Discuss nursing strategies to help prevent infection in immuno-compromised clients

Strategies to prevent infection discussed in seminar included:

• Patient teaching
• Calculation of Absolute Granulocyte Count
• Neutropenic precautions
• Assessments, including oral, lymph nodes
• Adequate nutrition
• Antibiotic therapy

Mary is preparing an inservice on "Panic Lab Values" for the staff on the medical/surgical unit. She decides to include the Absolute Granulocyte Count as one of the labs to review. Which of the following statements should be included

1. The AGC is calculated by totaling the differential count and multiplying by the red cell count.
2. If the lymphocyte count is 1000 the patient needs to avoid fresh fruits and vegetables.
3. A low AGC is the same as anemia.
4. The patient with an AGC less than 1000 needs to be placed on neutropenic precautions.

The correct answer is d, a client with an AGC less than 1000 would be at risk for developing an infection. Anemia is not the same thing. If the AGC is less than 1000, then the patient should avoid fresh fruits and vegetables. The white cell or lymphocyte count is only used for the calculation, which is the granulocytes count (basophils + esosinophil + neutrophil) multiplied by the white cell count divided by 100.

Regulation and Sensation: Non-endocrine (class)
Example 1
Objective
Apply the nursing process to care of the client with complex non-endocrine based alterations in regulation and sensation

Testing
Assessment of the client with non-endocrine based alterations of regulation and sensation

Nursing diagnoses

1. Sensory perceptual alterations
2. Altered thought processes
3. Powerlessness

Mary, a 22 year old college student with a complaint of severe headaches and fever, was admitted with a diagnosis of meningococal meningitis. Several weeks later during a home visit Mary expresses her frustrations about not returning to school because of her difficulty walking. Which of the following nursing diagnoses would be most appropriate for Mary?

1. Altered tissue perfusion: cerebral related to decreased metabolism
2. Impaired walking related to pain
3. Altered comfort related to inflammation of cerebral tissue
4. Powerlessness related to residual effects of disease

The correct answer is d, while she is having trouble walking, the focus needs to be on the big picture: her frustrations about not returning to school. A and c might have been the choice on admission, but the question relates to several weeks later. There is no indication Mary is having pain at this point.

Example 2
Objective
Describe current treatment modalities for the client with complex non-endocrine based alterations in regulation and sensation

Testing
Knowledge of and related nursing interventions for pharmacologic interventions including chemotherapy and seizure control

The nurse is caring for a patient receiving a vinca alkaloid. The patient complains that there is a burning sensation around the IV insertion site. Which action by the nurse has the highest priority?

1. Attempt to aspire any residual drug
2. Administer Regitine as antidote
3. Apply cool compress
4. Call the MD

All actions are part of treatment protocols for extravasation. The first action would be to a, attempt to aspirate any residual drug.

Example 3
Objective
Differentiate between normal and cancerous cell growth
Describe current treatment modalities for the oncologic client

Testing
Stages of neoplastic growth

1. Initiation
2. Latency
3. Progression
4. Invasion

Classifications of malignancies: staging
Treatment options
Radiation therapy

Mrs. Pool has been receiving internal radiation for uterine cancer. A new graduate asks the radiation nurse to explain any precautions needed. Which statement made by the radiation nurse is correct?

1. Limit visitors less than 7 years old to a daily 30-minute visit.
2. In the event the implant is found in the bed be sure to replace it using forceps.
3. Provide only necessary nursing care in spurts of 30 minute exposure
4. Stand within 3 feet of the bed when speaking to the patient.

It is important to limit exposure to 30-minutes at a time with minimal contact with the patient, making c the correct answer. You should stand at least 6 feet from the client. Any implant found should be placed in a lead container and the physician contacted. Children should not be allowed to visit a patient with an internal implant.

Bowel Elimination
Example 1
Question from seminar
What are the nursing responsibilities related to the diagnostic studies ordered for Mr. Black?

Content
Reflects objective 5; Nursing management of clients with alterations in bowel elimination

Testing
A question here might look at your knowledge of teaching to be done with this client. It could also ask you about any other step of the process. An evaluation question would be appropriate.

Sample Test Questions
Example

Mr. J tells you he had a lower GI study done last year. Which of the following statements made by Mr. J indicates the need for more teaching?

1. Do I have to drink that disgusting white stuff?
2. I hated the way I had to move around with all that stuff in me.
3. Do I need enemas again?
4. I shouldn't eat for a few hours after the test, right?

D is the correct answer. The patient should not eat for 8-12 hours before the test. A, b, and c all contain correct information. The question could have asked which statement indicates the client understood your teaching and accomplished the same evaluation.

Example
A question could ask about your assessment abilities. Such as:

Mr. J had a Barium enema yesterday. Which of the following statements made by your client warrants physician contact?

1. I finally went to the bathroom.
2. I feel all bloated.
3. I had a soft bowel movement.
4. I feel warm since the test.

All 4 statements provide a minimum of information. A and c are essentially the same, and hopefully should happen. D may or may not warrant contact - maybe it is hot outside. B is the correct answer - bloating is a symptom of possible bowel perforation.

Example 2
Question from seminar
What is the rationale for requiring daily TPN orders, a nutritional consult, and regular laboratory studies while Mr. Black is receiving TPN?

Content
Medical treatment and associated nursing care

Testing
Since the focus here is on nursing, I might want to know if you know the consequence of your actions. This would be synthesis type question, looking at interventions/implementation. For example

Mr. D has been receiving TPN. His last bag is complete and the physician did not write any new orders. The nurse decides to stop the IV until the physician arrives. Which if the following may occur as a result of this action?

1. The client's output increases to 120ml/h
2. There is a weight gain of 3 pounds noted on today's weight sheet.
3. The lab report shows a glucose level of 60.
4. The client tells you he would like to eat.

C is the correct answer since the body adjusts to elevated glucose level by producing more insulin, therefore must be weaned off TPN or will develop rebound hypoglycemia. A is an elevated output and should be monitored, but is not a result of the nurse's action. B and d may be true, but are also not related to the action of the nurse.

Example 3
Question from Seminar
Complete a care plan using 3 nursing diagnoses that you feel have the highest priority. Include rationale for your choices.

Content
Nursing process

Testing
Questions evaluating your ability to care plan would reflect any step of the nursing process. Remembering the fact that goals reflect the diagnosis and interventions the related to, can you identify interventions or goals. Can you select a diagnosis based on the data provided?

Mr. K presents with the following data ... Which of these nursing diagnoses are appropriate?

1. Ineffective individual coping r/t fear
2. Powerlessness r/t fear
3. Knowledge deficit r/t Cancer
4. Altered nutrition < body requirements r/t anorexia

The correct answer could be any of them except c depending on the data provided. C would definitely be wrong since it is in the wrong format.

Example 4
Question from seminar
What are the discharge planning needs of Mr. Black?

Content
Nursing care of client being discharged

Testing
Can you pick up on cues from the client? For example:

Sample Test Question

Mr. Black recently had a colostomy. Which of the following statements made by Mr. B indicates the need for further teaching?

1. My wife and I have a pretty active sex life. What's going to happen now?
2. I can return to work once I'm feeling up to it.
3. I can't wait to get outside and play a round of golf with my son.
4. It's such a shame I can no longer eat cabbage - it was one of my favorite vegetables.

B and c indicate positive attitude and are incorrect choices. D is true because he wants to avoid gas-producing foods. That leaves a as the correct answer. He needs to realize that a colostomy does not mean you cannot have sex.

Circulatory Disorders
Example 1
Objective
Apply the nursing process to care of the client with complex alterations in circulation
For example: Assessment of clients with alteration in circulation

Testing
Nursing diagnoses questions would evaluate your understanding of the following:

1. Decreased cardiac output
2. Altered tissue perfusion: cardiac
3. Health seeking behaviors

Miss Rhyme is admitted following a diagnosis of congestive heart failure. She tells you she is unable to wash herself without assistance because of shortness of breath. You notice she also has difficulty walking to the bathroom unassisted for the same reason. Which of the following nursing diagnoses is most appropriate?

1. Decreased cardiac output related to side effects of medications
2. Activity Intolerance related to decreased oxygenation
3. Altered tissue perfusion related to impaired gas exchange
4. Self-care deficit related to congestive heart failure

The correct choice would be b based on the limited data. The patient is unable to perform routine ADL without shortness of breath. D is not correct because you cannot intervene in the congestive heart failure, a medical diagnosis. The stem does not say anything about the patient's medications and c uses a related to that is simply a repetition of the problem.

Example 2
Objective
Discuss the implications of diagnostic study finding associated with complex alterations in circulation

Testing
For example: related to diagnostic imaging, I may ask about positioning, or client sensations, prep or post-test assessments on cardiac catheterization. Similar to questions noted in seminar sections.

Mr. Brown is admitted to the hospital following complaints of chest pain. His enzymes and Echocardiogram are indicative for a possible myocardial infarction, but are inconclusive. The physician decides to perform a cardiac catheterization to determine the exact extent of the damage. The nurse has completed the recommended patient teaching pre-procedure. Which statement made by the patient indicates an understanding of the procedure?

1. "I'll be able to return to the gym and my weight lifting regimen by the end of the week."
2. "I need to lie still after the procedure."
3. "I need to tell the nurse if I feel bloated."
4. "It is normal to feel a cool rush in my groin during the procedure."

B is the correct answer, based on the need for the patient to lie still during the and after the procedure. Patients are usually limited on weight-lifting until after follow-up appointment with the physician. Bloating does not indicate a problem with a cardiac catheterization. It is common for patients to feel a warm flow throughout the body following administration of the dye.

Example 3
Objective
Interpret cardiac rhythm strips for first, second and third degree blocks

Testing
Other questions may ask about EKG interpretation. You are responsible for knowing the following:

1. 1° block
2. 2° block
3. 3° block
4. Pacer

Which of the following EKG interpretations would be indicative of a third degree heart block?

1. Prolonged PR interval
2. Consistent P wave and QRS rhythm, but are not related to each other
3. Every P wave is preceded by a straight line
4. PR interval = 0.08; QRS = 0.16

Prolonged PR interval is indicative of 1^st or 2^nd degree blocks, pacer spikes occur with pacemakers only. D is indicative of a normal EKG. B is the correct choice.

Example 4
Objective
Describe the anticipated medical treatment, with rationale, of clients with complex alterations in circulation

Testing
Questions about nursing interventions will look at your knowledge of fibrinolytics and blood transfusions, including reactions.

Mrs. Dale is started on Retivase for thrombolytic therapy following a diagnosis of Pulmonary Embolism. Which intervention by the nurse is most appropriate?

1. Hemetest vomitus.
2. Monitor I & O
3. Assess IV catheter for thrombosis
4. Contact MD with results of PT/INR

The correct choice would be A based on the need to monitor the patient for any possible bleeding. I&O and monitoring a patient, not the catheter, for thrombosis may be appropriate, but are not specific for thrombolytic therapy. PT/INR is not used for monitoring Retivase therapy.

Example 5
Objective
Describe the nursing management of a client undergoing cardiac surgery

Testing
Questions will look at understanding and related nursing interventions for the following:

1. Pacemakers
1. temporary
2. permanent
2. Percutaneous transluminal coronary angioplasty (PTCA)
3. Coronary artery by-pass graft (CABG)
4. Femoral-popliteal bypass

Which of the following nursing assessments would be recommended for the patient following a CABG?

1. Clean wound daily with antibiotic ointment
2. Assess peripheral pulses q shift
3. Instruct patient to call for any chest pain
4. Monitor patient activity for 48 hours

Only b and d are assessments. While the patient's activity may be restricted, it is not an assessment of all CABG patients, leaving b as the correct answer. The presence of peripheral pulses indicates adequate circulation.

Renal
Objective
Discuss the effects of pharmacologic intervention

Testing
Drugs identified in class and seminar, pharmacological action, adverse effects, nursing interventions

• Antibiotics
• Chemotherapy: Thiotepa, Actinomycin-D
• Corticosteroids
• Diuretics
• Mannitol

Dr. Brown orders a fluid challenge for Mrs. Jones, an 85-year-old patient with renal failure. Mrs. Jones asks you why she is getting all this medicine in her IV. You tell her

1. The doctor ordered it
2. The medicine will help her kidneys begin to work
3. Not to worry, it will make her urinate a lot
4. To let you know if she develops a headache

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