collection is needed to measure total daily protein excretion

66. Which of the following side effect of ritodrine administration that would require physician’s notification?
a. Diuresis of 100ml/hr
b. Maternal tachycardia of over 120 bpm
c. Nausea followed by projectile vomiting
d. Fetal bradycardia of 110 bpm

67. Betamethasone (Celestone) a glucocorticoid is ordered to patient with premature labor because this medication:
a. Acts as mild tranquilizer during pregnancy and will enhance uterine relaxation
b. Promotes fetal lung maturity, which can prevent respiratory distress syndrome in a premature infant
c. Is an anti-inflammatory agent and will decrease the irritability of her uterine muscles
d. Elevates maternal blood glucose levels, which could lessen hypoglycemia in the premature infant

68. Which of the following responses would a nurse expect to find in a reactive non-stress test?
a. Acceleration of the fetal heart rate with fetal movement
b. Deceleration of the FHR without fetal movement
c. No change in the FHR with fetal movement
d. No change in FHR without fetal movement

69. Which of the following symptoms would be most significant when assessing a woman who has PIH?
a. Severe headache
b. Urine output of 200ml in the last 4 hours
c. Dependent edema
d. Patellar reflex of +2

70. A woman who is at 34 weeks pregnant is experiencing a sudden painless bright red vaginal bleeding. A nurse observes a colleague taking all of the following measures with the woman. Which one would the nurse question?
a. Palpating uterine firmness
b. Performing Leopold maneuvers
c. Preparing a vaginal exam
d. Preparing a non-stress test

71. Which of the following clients would the nurse prepare for an emergency CS?
a. A woman who has prolapsed cord
b. A woman with twin gestation
c. A woman who has meconium-stained amniotic fluid
d. A woman who has a non-reactive non-stress test

Mrs. Dantes, gravida 2 para 1 is admitted to the labor unit by ambulance and deliver is imminent. She keeps bearing down and after two contractions the baby’s head is crowning.

72. The nurse should:
a. Tell her to breathe through her mouth and pant during contractions
b. Tell her to breathe through her mouth the not to bear down
c. Transfer her immediately by stretcher to the delivery room
d. Tell her to pant while supporting the perineum with the hand to prevent tearing

73. With the nest contraction Mrs. Dantes delivers a large baby boy spontaneously. The nurse’s initial action should be:
a. Ascertain the condition of the fundus
b. Establish airway for the baby
c. Quickly tie and cut the umbilical cod
d. Move mother and baby to the delivery room.

74. The physician arrives and cares for the baby and delivers the placenta. Pitocin, an oxytocic drug, is administered IM. Since Mrs. Dantes has had a precipitous delivery, it is important to observe for:
a. Bleeding
b. Sudden chilling
c. Elevation of RR
d. Respiratory insufficiency in the baby

75. If involution is progressing normally, few hours after birth the nurse should expect the fundus to be located:
a. Three cm above the umbilicus
b. At the level of the umbilicus
c. 2 cm below the umbilicus
d. 2 cm above the symphysis pubis

Mrs. Roldan was admitted to the OB ward in active labor.

76. During contraction, the nurse observes a 15-beat per minute deceleration of the FHR. The most appropriate action would be to:
a. Prepare for immediate delivery because the fetus is in distress
b. Call the physician immediately and await the orders
c. Turn Mrs. Roldan on her left side to increase venous return
d. Record this normal fetal response to contractions in the chart.

77. The patient begins to experience contractions 2-3 minutes apart that last about 45 seconds. Between contractions, the nurse records a fetal heart rate of 100 bpm. The nurse should:
a. Closely monitor maternal vital signs
b. Chart the rate as a normal response to contractions
c. Notify the physician immediately
d. Continue to monitor the fetal heart rate

78. During delivery, episiotomy was performed. When caring for the patient during the post partum period, the nurse encourages sitz bath TID for 15 mins. Sitz baths primarily aid the healing process by:
a. Softening the incision site
b. Promoting vasodilation
c. Cleansing the perineal area
d. Tightening the perineal sphincter

79. When preparing Mrs. Roldan to care for her episiotomy after discharge, the nurse should include, as a priority, instructions to:
a. Continue the Sitz bath TID if it provides comfort
b. Discontinue the sitz bath once she is at home
c. continue perineal care after toileting until healing occurs
d. avoid stair climbing for at least a few days after discharge

Mrs. Walang, a 32 year old G3P2, spontaneously delivers a 4082g baby boy in route after a brief labor.

80. The nurse should be aware that the chief hazard to a child in precipitate delivery is:
a. Brachial palsy                     c. Dislocated hip
b. Intracranial hemorrhage d. Fractured clavicle

81. Perineal laceration is a common complication of precipitate delivery. In addition to regular perineal care, Mrs. Walang’s nursing care should include:
a. Encouraging early and frequent ambulation
b. Encouraging perineal exercises to strengthen the muscles
c. Telling the client to expect slower healing
d. Providing a high protein, high roughage diet

82. Baby Walang sustained a tear in the tentorial membrane which leads to intracranial bleeding. The nurse should expect the baby to display:
a. Extreme lethargy
b. Weak, timorous cry
c. Abnormal respirations
d. Generalized purpura

83. Nursing care of Baby Walang should include:
a. Stimulating frequently to monitor level of consciousness
b. Elevating his head higher than his hips
c. Checking reflexes every 15 minutes
d. Weighing him daily before feeding

84. The nurse who has been caring for the baby decides on a plan of care for the mother as well. The plan calls for:
a. Setting up a schedule for teaching the mother how to care for her baby.
b. Discussing the matter with her in a non-threatening way
c. Showing by example how to care for the infant and satisfy her own needs
d. Supplying emotional support to the mother and encouraging her dependence.

Mercedes, age 41, is admitted to the labor and delivery unit at 4:00 pm. While taking the history, the nurse notes the following: gravida 8, para 7, 41 weeks AOG, membranes ruptures at 10:00 am that day, contractions occur every 3 minutes; strong intensity with a duration of 60seconds.

85. What nursing action would take the highest priority at this time?
a. Get blood and urine samples
b. Do perineal prep and give enema
c. Attach monitor to the client
d. Determine extent of cervical dilation

86. Mercedes has just been given epidural anesthesia. What is the most important assessment at this time?
a. Maternal blood pressure
b. Fetal heart rate
c. Maternal level of consciousness
d. Fetal position

87. Mercedes had a normal spontaneous delivery. Why would she be considered at risk for development of postpartal hemorrhage?
a. Grand multiparity
b. Premature rupture of membranes
c. Post term delivery
d. Anesthesia

Sylvia Mariano has just delivered a 10-lb girl.

88. In assessing Sylvia immediately after delivery, which of the following would the nurse most likely to find?
a. Fundus located halfway between the symphysis pubis and umbilicus, lochia rubra
b. Fundus displaced to the right and 3 cm above the umbilicus, lochia serosa
c. Fundus located at the umbilicus, lochia rubra
d. Fundus located halfway between the symphysis pubis and the umbilicus, lochia serosa

89. Sylvia is having vaginal bleeding of bright red blood that is continuously trickling from the vagina. Her fundus is firm and in the midline. What is the most likely cause of this bleeding?
a. Lacerations
b. Subinvolution
c. Uterine atony
d. Retained placental fragment

90. Which of the following conditions predispose a client to postpartal hemorrhage?
a. Twin pregnancy
b. Breech presentation
c. Premature rupture of membranes
d. Ceasarian section

91. After 24 hours, Sylvia has a temperature of 38 degrees Celsius, has voided 2,000ml since delivery, and her skin is diaphoretic. Nursing actions should include which of the following?
a. Notify the physician of the findings
b. Notify the nursery to feed the baby in the nursery, as the mother has a fever
c. Explain to Sylvia that these symptoms are very normal for a woman who has just delivered
d. Suspect a postpartal infection and isolate the mother and the newborn

92. Sylvia’s sister warned her to suspect afterpains. The nurse’s teaching is based on the knowledge that the most likely candidate for afterpains is the:
a. Primipara who is bottle-feeding
b. Grand multipara who is breast feeding twin boys
c. Primipara who delivered prematurely and who is pumping her breasts
d. Adolescent primipara who is breastfeeding

93. Sylvia is using bottlefeeding for her baby and asks when she should expect her first menses. The appropriate response would be:
a. It usually takes at least 3 months before menstruation resumes after delivery
b. “As you aren’t breastfeeding, it should occur in 4-6 weeks.”
c. Two weeks is the average time for menses to return
d. “Ask your doctor. I’m sure that after doing a pelvic exam, she can tell you.”

Sheila, 32 weeks AOG, enters the emergency room complaining of premature labor.

94. Which of the following nursing actions is appropriate when caring for Sheila?
a. Prepare for an oxytocin challenge test to determine fetal status
b. Prepare for application of an internal monitor
c. Give frequent analgesia to relieve anxiety and promote comfort
d. Discuss the potential problems and preparations being made for the infant

95. Bed rest is prescribed for Sheila primarily because:
a. It will keep the pressure of the fetus off the cervix
b. May stop the labor by decreasing uterine irritability
c. Will promote and reduce anxiety
d. Will reduce fetal activity

96. A tocolytic agent is administered to suppress her labor. Which of the following nursing actions would be most appropriate in preventing side effects from this type of drug?
a. Side lying, anitembolic stockings, adequate hydration
b. Reduction in extraneous stimuli, frequent assessment of FHT
c. Use of side rails, frequent monitoring of uterine contractions
d. Frequent monitoring of BP and pulse

97. Which of the following drugs is considered a tocolytic agent?
a. Levallorphan            c. Phenobarbital
b. Terbutaline               d. Betamethasone

98. Attempts to stop labor were unsuccessful and a baby boy was born weighing 4lb 2 oz. Which of the following observations of the baby suggest a gestational age of less than 40 weeks?
a. Small amounts of lanugo and vernix, testes descended, palmar and plantar creases
b. Parchment-like skin, no lanugo, full areola in breast
c. Upper pinna of ear well curbed with instant recoil, small amounts of lanugo, pink in color
d. Dark red skin, testes undescended with few rugae, abundant lanugo

99. Which of the following is an important difference between a premature and a term infant?
a. Owing to size, a premature infant will have a more efficient metabolic rate for heat productions and maintenance
b. In proportion to size, the premature infant will have more lanugo, and more vernix than a full-term infant
c. GI motility is decreased in preterm infant. Stools may be infrequent resulting in abdominal distention
d. Heat production is low in premature infant because of the greater boy surface related to weight and lack of subcutaneous fat

Situation: Susan delivered her first child, a boy, 24 hours ago. She had a normal vaginal delivery with midline episiotomy and is breast feeding.

100. Instructions to Susan regarding care of the perineal area should include which of the following?
a. Separate the labia while cleansing
b. Cleanse the perineum with soap and water after elimination
c. Pour sterile water over the perineum after elimination
d. Perform perineal care only if an episiotomy is performed

Lumber Puncture

Indications

  1. Suspected CNS infection
  2. Suspected subarachnoid hemorrhage
  3. Therapeutic reduction of cerebrospinal fluid (CSF) pressure
  4. Sampling of CSF for any other reason

Contraindications

  1. Local skin infections over proposed puncture site (absolute contraindication)
  2. Raised intracranial pressure (ICP); exception is pseudotumor cerebri
  3. Suspected spinal cord mass or intracranial mass lesion (based on lateralizing neurological findings or papilledema)
  4. Uncontrolled bleeding diathesis
  5. Spinal column deformities (may require fluoroscopic assistance)
  6. Lack of patient cooperation

Materials

  1. Lumbar puncture tray (to include 20 or 22 gauge Quinke needle with stylet, prep solution, manometer, drapes, tubes, and local anesthetic)
  2. Universal precautions materials

Pre-procedure patient education

  1. Obtain informed consent
  2. Inform patient of possibility of complications (bleeding, persistent headache, infection) and their treatment
  3. Explain the major steps of the procedure, positioning, and postpocedure care

Procedure

  1. Assess indications for procedure and obtain informed consent as appropriate
  2. Provide necessary analgesia and/or sedation as required
  3. Position patient: lateral decubitus position with “fetal ball” curling up, or seated and leaning over a table top; both these positions will open up the interspinous spaces (see Figure 1)

LUMBAR%20PUNCTURE1_files/image001.jpg

 

Figure 1: Positioning patient for lumbar puncture

  1. Locate landmarks: between spinous processes at L4-5, L3-4, or L2-3 levels (see Figure 2). On obese patients, find the sacral promontory; the end of this structure marks the  L5-S1 interspace.  Use this reference to locate L4-5 for the entry point. You will aim the needle towards the navel.

Figure 2. Anatomy of lumbar spine

 

LUMBAR%20PUNCTURE1_files/image002.jpg

  1. Prep and drape the area after identifying landmarks. Use lidocaine 1% with or without epinephrine to anesthetize the skin and the deeper tissues under the insertion site
  2. Assemble needle and manometer. Attach the 3-way stopcock to manometer
  3. Insert Quinke needle bevel-up through the skin and advance through the deeper tissues. A slight pop or give is felt when the dura is punctured. Angle of insertion is on a slightly cephalad angle, between the vertebra (Figure 3). If you hit bone, partially withdraw the needle, reposition, and re-advance

LUMBAR%20PUNCTURE1_files/image003.jpg  

Figure 3

  1. When CSF flows, attach the 3-way stopcock and manometer. Measure ICP…this should be 20 cm or less. Note that the pressure reading is not reliable if the patient is in the sitting position
  2. If CSF does not flow, or you hit bone, withdraw needle partially, recheck landmarks, and re-advance
  3. Once the ICP has been recorded, remove the 3-way stopcock, and begin filling collection tubes 1-4 with 1-2 ml of CSF each

Tube 1: glucose, protein, protein electrophoresis

Tube 2: Gram’s stain, bacterial and viral cultures

Tube 3: cell count and differential

Tube 4: reserve tube for any special tests

  1. After tap, remove needle, and place a bandage over the puncture site. Instruct patient to remain lying down for 1-2 hours before getting up

NOTES:

  1. Insertion of the needle bevel-up minimizes dural trauma
  2. A traumatic “bloody tap” occurs when a spinal venous plexus is penetrated. Often the fluid will clear as succeeding tubes are filled. Spin down the first tube: if red blood cells have been in the spinal fluid for some time (for example, subarachnoid hemorrhage), xanthochromia will be present in the supernatant fluid. If the fluid is clear after it is spun down, the tap was only traumatic
  3. In some cases, conscious sedation is helpful in reducing patient anxiety and allowing maximal spinal flexion

COMPLICATIONS, PREVENTION, AND MANAGEMENT

Complication  Prevention  Management 
 Bleeding from puncture site post-tap  None

 

 Local pressure 
Bloody spinal fluid

 

 

None

 

Withdraw needle and perform tap at interspace either above or below
Infection

 

 

Do not perform tap through infected skin

Use sterile technique

Antibiotics

 

Post-tap persisting headache

 

Use pencil-tipped needle if possible; insert needle bevel-up  Post-procedure epidural blood patch by anesthesia consultant

Documentation in the medical record

Include in your note a brief history and physical examination of the patient, the reasons for performing the lumbar puncture, and consent. Note in particular a brief examination of the cranial nerves, presence or absence of papilledema, or any other lateralizing neurological finding. Also include a brief note of examination of the patient’s spine with attention to any obvious spinal deformity.

 Document position of patient during the procedure, opening pressure, and clarity/color of the CSF. Once results of the CSF analysis are available, they can be appended to your note.

 NORMAL CSF VALUES

Parameter Normal Values
Protein 15-45 mg/dl
Glucose 50-80 mg/dl
WBC < 5 mm3
RBC 0-5
Opening pressure 5-20 cm
Clarity, color Clear and colorless

 Items for evaluation of person learning this procedure

  1. Anatomy of lumbar spine
  2. Indications of procedure
  3. Contraindications for procedure
  4. Interaction between physician, staff, patient, and/or family
  5. Sterile technique, universal precautions
  6. Technical ability
  7. Appropriate documentation
  8. Understanding of potential complications and their correction

 

Application of Pharmacology in Nursing Practice

I. Evolution of Nursing Responsibilities Regarding Drugs

A. Five Rights of Drug Administration
– give the right drug to the right patient in the right dose by the right route at the right time
– proper delivery is only the beginning of responsibilities: Important events will take place after the “pill” is delivered, and these must be responded to.
– a broad base of pharmacology knowledge is needed so as to contribute fully to achieving the therapeutic objective
– should include a patient advocate position
PRE-TEST ? When applying pharmacology to patient care what is most important: assessment of the patient

II. Application of Pharmacology in Patient Care
– pharmacologic knowledge is applied in patient care and patient education
A. Pre-administration Assessment
1. Goals
a. collecting baseline data needed to evaluate therapeutic and adverse responses
b. identifying high-risk patients
c. assessing the patient’s capacity for self care
B. Collecting Baseline Data
– baseline data are needed to evaluate drug responses, both therapeutic and adverse

C. Identifying High Risk Patients
– predisposing factors are pathophysiology (especially liver and kidney function), genetic factors, drug allergies, pregnancy, old age, and extreme youth
– tools for identification are the patient history, physical examination and laboratory tests – need to know what to look for: factors that can increase the risk of severe reactions to the drug in question
PRE-TEST ? What predisposing factor can make a patient high risk when giving medications: pathophysiological conditions
D. Dosage and Administration
1. Read the medication order carefully. If the order is unclear, verify it with the prescribing physician.
2. Verify the identity of the patient by comparing the name on the wristband with the name on the drug order or administration record.
3. Read the medication label carefully. Verify the identity of the drug, the amount of drug (per tablet, volume of liquid, etc.) and its suitability for administration by the intended route.
4. Verify dosage calculations.
5. Implement any special handling the drug may require.
6. Don’t administer any drug if you don’t understand the reason for its use.

E. Evaluating and Promoting Therapeutic Effects
1. Evaluating Therapeutic Responses – evaluation is one of the most important aspects of drug therapy
– process that tells us whether or not our drug is doing anything useful
– need to know the rationale for treatment and the nature and time course of the intended response
2. Promoting Compliance – drugs an be of great value to patients, but only if they are taken correctly
3. Implementing Non-drug Measures – supportive measures directly, through patient education, or by coordinating the activities of other healthcare providers
F. Minimizing Adverse Effects – all drugs have the potential to produce undesired effects. In order to help reduce adverse effects, you must know the following about the drugs you’re working with:
– major adverse effects that the drug can produce
– time when these reactions are likely to occur
– early signs that an adverse reaction is developing
– interventions that can minimize discomfort and harm

G. Minimizing Adverse Interactions – when a patient is taking two or more drugs, those drugs may interact with one another to diminish therapeutic effects or intensify adverse effects. Ways to help reduce adverse interactions include:
– taking a thorough drug history
– advising the patient to avoid over the counter drugs that can interact with the prescribed
medication
– monitoring for adverse interactions known to occur between the drugs the patient is taking
– being alert for as-yet unknown interactions
H. Making PRN Decisions – PRN medication order is one in which the nurse has discretion regarding how much drug to give and when to give it.
– PRN is an abbreviation that stands for pro re nata (Latin for as needed or as the occasion arises)
– in order to implement a PRN order rationally, the reason for the drug use and the patient’s medication needs must be known
PRE-TEST ? What does PRN mean: as needed
I. Managing Toxicity – some adverse drug reactions are extremely dangerous; if toxicity is not diagnosed early and responded to quickly, irreversible injury or death can result.
– early signs of toxicity and the procedure for toxicity management must be known
III. Application of Pharmacology in Patient Education
As a patient educator, you must give the patient the following information:
– drug name and therapeutic category – dosage size
– dosing schedule – route and technique of administration
– duration of treatment – method of drug storage
– expected therapeutic response and when it should develop
– non-drug measures to enhance therapeutic responses
– symptoms of major adverse effects and measure to minimize discomfort and harm
– major adverse drug-drug and drug-food interactions
– whom to contact in the event of therapeutic failure, severe adverse reactions, or severe adverse interactions

A. Dosage and Administration
1. Drug Name – if the drug has been prescribed by trade name, the patient should be given its generic name too
– this information will reduce the risk of overdose that can result when a patient fails to realize that two prescriptions that bear different names actually contain the same medicine
2. Dosage Size and Schedule of Administration – patients need to be told how much drug to take and when to take it
3. Technique of Administration – patients must be taught how to administer their drugs
4. Duration of Drug Use – just as patient must know when to take their medicine, they must know when to stop
5. Drug Storage – certain medications are chemically unstable and hence deteriorate rapidly if stored improperly. Patients must be taught how to store their medications correctly. – all drugs should be stored where children cannot reach them

B. Promoting Therapeutic Effects – patients must know the nature and time course of expected beneficial effects
– non-drug measures can complement drug therapy; teaching patients about non-drug measures can greatly increase the chances of success

C. Minimizing Adverse Effects – knowledge of adverse drug effects will enable the patient to avoid some adverse effects and minimize others through early detection
D. Minimizing Adverse Interactions – patient education can help avoid hazardous drug-drug and drug-food interactions.

***IF IT’S NOT DOCUMENTED, IT’S NOT BEEN ADMINISTERED***

IV. Application of Nursing Process in Drug Therapy

A. Review of Nursing Process
1. Assessment – consists of collecting data about the patient
– methods of data collection are:

  • patient interview
  • medical and drug use histories
  • physical examination
  • observation of the patient
  • laboratory tests

    2. Analysis: Nursing Diagnosis – nurses analyze the database to determine the actual and potential health problems, which can be physiologic, psychologic or sociologic
    nursing diagnosis – states each problem as an actual or potential health problem that nurses
    are qualified and licensed to treat
    – consists of two statements that are usually separated by the phrase related to:
    a. statement of the patient’s actual or potential health problem
    b. statement of the problem’s probable cause or risk factors
    3. Planning – the nurse delineates specific interventions directed at solving or preventing the problems identified in analysis
    – in the care plan, the nurse must define goals, set priorities, and identify nursing interventions performed by other healthcare providers
    4. Implementation (Intervention) – begins with carrying out the interventions identified during planning
    collaborative interventions – require a physician’s order
    independent interventions – do not require a physician’s order
    – involves coordinating actions of other members of the healthcare team
    – is completed by observing and recording the outcomes of treatment
    5. Evaluation – performed to determine the degree to which treatment has succeeded
    – accomplished by analyzing the data collected during implementation
    – should identify those interventions: – that should be continued
    – those that should be discontinued
    – potential new interventions that should be implemented

    B. Applying the Nursing Process in Drug Therapy – overall objective in drug therapy is to produce maximum benefit with minimum harm
    – therapy must be individualized

    1. Pre-administration Assessment – establishes the baseline data needed to tailor drug therapy to the individual
    a. Basic Goals
    i. collection of baseline data needed to evaluate therapeutic responses
    – in order to know what baseline measurements to make, the reason for the drug use must be known
    ii. collection of baseline data needed to evaluate adverse effects
    – all drugs have the ability to produce undesired effects
    – knowing what data to collect comes directly from your knowledge of the drug under consideration
    iii. identification of high-risk patients
    – just which individual characteristics will predispose a patient to an adverse reaction depends on the drug under consideration
    – multiple factors that can increase the patient’s risk of adverse reactions to a particular drug include:
    – impaired liver and kidney function – age
    – body composition – pregnancy
    – diet – genetic heritage
    – other drugs being used
    – practically any pathophysiological conditions
    – distinguish between factors that put the patient at extremely high risk versus factors that put the patient at moderate or low risk

    contraindication – a pre-existing condition that precludes use of a particular drug under all but the most desperate circumstances

    precaution – a pre-existing condition that significantly increases the risk of an adverse reaction to a particular drug, but not to a degree that is life threatening
    iv. assessment of the patient’s capacity for self-care
    – for drug therapy to succeed, the outpatient must be willing and able to self-administer medication as prescribed
    – factors that can affect the capacity for self-care and probability of adhering to the prescribed regimen include:
    – reduced visual acuity – limited manual dexterity
    – limited intellectual ability – severe mental illness
    – inability to afford drugs
    – individual and/or cultural attitude toward drugs
    – conviction that the drug was simply not needed in the dosage prescribed
    – methods of data collection include:
    – interviewing the patient and family – observing the patient
    – physical examination – laboratory tests
    – patient’s medical history
    – patient’s drug history (including prescription drugs, over the counter drugs, herbal medications, non-medical drugs, such as alcohol, nicotine, caffeine, illicit drugs)
    – prior drug reactions should be noted

    b. Components of Drug History
    i. Allergies to medications (OTC and prescribed) or food

    ***If there are more than 2 medications, BE AWARE***
    ii. Habits
    – dietary
    – recreational drug usage (alcohol, tobacco, stimulants, illicit drugs) ask the patient “How much do you smoke? drink?”
    “What social drugs do you use?”
    iii. Socioeconomic Status
    – age – occupation
    – education level – insurance coverage

    iv. Life Style Beliefs
    – marital status – childbearing status
    – personal support system – utilization of health care system
    – typical pattern of daily activities
    v. Sensory Deficit / Capacity for self-care
    vi. Pre-existing conditions
    vii. Prescription and OTC Drugs:
    – reasons for use – knowledge of drugs
    – frequency of dosage – effectiveness or reaction
    – pattern and route of administration

2. Analysis and Nursing Diagnosis
a. Three objectives:
i. First, judge to appropriateness of the prescribed regimen
– the data collected during assessment must be analyzed to determine if the proposed treatment has a reasonable likelihood of being effective and safe
– judgment is made by considering:
– medical diagnosis – known actions of the prescribed drug
– patient’s prior responses to the drug
– presence of contraindications
– question the drug’s appropriateness:
– if the drug has no actions that are known to benefit individuals with the patient’s medical diagnosis
– if the patient failed to respond to the drug in the past
– if the patient has a serious adverse reaction to the drug in the past
– if the patient has a condition or is using a drug that contraindicates the prescribed drug
ii. Second, identify potential health problems that the drug might cause
– accomplished by synthesizing knowledge of the drug under consideration and the data collected during assessment

iii. Third, determine the patient’s capacity for self-care
– should indicate potential impediments to self-care (visual impairment, reduced manual dexterity, impaired cognitive function, insufficient understanding of the prescribed regimen)
– nursing diagnosis applicable to almost every patient is “deficient knowledge related to the drug regimen”
b. Planning – consists of defining goals, stabling priorities, identifying specific interventions, and establishing criteria for evaluating success

i. Defining Goals – the goal of drug therapy is to produce maximum benefit with minimum harm
– maximize therapeutic responses while preventing or minimizing adverse
reactions and interactions
ii. Setting Priorities – highest priority is given to life threatening conditions and reactions that cause severe, acute discomfort and to reactions that can result in long-term harm
iii. Identifying Intervention – heart of planning
i. Major Groups:
– drug administration = must consider dosage size and route of administration as well as less obvious factors, including timing of administration with respect to meals and with respect to administration of other drugs
– enhanced therapeutic effects = non-drug measures can help promote therapeutic effects and should be included in the planning
– interventions to minimize adverse effects and interactions distinguish between reactions that develop quickly and reactions that are delayed
– patient education = well planned patient education is central to success
– address the following: – technique of administration
– dosage size and timing
– duration of treatment
– method of drug storage
– measures to promote therapeutic effects
– measures to minimize adverse effects
iv. Establishing Criteria for Evaluation – the need for objective criteria by which to measure desired drug responses is obvious: without such criteria we could not determine if our drug was doing anything useful

3. Implementation
a. Four Major Components:
i. drug administration ii. patient education
iii. interventions to promote therapeutic effects
iv. interventions to minimize adverse effects

4. Evaluation – over the course of drug therapy, the patient must be evaluated for:
a. therapeutic responses
– how frequently evaluations are performed depends on the expected time course of therapeutic and adverse effects
– based on laboratory tests, observation of the patient, physical examination and patient interview
– to evaluate therapeutic responses, compare patient’s current status with baseline data
– to evaluate treatment, know the reason for drug use, criteria for success, and expected time course of responses
b. adverse drug reactions and interactions
– to make evaluates, know which adverse effects are likely to occur, how they are manifested, and their probable time course
c. compliance (adhere to prescribed regimen)
– include measurement of plasma drug levels, interviewing patient and counting pills
d. satisfaction with treatment
– satisfaction with drug therapy increases quality of life and promotes compliance
– factors that can cause dissatisfaction include unacceptable side effects, inconvenient dosing schedule, difficulty of administration, and high cost

C. Use of a Modified Nursing Process Format to Summarize Nursing Implications
1. Pre-administration Assessment – summarizes the information you should have before giving a drug
2. Implementation Administration – summarizes the routes of administration guidelines for dosage adjustment, and special considerations in administration
3. Implementation: Measures to Enhance Therapeutic Effects – addresses issues such as diet modification, measures to increase comfort and ways to promote adherence to the prescribed regimen

4. Ongoing Evaluation and Intervention – summarizes nursing implications that relate to drug responses, both therapeutic and undesired
a. Subsections:
i. summary of monitoring = summarizes the physiologic and psychologic parameters that must be monitored in order to evaluate therapeutic and adverse responses
ii. evaluating therapeutic effects = summarizes criteria and procedures for evaluating therapeutic responses
iii. minimizing adverse effects = summarizes the major adverse reactions that should be monitored for and presents interventions to minimize harm
iv. minimizing adverse interactions = summarizes the major drug interactions to be alert for and gives interventions to minimize them
v. managing toxicity – describes major symptoms of toxicity and treatment

Preceptor and Preceptee

PRECEPTOR

An experienced and competent professional

  • Acquire the necessary education and training
  • Act as a positive role model for the profession and demonstrates best practice and excellence in professional behaviours
  • Orientate and  integrate  the  preceptee  into  the  profession  and  the  clinical environment
  • Provide support and opportunity for learning
  • Respond to learner diversity and needs
  • Develop and maintain a respectful and inclusive environment
  • Instruct, supervise, assess and evaluate the preceptee
  • Provide and receive coaching and constructive feedback
  • Assist in the development of clinical skills
  • Assist in the transitioning of the preceptee from learner to practitioner who are reflective decision makers
  • Assist in the integration of theory with practice and consolidation of knowledge
  • Collaborate with preceptee at all stages of preceptorship

PRECEPTEE

  An active learner who is engaged in learning from a preceptor

  • Collaborate with preceptor at all stages of preceptorship
  • Take initiative, demonstrate motivation to learn and apply best practice principles
  • Be accountable and take responsibility for learning
  • Acquire and develop clinical skills
  • Integrate theory with practice and consolidate knowledge
  • Transition to a reflective decision maker
  • Integrate into the profession and clinical environment

Abortion

Ending of pregnancy, either spontaneous (miscarriage) or induced (termination of pregnancy) before 22 weeks LMP.

In countries where termination of pregnancy is legally restricted, induced abortions are often performed under poor conditions (non-sterile equipment, inappropriate equipment and/or substances, unqualified health care personnel, etc.). Complications (trauma, bleeding and severe infection) are common and may be life-threatening.

https://static.timesofisrael.com/atlantajewishtimes/uploads/2019/06/fetal-development.jpg

Diagnosis

Signs and symptoms

– Threatened abortion or missed abortion: light bleeding, abdominal pain, closed cervix.

– Incomplete abortion: more or less severe bleeding, abdominal pain, uterine contractions, expulsion of products of conception, open cervix.

– Trauma to the vagina or cervix or the presence of a foreign bodies are strongly suggestive of unsafe abortion. Look for complications, especially infection.

Additional investigations

– A pregnancy test is useful if the history and clinical examination are inconclusive.

– Ultrasound is useful for confirming failed pregnancy or the presence of retained products of conception after incomplete abortion.

Differential diagnosis

The main differential diagnoses are: ectopic pregnancy, cervicitis, ectropion (eversion of the cervical mucosa, which is more fragile and may bleed easily on contact, especially after a vaginal examination or sexual intercourse), cervical polyp, and functional uterine bleeding.

Management

Threatened abortion

– Advise the patient to reduce activity. Either the threat of abortion recedes, or abortion is inevitable.

– Look for a possible infectious cause (malaria or sexually transmitted infection) and treat it.

– Treat pain according to severity.

Missed abortion

If there are no signs of infection and/or no heavy bleeding, there is no urgency to perform uterine evacuation.

– Before 13 weeks LMP

Uterine evacuation can be performed by:

  • medication: misoprostol 600 micrograms sublingually or 800 micrograms vaginally (in the posterior fornix). Bleeding and cramping can be expected to start within 3 hours. If expulsion has not started within 3 hours, administer additional doses of misoprostol every 3 hours; max. 3 doses in total.

or

  • manual vacuum aspiration.

– Between 13 and 22 weeks LMP

mifepristone PO: 200 mg single dose, and 1 to 2 day later, misoprostol 400 micrograms sublingually

or intravaginally (into the posterior fornix), every 4 to 6 hours until labour starts, to be repeated if necessary the following day

or

misoprostol alone 400 micrograms sublingually or intravaginally (into the posterior fornix), every 4 to 6 hours until labour starts, to be repeated if necessary the following day

In case of 2 or more previous uterine scars or grand multiparity or overdistention of the uterus:

  • Preferably use the combined regimen mifepristone + misoprostol, as fewer numbers of misoprostol doses are required.
  • Reduce the dose of misoprostol to 200 micrograms every 6 hours.
  • Closely monitor the mother for possible signs of impending rupture (heart rate, blood pressure, uterine contractions, pain).

Ongoing or incomplete abortion without signs of infection

General measures

– Measure heart rate, blood pressure, temperature; assess severity of bleeding.

– In the event of heavy bleeding:

  • insert an IV line (16-18G catheter) and administer Ringer lactate;
  • closely monitor heart rate, blood pressure, bleeding;
  • prepare for a possible transfusion: determine the patient’s blood type, select potential donors or ensure that blood is available. If transfusion is necessary, only use blood that has been screened (HIV-1, HIV-2, hepatitis B, hepatitis C, syphilis, and malaria in endemic areas).

– Treat pain according to severity.

– Remove products of conception from the vagina and cervix, if present.

– Look for a cause (e.g. malaria or sexually transmitted infections) and treat it.

– Afterwards, provide iron + folic acid supplementation or, in the event of severe anaemia, a blood transfusion.

Uterine evacuation

– Before 13 weeks LMP

Uterine evacuation is usually required due to retained products of conception, which can cause bleeding and infection. There are 2 options:

  • Instrumental evacuation: manual vacuum aspiration or, if not available, instrumental curettage. Aspiration under local anaesthesia is the method of choice. It is technically easier to perform, less traumatic and less painful than curettage.
  • Medication: misoprostol 400 micrograms sublingually or 600 micrograms PO single dose

– Between 13 and 22 weeks LMP

  • Instrumental evacuation in case of haemorrhage: manual vacuum aspiration or instrumental curettage or digital curettage.
  • Medication: misoprostol 400 micrograms sublingually every 3 hours until expulsion. In the absence of expulsion after 3 additional doses, consider instrumental evacuation.

In case of 2 or more previous uterine scars or grand multiparity or overdistention of the uterus: same precautions as for missed abortion (see above).

Septic abortion

In the event of septic abortion (fever, abdominal pain, tender uterus, foul-smelling discharge), as above

AND:

– Remove foreign bodies from the vagina and cervix, if present; clean wounds.

– Perform uterine evacuation as soon as possible, irrespective of gestational age.

– Administer antibiotherapy as soon as possible:

amoxicillin/clavulanic acid IV (dose expressed in amoxicillin): 1 g every 8 hours + gentamicin IM: 5 mg/kg once daily

or

ampicillin IV: 2 g every 8 hours + metronidazole IV: 500 mg every 8 hours + gentamicin IM: 5 mg/kg once daily

Continue until the fever disappears (at least 48 hours), then change to:

amoxicillin/clavulanic acid PO (dose expressed in amoxicillin) to complete 5 days of treatment

Ratio 8:1: 3000 mg daily (= 2 tablets of 500/62.5 mg 3 times daily)

Ratio 7:1: 2625 mg daily (= 1 tablet of 875/125 mg 3 times daily)

or

amoxicillin PO: 1 g 3 times daily + metronidazole PO: 500 mg 3 times daily, to complete 5 days of treatment

For very severe infection (infected perforated uterus or peritonitis), treat for 10 days.

– Check and/or update tetanus immunisation (Table 2.1).

Table – Tetanus prophylaxis

Immunisation status Spontaneous abortion Unsafe abortion, with wound or foreign bodies
Not immunised
or
Immunisation status unknown
Begin immunisation against tetanus Begin immunisation against  tetanus
+
Human tetanus immune globulin
Incompletely immunised Tetanus booster Tetanus booster 
+
Human tetanus immune globulin
Fully immunised Last booster dose:
< 5 years No prophylaxis No prophylaxis
5 to 10 years No prophylaxis Tetanus booster
> 10 years Tetanus booster Tetanus booster
+
Human tetanus immune globulin

 

Boys and Puberty

Puberty is the time when you grow from a boy into a young man. Everyone goes through it. It can be exciting, but some people find it tough. Here’s what to expect.

How does my body change?
During puberty, your testicles (testes or ‘balls’) start producing the male hormone testosterone. This hormone triggers changes in your body. Suddenly you grow taller and begin to develop muscles. You will also find physical changes happening to your voice, your body hair and your genitals, and possibly even your breasts.

There are plenty of signs that puberty has started. Every boy is different, but here are some of the most common changes to look out for.

  • You grow taller, and you may become more muscular.
  • Your Adam’s apple (larynx) gets bigger and your voice deepens or begins to ‘break’.
    Your testicles begin to produce sperm.
  • Your body produces more hormones, so you might get erections when you least expect them.
  • Ejaculations can happen while you are asleep. These are called ‘nocturnal emissions’, or ‘wet dreams’. Wet dreams are totally normal.
  • You may get oily skin and hair, and spots (acne) may develop on your face and body.
    You may find you sweat more.
  • Hair will start to grow under your arms and around your penis and testicles. You may also find more hair growing on your legs and arms. Hair will also appear on your chin and upper lip.
  • You may have mood swings and feel emotional, but your feelings will settle down in time.
  • You may notice a swelling or lump under your nipples. This is normal and it will go away after a few months.

Girls and Puberty

What is puberty?
Puberty refers to the specific physical changes that happen as a child develops into an adult. Though they happen in different areas of the body, these changes are all related to each other.

Some of these changes include: bone growth; getting taller; making hormones in the adrenal glands and ovaries; growing pubic hair, underarm hair, and breasts; and the start of regular, monthly menstrual bleeding. Ultitmately puberty causes the girl to become fertile and release eggs regularly.

During puberty, the brain starts to send increasing signals to the ovaries and adrenal glands. In response, the ovaries make the hormones estrogen and progesterone. Adrenal glands make small amounts of the “male” hormones (androgens) that are made in females. These cause the breasts to grow, cause pubic and underarm hair to grow, and start the menstrual periods.

How does my body change?
Your body changes during puberty — you are going from being a child to how you will be when you are an adult.

During puberty, a lot of different things happen.

  • You’ll get taller, and this might happen quite quickly.
  • Your nipples may look swollen and feel tender. This is the start of your breasts growing, and usually happens between the ages of 8 to 13.
  • Your hips, bottom and thighs will probably get bigger and rounder.
  • Inside your body, your ovaries and womb will get larger.
  • Pubic hair will start growing around your vagina and under your arms. You may also find you have more hair on your legs. The hair will start off fine and straight, but become thicker and curlier.
  • Your clitoris will get larger.
  • Your first period, or menstruation, will probably arrive between the ages of 9 and 15 years. Every girl is different.
  • Your vagina will start to produce a small amount of clear or cream-coloured fluid (called vaginal discharge). This fluid, which keeps the walls of the vagina clean, is normal and healthy.
  • You may get oily skin and hair, and spots (acne) may develop on your face and body.
    You may also find you sweat more.
  • You may feel more emotional than usual and find you are sensitive to what others say.

These changes usually take place over about 4 years. By the time you are 16, you will have done most of your physical developing.

FACTS YOU DIDN’T KNOW ABOUT YOUR HYMEN

Surely on more than one occasion, you’ve heard about the supposed relationship between the hymen and a woman’s virginity. But this information is even faker than the love you swore to your ex 😉, since it really is just a myth that has been believed by women for years, and we’ll explain why here.

The first thing you need to know is that the hymen is a thin, elastic membrane located at the entrance of your vagina, which has a small hole that allows for menstrual flow each month and facilitates the placement of tampons, which, like any other part of our body, is different in every woman.

Does having a hymen means I’m a virgin?

Actually… They aren’t related! There are people who believe that if you’re a virgin the hymen is intact, but this is totally FALSE. A woman loses her virginity the moment she has sex with another person, that is when there’s intercourse. The hymen may or may not break during this activity due to its elasticity.

It’s important to know that there are women who are born with the hymen naturally open, or even without one, which is completely normal. There are also many activities that can break the hymen, such as biking, sports, or a hard fall. So you can’t really tell if someone has had sex by the way their hymen is. 

Learn to identify the myths and truths of your hymen with these 6 facts:

1. There are many shapes and sizes: as with the rest of our body, the hymen can vary in shape and size for each woman.

2. Some women don’t have one: there are many women who are born without a hymen but relax, it’s super normal!

3. It doesn’t always cause bleeding when you stretch: some women have hymens that stretch very easily and don’t cause bleeding. In fact, less than half of women experience some type of bleeding during their first sexual intercourse.

4. It isn’t something that can explode: it’s a false myth, the idea comes from the bleeding that some women have after having sex for the first time. The truth is that bleeding can happen when the hymen is stretched, not because it explodes.

5. It may hurt a little when it’s being stretched for the first time: it’s something that doesn’t happen to all women, but if it does, it’s a very small discomfort. 

6. It changes over time: in girls, the hymen is thick and bulky, but over time it becomes thinner and more fragile.

Remember that it’s really important to know our body in order to have better physical and sexual health. Before any strange change, it’s always better to visit your doctor

Virginity, Difference between True Virgin and False Virgin

Virginity

  • Also known as Virgo Intacta.
  • Definition: Virgin is a female who has not experienced sexual intercourse.

Signs of virginity :

  1. Extra genital signs (in breast)
  2. Genital signs

Difference between Virginity and Defloration

features virginity Defloration
1.Basic difference No experience of sexual intercourse Have experience of sexual intercourse
2.hymen Intact Torn except in false virgin
3.introitus Does not admit more than tip of little finger, it is painful May admit 2 fingers , it is painless
4.vagina. Marked rugosity on wall

Full length of a finger cannot be admitted

Rugosity diminishes

Full length of finger can be admitted

5.Fossa navicularis Less conspicuous More conspicuous after sexual intercourse
6.Fourchette Intact Healed tear
7.Labia minora Smaller pinkish, covered with majora enlarged, pigmented, not covered
8.Labia majora Thick, fleshy, both majora are in close apposition Less fleshy, not in full apposition
9.Breasts Smaller, firm, pinkish smaller areola, and small nipple Larger, flabby, pendulous, wider areola, large and raised nipple

Other conditions which may affect signs of virginity 

  • Trauma or Accident
  • Surgical operation or Gynaecological examination
  • Sanitary tampons
  • Foreign body – sola pith (APTAE VARIS)
  • Scratching due to irritation from uncleaniness
  • Masturbation
  • Ulceration – d/t diphtheria , fungus, etc. 

False Virgins

  • Hymen is intact but the woman has had sexual intercourse.

Difference between True Virgin and False Virgin

Point of  difference

True virgin

False virgin

1.Basic difference The woman has no experience of sexual intercourse Has experience of sexual intercourse
2.Hymen Not ruptured. It is thin flap of tissue of regular shape and appearance Not ruptured. It is thick , fleshy or fibrous elastic with folds
3.Introitus Does not admit more than the tip of little finger, it is painful May admit 2 fingers, it is not painful
4.Vagina. Marked rugosity on wall

Full length of a finger cannot be admitted

Rugosity diminishes

Full length of finger can be admitted

5.Fossa navicularis Less conspicuous More conspicuous after sexual intercourse
6.Fourchette Intact Healed tear
7.Labia minora Smaller pinkish, covered with majora enlarged, pigmented, not covered
8.Labia majora Thick, fleshy, both majora are in close apposition Less fleshy, not in full apposition
9.Breasts Smaller, firm, pinkish smaller areola and small nipple Larger, flabby,  pendulous, wider areola,  large and raised nipple

 

               

Chronic Obstructive Pulmonary Disease (COPD)

Key facts

  • Chronic obstructive pulmonary disease (COPD) is a progressive life-­threatening lung disease that causes breathlessness (initially with exertion) and predisposes to exacerbations and serious illness.
  • The Global Burden of Disease Study reports a prevalence of 251 million cases of COPD globally in 2016.
  • Globally, it is estimated that 3.17 million deaths were caused by the disease in 2015 (that is, 5% of all deaths globally in that year).
  • More than 90% of COPD deaths occur in low­ and middle-­income countries.
  • The primary cause of COPD is exposure to tobacco smoke (either active smoking or second­hand smoke).
  • Other risk factors include exposure to indoor and outdoor air pollution and occupational dusts and fumes.
  • Exposure to indoor air pollution can affect the unborn child and represent a risk factor for developing COPD later in life.
  • Some cases of COPD are due to long-term asthma.
  • COPD is likely to increase in coming years due to higher smoking prevalence and aging populations in many countries.
  • Many cases of COPD are preventable by avoidance or early cessation of smoking. Hence, it is important that countries adopt the WHO Framework Convention on Tobacco Control (WHO-FCTC) and implement the MPOWER package of measures so that non-smoking becomes the norm globally.
  • COPD is not curable, but treatment can relieve symptoms, improve quality of life and reduce the risk of death.

Chronic obstructive pulmonary disease (COPD) is a disease state characterized by airflow limitation that is not fully reversible. This newest definition of COPD, provided by the Global Initiative for Chronic Obstructive Lung Disease, provides a broad description that better explains this disorder and its signs and symptoms (National Institutes of Health [NIH], 2001).

Chronic obstructive pulmonary disease (COPD)

While previous definitions have included emphysema and chronic bronchitis under the umbrella classification of COPD, this was often confusing because most patients with COPD present with overlapping signs and symptoms of these two distinct disease processes.

 COPD may include diseases that cause airflow obstruction (eg, emphysema, chronic bronchitis) or a combination of these disorders. Other diseases such as cystic fibrosis, bronchiectasis, and asthma were previously classified as types of chronic obstructive lung disease. However, asthma is now considered a separate disorder and is classified as an abnormal airway condition characterized primarily by reversible inflammation. COPD can coexist with asthma. Both of these diseases have the same major symptoms; however, symptoms are generally more variable in asthma than in COPD.

People with COPD commonly become symptomatic during the middle adult years, and the incidence of COPD increases with age. Although certain aspects of lung function normally decrease with age (eg, vital capacity and forced expiratory volume in 1 second [FEV1]), COPD accentuates and accelerates these physiologic changes.

Pathophysiology

In COPD, the airflow limitation is both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases. The inflammatory response occurs throughout the airways, parenchyma, and pulmonary vasculature (NIH, 2001). Because of the chronic inflammation and the body’s attempts to repair it, narrowing occurs in the small peripheral airways. Over time, this injury-and-repair process causes scar tissue formation and narrowing of the airway lumen. Airflow obstruction may also be due to parenchymal destruction as seen with emphysema, a disease of the alveoli or gas exchange units.

In addition to inflammation, processes relating to imbalances of proteinases and antiproteinases in the lung may be responsible for airflow limitation. When activated by chronic inflammation, proteinases and other substances may be released, damaging the parenchyma of the lung. The parenchymal changes may also be consequences of inflammation, environmental, or genetic factors (eg, alpha1 antitrypsin deficiency).

Early in the course of COPD, the inflammatory response causes pulmonary vasculature changes that are characterized by thickening of the vessel wall. These changes may occur as a result of exposure to cigarette smoke or use of tobacco products or as a result of the release of inflammatory mediators (NIH, 2001).

Chronic Bronchitis

Chronic bronchitis, a disease of the airways, is defined as the presence of cough and sputum production for at least 3 months in each of 2 consecutive years. In many cases, smoke or other environmental pollutants irritate the airways, resulting in hypersecretion of mucus and inflammation. This constant irritation causes the mucus-secreting glands and goblet cells to increase in number, ciliary function is reduced, and more mucus is produced. The bronchial walls become thickened, the bronchial lumen is narrowed, and mucus may plug the airway. Alveoli adjacent to the bronchioles may become damaged and fibrosed, resulting in altered function of the alveolar macrophages. This is significant because the macrophages play an important role in destroying foreign particles, including bacteria. As a result, the patient becomes more susceptible to respiratory infection. A wide range of viral, bacterial, and mycoplasmal infections can produce acute episodes of bronchitis. Exacerbations of chronic bronchitis are most likely to occur during the winter.

Emphysema

In emphysema, impaired gas exchange (oxygen, carbon dioxide) results from destruction of the walls of overdistended alveoli. “Emphysema” is a pathological term that describes an abnormal distention of the air spaces beyond the terminal bronchioles, with destruction of the walls of the alveoli. It is the end stage of a process that has progressed slowly for many years. As the walls of the alveoli are destroyed (a process accelerated by recurrent infections), the alveolar surface area in direct contact with the pulmonary capillaries continually decreases, causing an increase in dead space (lung area where no gas exchange can occur) and impaired oxygen diffusion, which leads to hypoxemia. In the later stages of the disease, carbon dioxide elimination is impaired, resulting in increased carbon dioxide tension in arterial blood (hypercapnia) and causing respiratory acidosis. As the alveolar walls continue to break down, the pulmonary capillary bed is reduced.

Consequently, pulmonary blood flow is increased, forcing the right ventricle to maintain a higher blood pressure in the pulmonary artery. Hypoxemia may further increase pulmonary artery pressure. Thus, right-sided heart failure (cor pulmonale) is one of the complications of emphysema. Congestion, dependent edema, distended neck veins, or pain in the region of the liver suggests the development of cardiac failure.

Risk Factors for COPD

  • Exposure to tobacco smoke accounts for an estimated 80% to 90% of COPD cases (Rennard, 1998)
  • Passive smoking
  • Occupational exposure
  • Ambient air pollution
  • Genetic abnormalities, including a deficiency of alpha1-antitrypsin, an enzyme inhibitor that normally counteracts the destruction of lung tissue by certain other enzymes

Clinical Manifestations

COPD is characterized by three primary symptoms:

Katie Hrubec Hrubec Hrubec Burroughs @Megan Ward Ward Ward Anderson i guess i finally know what COPD is | Nursing school survival, Nursing mnemonics, Nurse

  • cough,
  • sputum production, and
  • dyspnea on exertion. These symptoms often worsen over time.
  • Chronic cough and sputum production often precede the development of airflow limitation by many years. However, not all individuals with cough and sputum production will develop COPD.
  • Dyspnea may be severe and often interferes with the patient’s activities.
  • Weight loss is common because dyspnea interferes with eating, and the work of breathing is energy-depleting.

Often the patient cannot participate in even mild exercise because of dyspnea; as COPD progresses, dyspnea occurs even at rest. As the work of breathing increases over time, the accessory muscles are recruited in an effort to breathe. The patient with COPD is at risk for respiratory insufficiency and respiratory infections, which in turn increase the risk for acute and chronic respiratory failure.

  • In COPD patients with a primary emphysematous component, chronic hyperinflation leads to the “barrel chest” thorax configuration. This results from fixation of the ribs in the inspiratory position (due to hyperinflation) and from loss of lung elasticity. Retraction of the supraclavicular fossae occurs on inspiration, causing the shoulders to heave upward. In advanced emphysema, the abdominal muscles also contract on inspiration.

Complications

There are two major life-threatening complications of COPD: respiratory insufficiency and failure.

  • Respiratory failure. The acuity and the onset of respiratory failure depend on baseline pulmonary function, pulse oximetry or arterial blood gas values, comorbid conditions, and the severity of other complications of COPD.
  • Respiratory insufficiency. This can be acute or chronic, and may necessitate ventilator support until other acute complications can be treated.

Assessment and Diagnostic Findings

Diagnosis and assessment of COPD must be done carefully since the three main symptoms are common among chronic pulmonary disorders.

  • Health history. The nurse should obtain a thorough health history from patients with known or potential COPD.
  • Pulmonary function studies. Pulmonary function studies are used to help confirm the diagnosis of COPD, determine disease severity, and monitor disease progression.
  • Spirometry. Spirometry is used to evaluate airway obstruction, which is determined by the ratio of FEV1 to forced vital capacity.
  • ABG. Arterial blood gas measurement is used to assess baseline oxygenation and gas exchange and is especially important in advanced COPD.
  • Chest x-ray. A chest x-ray may be obtained to exclude alternative diagnoses.
  • CT scan. Computed tomography chest scan may help in the differential diagnosis.
  • Screening for alpha1-antitrypsin deficiency. Screening can be performed for patients younger than 45 years old and for those with a strong family history of COPD.
  • Chest x-ray: May reveal hyperinflation of lungs, flattened diaphragm, increased retrosternal air space, decreased vascular markings/bullae (emphysema), increased bronchovascular markings (bronchitis), normal findings during periods of remission (asthma).
  • Pulmonary function tests: Done to determine cause of dyspnea, whether functional abnormality is obstructive or restrictive, to estimate degree of dysfunction and to evaluate effects of therapy, e.g., bronchodilators. Exercise pulmonary function studies may also be done to evaluate activity tolerance in those with known pulmonary impairment/progression of disease.
  • The forced expiratory volume over 1 second (FEV1): Reduced FEV1 not only is the standard way of assessing the clinical course and degree of reversibility in response to therapy, but also is an important predictor of prognosis.
  • Total lung capacity (TLC), functional residual capacity (FRC), and residual volume (RV): May be increased, indicating air-trapping. In obstructive lung disease, the RV will make up the greater portion of the TLC.
  • Arterial blood gases (ABGs): Determines degree and severity of disease process, e.g., most often Pao2is decreased, and Paco2 is normal or increased in chronic bronchitis and emphysema, but is often decreased in asthma; pH normal or acidotic, mild respiratory alkalosis secondary to hyperventilation (moderate emphysema or asthma).
  • DL CO test: Assesses diffusion in lungs. Carbon monoxide is used to measure gas diffusion across the alveocapillary membrane. Because carbon monoxide combines with hemoglobin 200 times more easily than oxygen, it easily affects the alveoli and small airways where gas exchange occurs. Emphysema is the only obstructive disease that causes diffusion dysfunction.
  • Bronchogram: Can show cylindrical dilation of bronchi on inspiration; bronchial collapse on forced expiration (emphysema); enlarged mucous ducts (bronchitis).
  • Lung scan: Perfusion/ventilation studies may be done to differentiate between the various pulmonary diseases. COPD is characterized by a mismatch of perfusion and ventilation (i.e., areas of abnormal ventilation in area of perfusion defect).
  • Complete blood count (CBC) and differential: Increased hemoglobin (advanced emphysema), increased eosinophils (asthma).
  • Blood chemistry: alpha1-antitrypsin is measured to verify deficiency and diagnosis of primary emphysema.
  • Sputum culture: Determines presence of infection, identifies pathogen.
  • Cytologic examination: Rules out underlying malignancy or allergic disorder.
  • Electrocardiogram (ECG): Right axis deviation, peaked P waves (severe asthma); atrial dysrhythmias (bronchitis), tall, peaked P waves in leads II, III, AVF (bronchitis, emphysema); vertical QRS axis (emphysema).
  • Exercise ECG, stress test: Helps in assessing degree of pulmonary dysfunction, evaluating effectiveness of bronchodilator therapy, planning/evaluating exercise program.

Medical Management

Healthcare providers perform medical management by considering the assessment data first and matching the appropriate intervention to the existing manifestation.

Pharmacologic Therapy

  • Bronchodilators. Bronchodilators relieve bronchospasm by altering the smooth muscle tone and reduce airway obstruction by allowing increased oxygen distribution throughout the lungs and improving alveolar ventilation.
  • Corticosteroids. A short trial course of oral corticosteroids may be prescribed for patients to determine whether pulmonary function improves and symptoms decrease.
  • Other medications. Other pharmacologic treatments that may be used in COPD include alpha1-antitrypsin augmentation therapy, antibiotic agents, mucolytic agents, antitussive agents, vasodilators, and narcotics.

Management of Exacerbations

  • Optimization of bronchodilator medications is first-line therapy and involves identifying the best medications or combinations of medications taken on a regular schedule for a specific patient.
  • Hospitalization. Indications for hospitalization for acute exacerbation of COPD include severe dyspnea that does not respond to initial therapy, confusion or lethargy, respiratory muscle fatigue, paradoxical chest wall movement, and peripheral edema.
  • Oxygen therapy. Upon arrival of the patient in the emergency room, supplemental oxygen therapy is administered and rapid assessment is performed to determine if the exacerbation is life-threatening.
  • Antibiotics. Antibiotics have been shown to be of some benefit to patients with increased dyspnea, increased sputum production, and increased sputum purulence.

Surgical Management

Patients with COPD also have options for surgery to improve their condition.

  • Bullectomy. Bullectomy is a surgical option for select patients with bullous emphysema and can help reduce dyspnea and improve lung function.
  • Lung Volume Reduction Surgery. Lung volume reduction surgery is a palliative surgery in patients with homogenous disease or disease that is focused in one area and not widespread throughout the lungs.
  • Lung Transplantation. Lung transplantation is a viable option for definitive surgical treatment of end-stage emphysema.

Nursing Management

Management of patients with COPD should be incorporated with teaching and improving the respiratory status of the patient.

Nursing Assessment

Assessment of the respiratory system should be done rapidly yet accurately.

  • Assess patient’s exposure to risk factors.
  • Assess the patient’s past and present medical history.
  • Assess the signs and symptoms of COPD and their severity.
  • Assess the patient’s knowledge of the disease.
  • Assess the patient’s vital signs.
  • Assess breath sounds and pattern.

Diagnosis

Diagnosis of COPD would mainly depend on the assessment data gathered by the healthcare team members.

  • Impaired gas exchange due to chronic inhalation of toxins.
  • Ineffective airway clearance related to bronchoconstriction, increased mucus production, ineffective cough, and other complications.
  • Ineffective breathing pattern related to shortness of breath, mucus, bronchoconstriction, and airway irritants.
  • Self-care deficit related to fatigue.
  • Activity intolerance related to hypoxemia and ineffective breathing patterns.

Planning & Goals

Goals to achieve in patients with COPD include:

  • Improvement in gas exchange.
  • Achievement of airway clearance.
  • Improvement in breathing pattern.
  • Independence in self-care activities.
  • Improvement in activity intolerance.
  • Ventilation/oxygenation adequate to meet self-care needs.
  • Nutritional intake meeting caloric needs.
  • Infection treated/prevented.
  • Disease process/prognosis and therapeutic regimen understood.
  • Plan in place to meet needs after discharge.

Nursing Priorities

  1. Maintain airway patency.
  2. Assist with measures to facilitate gas exchange.
  3. Enhance nutritional intake.
  4. Prevent complications, slow progression of condition.
  5. Provide information about disease process/prognosis and treatment regimen.

Nursing Interventions

Patient and family teaching is an important nursing intervention to enhance self-management in patients with any chronic pulmonary disorder.

To achieve airway clearance:

  • The nurse must appropriately administer bronchodilators and corticosteroids and become alert for potential side effects.
  • Direct or controlled coughing. The nurse instructs the patient in direct or controlled coughing, which is more effective and reduces fatigue associated with undirected forceful coughing.

To improve breathing pattern:

  • Inspiratory muscle training. This may help improve the breathing pattern.
  • Diaphragmatic breathing. Diaphragmatic breathing reduces respiratory rate, increases alveolar ventilation, and sometimes helps expel as much air as possible during expiration.
  • Pursed lip breathing. Pursed lip breathing helps slow expiration, prevents collapse of small airways, and control the rate and depth of respiration.

To improve activity intolerance:

  • Manage daily activities. Daily activities must be paced throughout the day and support devices can be also used to decrease energy expenditure.
  • Exercise training. Exercise training can help strengthen muscles of the upper and lower extremities and improve exercise tolerance and endurance.
  • Walking aids. Use of walking aids may be recommended to improve activity levels and ambulation.

To monitor and manage potential complications:

  • Monitor cognitive changes. The nurse should monitor for cognitive changes such as personality and behavior changes and memory impairment.
  • Monitor pulse oximetry values. Pulse oximetry values are used to assess the patient’s need for oxygen and administer supplemental oxygen as prescribed.
  • Prevent infection. The nurse should encourage the patient to be immunized against influenza and S. pneumonia because the patient is prone to respiratory infection.

Evaluation

During evaluation, the effectiveness of the care plan would be measured if goals were achieved in the end and the patient:

  • Identifies the hazards of cigarette smoking.
  • Identifies resources for smoking cessation.
  • Enrolls in smoking cessation program.
  • Minimizes or eliminates exposures.
  • Verbalizes the need for fluids.
  • Is free of infection.
  • Practices breathing techniques.
  • Performs activities with less shortness of breath.

Discharge and Home Care Guidelines

It is important for the nurse to assess the knowledge of patient and family members about self-care and the therapeutic regimen.

  • Setting goals. If the COPD is mild, the objectives of the treatment are to increase exercise tolerance and prevent further loss of pulmonary function, while if COPD is severe, these objectives are to preserve current pulmonary function and relieve symptoms as much as possible.
  • Temperature control. The nurse should instruct the patient to avoid extremes of heat and cold because heat increases the temperature and thereby raising oxygen requirements and high altitudes increase hypoxemia.
  • Activity moderation. The patient should adapt a lifestyle of moderate activity and should avoid emotional disturbances and stressful situations that might trigger a coughing episode.
  • Breathing retraining. The home care nurse must provide the education and breathing retraining necessary to optimize the patient’s functional status.

Documentation Guidelines

Documentation is an essential part of the patient’s chart because the interventions and medications given and done are reflected on this part.

  • Document assessment findings including respiratory rate, character of breath sounds; frequency, amount and appearance of secretions laboratory findings and mentation level.
  • Document conditions that interfere with oxygen supply.
  • Document plan of care and specific interventions.
  • Document liters of supplemental oxygen.
  • Document client’s responses to treatment, teaching, and actions performed.
  • Document teaching plan.
  • Document modifications to plan of care.
  • Document attainment or progress towards goals.