FPCC - Exam 3 with 100% correct answers 2024-2025 Graded A+, Exams of Nursing

Download FPCC - Exam 3 with 100% correct answers 2024-2025 Graded A+ and more Exams Nursing in PDF only on Docsity! 1 transdermal, intradermal, subQ, into joints - answer-4 routes that local and topical anesthesias can be administered through change in heart rate, burning, itching, rash, decreased sensation - answer-5 side effects/precautions for local/topical anesthesia massage, TENS, heat and cold, acupuncture - answer-4 types of cutaneous stimulation that are non- pharmacological interventions use a pain scale, reassess signs and symptoms of pain, vital signs, evaluate pain impact on physical and social function, evaluate family/friend's observations of patient pain, ASK how much or if pain prevents from ADLs - answer-6 ways to evaluate pain management cutaneous - answer-this is superficial pain, arising from subQ tissue or skin (ex. paper cut, hot to touch) 2 visceral - answer-this pain is caused by the stimulation of deep, internal pain receptors. Can be described as a tight pressure or cramping (ex. menstrual cramps, bowel disorders, labor pain, organ cancer) deep somatic - answer-this pain originates in ligaments, tendons, nerves, blood vessels, and bones. Localized and described as achy or tender. (ex. fracture, sprain, arthritis, bone cancer) psychogenic - answer-this pain is believed to originate from the mind; patient perceives pain despite no physical cause that can be identified. visceral, somatic - answer-two types of nociceptive pain are and . neuropathic - answer-type of pain that is a complex and often chronic pain that arises when injury to one or more nerves results in repeated transmission of pain signals even in the absence of stimuli. 5 2 nurses - answer-who does PCA have to be checked by before giving? increases circulation, lowers BP, improves venous return, healthy heart rate at resting level - answer-4 cardiovascular benefits of mobility RR comes to healthy rate faster, better oxygenation, helps diaphragmatic breathing - answer-3 pulmonary benefits of mobility hypostatic pneumonia - answer-this is when infection occurs from pooling secretions (seen with immobility) tracheal deviation and unilateral chest expansion - answer-2 things you may see if patient experiences atelectasis due to a mucous plug or secretion block. (no ventilation) 6 parathyroid - answer-With immobility, gland issues are common due to hypercalcemia and there's an increased release of Ca from bones. footdrop - answer-joint contracture of immobility when the foot permanently drops into plantar flexion UTI - answer-during immobility, urine can pool in the pelvis when laying down and increases the risk for developing kidney stones - answer-another name for renal calculi is disease (disorders and injuries), environment (workplace, school, community, family support), medical therapies (bed rest, splints/casts, restraints) - answer-3 categories to assess when assessing someone's mobility/immobility. sprain - answer-this is a torn ligament 7 low, wide - answer-you want a patient with a center of gravity and a base of support flexibility, aerobic, resistance - answer-3 types of exercise to encourage to your patients 1-1.5 - answer-daily protein intake should be - g/kg of body weight a day. high protein, high calorie, vitamins B and C - answer-3 dietary implementations to encourage in an immobile patient to aid METABOLIC function chest physiotherapy, HOB up, hydrate (2500mL/day) - answer-3 respiratory implementations to encourage in an immobile patient monitor color and amount of urine, acidify urine (cranberry juice), maintain positive fluid balance, assist 10 antibiotic therapy, chemo, parenteral nutrition - answer-3 common uses for a PICC central line. sutured - answer-a non-tunneled catheter for central IV therapy is directly into the jugular, femoral, or subclavian and is into place. measuring central venous pressure (to assess blood volume) - answer-a NON-tunneled catheter is most common for infection, catheter or air embolus, bleeding, circulatory fluid overload - answer-4 things to monitor for (possible complications) with IV therapy Abductor pillow - answer-edge shaped pillow between the patient's legs, *used to prevent internal hip rotation and hip abduction* Used after femoral fracture, hip fracture, or surgery. 11 Two point crutch gait - answer-*partial weight bearing*, use both feet. This is faster, but offers less support than the four point. The foot opposite of the crutch goes forward, so advance left foot along with right crutch, then right foot along with left crutch simultaneously. Three point crutch gait - answer-*non-weight bearing*. Faster than a four-point gait. Can use with walker. Injured leg must be kept off the ground. Advance crutches, then advance good leg. Four point crutch gait - answer-*Partial weight bearing*, use both feet. Patient must shift weight constantly. *Offers the most support, but is also the slowest.* 12 Patient will advance the right crutch, then advance the left foot. Then advance the left crutch, then advance the right foot. This is not done simultaneously. Logrolling - answer-special turning technique used when the pt's spine must be kept in straight alignment You will need at least two nurses for this procedure, more if the patient is large. Logrolling moves the patient's body as a unit. One nurse is positioned at the level of the patient's head. The other staff members are distributed along the length of the patient. Everyone must move the patient in unison. Trapeze bar - answer-Triangular- shaped device that is attached to an overhead bed frame. The patient can use the base of the triangle as a grip bar to move up in bed, turn, and pull up in preparation for getting out of bed or getting on & off the bed pan. Trochanter rolls - answer-made from tightly rolled towels, bath blankets, or foam pads. They are placed 15 Passive range of motion (PROM) - answer-movements of the joints through their range of motion *by another person* -support above & below the joint -take joint to point where pt starts to feel resistance -avoid pain. if pt feels pain, stop -slow & gentle movements -pts can perform by themselves. pt should be taught to promote independence/control Continuous passive motion (CPM) - answer-*device that repetitively but gently flexes & extends the knee joint* the CPM machine is often used after knee replacement or other knee procedures to allow the joint to improve range of motion, eliminate problem of stiffness, & prevent development of adhesions which can limit motion further. 16 Both AROM & PROM improve - answer-joint mobility, increase circulation to the area exercised, & help maintain function. AROM also improves respiratory & cardiac function Fowler's position - answer-semi sitting position, head of the bed is elevated 45-60 degrees Fowler's position promotes & increases - answer-Promotes *respiratory function* by lowering the diaphragm allowing the best chest expansion. ideal for some patients with cardiac problems. Semi-fowler's position - answer-head of the bed is at *30 degrees.* High-fowler's position - answer-head of the bed is at *90 degrees.* 17 Orthopneic position - answer-Head of the bed is at *90 degrees, and an over bed table with a pillow on top is positioned in front of the patient* -Have patient lean forward while resting his arms and head on the pillow. -*This helps patients who are short of breath.* Lateral position - answer-side-lying position with the top hip and knee *flexed* and placed in front of the rest of the body. Creates pressure on the lower scapula, ilium, and trochanter but relieves pressure from the heals and sacrum. Lateral recumbent position - answer-side-lying with legs in a *straight* line 20 -Patient lies on his/her back with head and shoulders elevated on a small pillow. The spine is aligned and the arms & hands rest comfortably at the side Technique for moving patients (3) - answer-1. Use a friction reducing device to move the patient if the patient can assist with movement. Use a full body swing if patient cannot assist. 2. Remove the pillow, have patient flex his/her neck, fold her arms across the chest, & place feet flat on the bed. 3. Have a nurse on each side of the bed and on the count of three, have him/her push off with their heels as the nurses shift the weight forward. Technique for turning the patient (3) - answer-1. Use a friction-reducing device and draw sheet to move the patient. 21 2. Position a nurse on each side of the bed, and place the patients arm & leg to the side you are going to roll them towards. 3. One nurse places hands on the patient's shoulders while the other places on the patients hips. Each nurse will roll the patient in the intended direction. Technique for transferring the patient: *bed to stretcher* (6) - answer-1. Move the patient to the side of the bed where the stretcher will be placed 2. Position stretcher next to bed & lock it in place. 3. Keep the stretcher situated a little lower than the surface the patient is on. 4. Place a draw sheet under the patient (see turning the patient, while turning the patient you put the draw sheet under him/her) 5. Place the transfer board against the patients back halfway between the bed and the stretcher. Position a friction-reducing device over the transfer board. Turn 22 the patient to his back and onto the transfer board with draw sheet. 6. On a count of three, use the draw sheet to slide the patient across the transfer board onto the stretcher Technique for transferring the patient: *bed to chair* (9) - answer-1. Place *nonskid footwear* on the patient. 2. Place the bed *low & locked* with the *head of the bed up.* 3. Assist the patient to *dangle* at the bedside 4. Brace your feet & knees against the patient, bend your hips at the knees, and hold onto the transfer belt. 5. If there are two nurses, have one on each side of the patient. 6. Instruct the patient to place their arms around you between your shoulders and waist. Ask the patient to stand as you move to an upright position by straightening your legs & hips. 7. Instruct the patient to pivot & turn with you toward the chair. 25 It should fit at the *top of the hip with a 30-degree angle flexion* Walkers - answer-*should be at hip level, with 30 degrees of flexion.* -Make sure patient stands *within the walker, not behind it* so when the walker goes forward they are not leaning far forward & the center of gravity isn't shifting too far forward causing the patient to fall. -the walker should ideally be lifted & not scooted, lifted then stepped into. -Tennis balls/wheels on walkers have the advantage of decreasing friction & work but the disadvantage is an increase in fall risk. Braces support - answer-joints and muscles that cannot independently support the body's weight. -Most commonly used in lower extremities. 26 nursing responsibilities: assisting the patient into and out of the brace and monitoring the condition of the skin under the brace Crutches - answer--The crutch should not hit the axilla, *it should be three finger widths below the axilla* -The hand grip must be at a position that there is enough flexion there that you can push a little bit with it. -If you have to teach a client to go up stairs or up a curb, they must go up with the uninjured leg, then they bring the crutch & injured extremity. When you go down, go down with the crutch & injured leg first. *Up with the good & down with the bad.* -When leaning on the crutch, they are at risk for damaging their nerves & cutting off their circulation in their arms. Restraints are a resort - answer-LAST 27 Use restraints to - answer-1. reduce fall risk 2. prevent interruption of therapy 3. maintain life support 4. reduce risk to others DO NOT use restraints just because it's easier for the nurse. 2 types of restraints - answer-1. physical 2. chemical Physical restraints - answer-ANY manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. Chemical restraints - answer-medications that are used to restraint (sedates or calms anxiety) 30 What is the most commonly used restraint? - answer- rails. Forms of restraints - answer-1. limb- goes around wrist or ankle 2. mitten- a patient who is trying to escape from soft wrist restraints; person who is scratching a lot 3. belt- allows patient to turn while being restrained 4. vest Measures to prevent injury & risk of complications in clients who are restrained - answer-Assess for: 1. pressure ulcers 2. pneumonia 3. constipation 4. emotional harm 31 How many fingers should you be able to get under a restraint? - answer-1-2 fingers to keep it from restricting circulation Documentation for a restrained client - answer-1. all nursing interventions that were done to eliminate the need for restraints 2. reason for placing the restraint 3. the initial restraint placement, location, circulation, & skin integrity 4. the teaching session with the patient & family members 5. circulation checks, & restraint removal per agency protocol. 6. entries on fall risk assessment sheet, restraint flowsheet, and nursing notes according to agency policy Culture & sensory function - answer-people of different cultural backgrounds tend to prefer differing amounts of eye contact, personal space, & physical touch 32 Illness & sensory function - answer-1. neurological disorders such as MS slow the transmission of nerve impulses 2. diseases that affect circulation may impair function of the sensory receptors and the brain, altering perception & response. 3. reduced or lack of oxygen harms & even destroys cells, causing widespread damage to the neurological system Medications & sensory function - answer-medications that cross the blood brain barrier affect neurologic or sensory function by damaging or killing brain cells Stress & sensory function - answer-stress can cause too much stimulation. stressors may lead to stimulation overload-- more stimuli than the person can handle Personality/lifestyle & sensory function - answer-clients are at risk for sensory alterations if their previous level of stimuli does not match their current level 35 2. communicate when you leave 3. stay in visual field 4. provide large print or magnifier to read 5. use audio tools to teach 6. light up the room well & eliminate clutter 7. assist with ambulation 8. identify locations. verbally confirm to the client where things are 9. keep bed in low position Vision health promotion - answer-1. encourage pt to start getting vision screenings around 40 & every 3-5 years after that 2. check pressures in eye/intraocular pressure to screen for glaucoma 3. screen pregnant patients for any history that can cause problems like loss of vision during pregnancy & delivery 4. teach pt to wear goggles if landscape worker 5. teach pt to wear sunglasses 36 6. sports equipment- make sure kids wear protective gear Presbycusis - answer-progressive sensorineural loss associated with aging. It results from deterioration of the hair cells in the cochlea. leads to diminished ability to hear high-pitched sounds and to distinguish sounds in a noisy environment. Tinnitus - answer-ringing in the ears Impacted cerumen - answer-condition in which earwax becomes tightly packed in the ear canal, blocking the canal. Congenital hearing deficit - answer-patient is born with it Illness/trauma causing hearing deficit - answer-trauma to ear or tympanic membrane can cause hearing loss. 37 ask the patient about medications (aspirin causes tinnitus, lasix causes hearing loss, aminoglycosides are ototoxic) Auditory assessment - answer-1. age- 30 year olds see hearing loss 2. medical history- frequent ear infections or any trauma 3. environment- ask client about noise exposure 4. assistive devices- hearing aids 5. ability to perform self care- can they do this safely? 6. patient behaviors that show they do not hear well 7. perform the whisper test 8. perform audiometry (hearing testing) Auditory deficit implementations - answer-1. use written tools 2. legally you have to have an interpreter when someone does not speak the same language. for deficits, you will use someone who knows sign language 40 Amnosia - answer-sense of smell is lost Olfactory deficits - answer-1. age 50 you lose the sense of smell 2. medical history- brain trauma, zinc deficiency, smoking 3. identify odors- have patient close eyes & see if they can correctly identify smells Olfactory deficit implementations - answer-1. assess nutritional status 2. have gas appliances regularly inspected & maintained to prevent gas leaks 3. check smoke detectors & replace batteries regularly 4. promote food safety by teaching them to read labels for expiration dates Tactile deficits - answer-inability to feel. -can be caused by a cerebrovascular accident (stroke), brain or spinal tumor or injury, or peripheral nerve 41 damage caused by diabetes, guillain-barre syndrome, or chronic alcoholism -ask patient if they have any numbness or tingling -observe function. frequently dropping things, lack of coordination in fine motor activities For tactile deficits, test - answer-Two point discrimination- the ability to perceive as 2 close but separate points pressed against the skin Stereognosis - answer-when you can identify what you are touching by the shape Tactile deficit implementations - answer-1. teach visual assessment 2. use bath thermometer to monitor water temp. & prevent burns 3. change position frequently to relieve pressure on bony prominences 42 4. use properly fitting shoes & socks 5. immediately report any signs of circulatory impairment 6. inspect daily for open areas, cuts, abrasions, or areas of redness. Speech deficit/aphasia - answer-aphasia- patient has difficulty with words medical history- strokes, head injuries Expressive aphasia - answer-patient can understand, but can't produce words to speak Receptive aphasia - answer-patient can't understand the language Global aphasia - answer-patient can't understand language or produce words 45 Sensory overload - answer-environmental or internal stimuli or combination of both exceed a higher level than the patient's sensory system can effectively process Causes of sensory overload - answer-1. hospitalized pts- combination of physical discomfort, anxiety, separation from loved ones, & being in an unfamiliar hospital environment 2. medications that stimulate the CNS 3. mental health conditions are exacerbated by high intensity noise & light in the environment Sensory overload CMs - answer-1. fatigue & sleeplessness 2. irritability or anxiety 3. reduced ability to problem-solve 4. scattered attention, racing thoughts 5. disorientation 6. delirium 7. dementia 46 8. confusion Delirium - answer-acute, reversible state of confusion caused by medications & a variety of physiological processes. Dementia - answer-chronic & progressive deterioration in mental function caused by physical changes in the brain & is not associated with changing levels of consciousness Sensory overload nursing interventions - answer-1. provide orientation 2. communicate simply 3. minimize environmental stimuli 4. consider limiting visitors 5. pain management 6. encourage rest/sleep 7. use stress-reducing techniques 47 Seizure assessment - answer-1. assess the cause: do they have history of seizures, brain tumor, head injury? what meds are they on? what is their blood sugar? 2. history- find out when it started & how long its lasting. What to do while patient is having a seizure - answer-1. airway can be blocked by secretions or tongue. never put anything in their mouth. set up suction 2. position pt on side in case they vomit 3. client may need oxygen during & after seizure 4. call for help. if pt is at risk for falling, help them to a safe place. 5. protect pt from injury (hitting head) 6. pad bed 7. bed low & locked, side rails up 8. provide privacy- pt may have been incontinent 9. administer meds 10. check glucometer and for injuries from the fall 11. watch for adequate breathing. pt may have amnesia 50 may occur as result of trauma, surgery, or inflammation. 2 types of nociceptive pain - answer-1. visceral pain (pain originating from internal organs) 2. somatic pain (pain originating from skin, muscles, bones, connective tissue) Neuropathic pain - answer-complex and often chronic pain that arises when injury to one or more nerves results in repeated transmission of pain signals even in the absence of painful stimuli. Acute vs. chronic pain - answer-1. acute- short duration, generally rapid in onset 2. chronic- pain that has lasted 6 months or longer and often interferes with daily activities. Words patients use to describe pain - answer-sharp or dull, aching, throbbing, stabbing, burning, ripping, searing, or tingling 51 What is the 5th vital sign? - answer-pain scale. pain is whatever the patient says it is & exists when the patient says it exists. PQRST - answer-P- provokes the pain, palliates the pain (makes it better), pattern Q- quality R- radiation, referred pain S- severity, pain scale. assess before & after every intervention T- timing, onset, duration Factors that influence pain - answer-emotions: 1. fear- if fears remain unresolved, a pts pain can be prolonged or increase 2. confusion & helplessness 3. anxiety & depression- anxiety is most often associated with acute pain, but the anticipation of pain 52 may also trigger anxiety. Depression is most often linked with chronic pain. 4. previous pain experience- patients who have had numerous painful experiences are more anxious about the prospect of experiencing pain & are more sensitive to pain. 5. sociocultural- some cultures expect not to express pain. When to assess pain - answer-1. on admission 2. before & after each potentially painful procedure or treatment 3. when the pt is at rest, as well as when involved in a nursing activity 4. before you implement a pain management intervention, and 30 minutes after the intervention 5. with each check of vital signs, if the pain is an actual or potential problem 6. when the patient complains of pain 55 Nonpharmacological cutaneous stimulation: TENS units - answer-transcutaneous electrical nerve stimulator -worn externally -consist of electrode pads, connecting wire, & stimulator. -pads are applied directly to painful area. once activated, the unit stimulates A-delta sensory fibers Nonpharmacological cutaneous stimulation: acupuncture - answer-application of extremely fine needles to specific sites in the body to relieve pain Nonpharmacological cutaneous stimulation: acupressure - answer-stimulates specific sites in body. instead of needles, fingertips provide firm, gentle pressure over the various pressure points. provides a calming effect through release of endorphins 56 Other cutaneous stimulation - answer-1. massage 2. application of heat & cold 3. contralateral stimulation- stimulating the skin in area opposite to the painful site. Cutaneous stimulation works best on pain that is - answer-localized and not diffuse Distraction for pain - answer-1. visual tactics such as watching TV 2. auditory such as music 3. tactile such as massage, holding a pet, hugging a loved one 4. intellectual such as crossword puzzles or a challenging game Progressive relaxation - answer-the person sits comfortably & tenses a group of muscles for 15 seconds and then relaxes the muscle while breathing out. 57 Guided imagery - answer-uses auditory and imaginary processes to affect emotions and help calm, divert, and relax Diaphragmatic breathing - answer-effective measure to invoke relaxation and improve tissue oxygenation for pain management. goal is to train patients to intentionally take slow, even breaths using the diaphragm to inhale & exhale at the same rate for 5 to 8 breaths per minute. Analgesics - answer-classified into 3 groups: nonopioids, opioids, & adjuvants Choice of treatment is based on of pain the patient is experiencing - answer-the level Pain levels & analgesics administered - answer-1. pain persisting or increasing- nonopioid & adjuvant 2. pain persisting or increasing- opioid for mild to moderate pain, nonopioid, & adjuvant 60 2. NV- reduce opioid dose by combing nonopioid or adjuvant drugs. premedicate or medicate with antiemetic 3. pruritus- reduce dose by combining. use cool packs, lotion, or topical anesthetics. administer antihistamines. 4. respiratory depression- assess resp. status before administering & frequently afterward. reduce dose by 25% when you observe signs of oversedation. if pt is nonresponsive, stop the opioid and administer an antagonist. 5. drowsiness- teach pt drowsiness will subside. during daytime, offer stimulants such as caffeine. offer a lower dose more frequently Patient controlled analgesia (PCA) - answer-PCA pumps are an effective & safe way to deliver opioids. they provide excellent pain relief & give pt a sense of control. most PCA pumps can be programmed with 1 or 4 hour maximum lockout interval to prevent overdosing. if the 61 pt reaches the set limit, the pump will trigger a "lockout" even if the pt keeps pressing the button PCA by proxy - answer-someone other than the patient presses the button to inject a dose of pain medication into the patient When you begin the PCA infusion, you will have another check dosage calculations & confirm the settings on the pump - answer-nurse Chemical pain relief measures: types of regional anesthesia - answer-nerve blocks & epidural injection anesthetic agent is injected into or around the nerve that supplies sensation to a specific part of the body Nerve blocks may be used for - answer-short term pain relief after surgical procedures or long term management of chronic pain 62 Local anesthesia - answer-injection of local anesthetics into body tissues. lidocaine or marcaine may be used. local anesthetics are injected into subcutaneous tissue for minor surgical procedures. they may also be injected into joints & muscles for pain relief Topical anesthesia - answer-involves applying an agent that contains cocaine, lidocaine, or benzocaine directly to the skin, mucous membranes, wounds or burns. it is quickly absorbed & provides pain relief for mild to moderate pain Addiction - answer-state of psychological dependence in which a person uses a drug compulsively & will engage in self-destructive behavior to obtain the drug 65 carbon dioxide ("acid") *signals respiratory causes* Normal HCO3 (bicarb) - answer-21-28 mEq/L sodium bicarbonate ("base") *signals metabolic cause* Normal PaO2 (arterial) - answer-80-100 mmHg Normal SaO2 saturation - answer->95% Acidosis - answer-occurs when the serum pH is below 7.35 Alkalosis - answer-occurs when the serum pH increases above 7.45 Respiratory acidosis - answer-may be caused by conditions or medications that impair gas exchange at the alveolar-capillary membrane, depressed respiratory 66 rate and depth, or injury to the respiratory center in the brain. *pH down, PaCO2 up, HCO3 normal* Respiratory acidosis acute CM - answer-1. increased pulse & RR 2. headache, dizziness 3. confusion, decreased LOC 4. muscle twitching Respiratory acidosis chronic CM - answer-1. weakness 2. headache Respiratory acidosis interventions - answer-1. provide pulmonary hygiene 2. institute measures to improve gas exchange, such as chest physiotherapy, bronchodilators, antibiotics possible. 3. provide supplemental oxygen 67 4. maintain hydration Respiratory alkalosis - answer-may be caused by hyperventilation resulting from anxiety, fever, sepsis, thyrotoxicosis, lesion in the respiratory center in the brain, or excessive ventilation with a mechanical ventilator *pH up, PaCO2 down, HCO3 normal* Respiratory alkalosis CM - answer-1. confusion, difficulty focusing 2. headache 3. tingling 4. palpitations 5. tremors Respiratory alkalosis interventions - answer-1. if caused by anxiety, encourage the pt to relax & breathe slowly 2. for other causes: identify & treat the underlying disorder. 70 2. treatment often includes administration of NaCl-rich fluids. Stroke volume - answer-Volume of blood pumped from the left ventricle per beat Cardiac output - answer-total quantity of blood pumped per minute. cardiac output= stroke volume x pulse rate Normal cardiac output - answer-4.6 LPM at rest Factors that influence the pulse rate - answer-1. developmental level- newborns have a rapid pulse rate. the rate stabilizes in childhood & gradually slows through old age 2. gender- adult woman have a slightly more rapid pulse 3. exercise 4. food- ingestion of food causes a slight increase 71 5. stress- pulse rate & stroke volume increases 6. fever- pulse increase about 10 bpm for each degree of temp elevation 7. disease 8. blood loss 9. position changes- standing & sitting cause a temporary increase in pulse rate 10. medications Nutrition & cardiac health - answer-a diet high in saturated fat predisposes to the development of atherosclerosis, coronary artery disease & HTN all of which can compromise circulation & oxygenation. a low fat, low cholesterol, low sodium diet is considered heart healthy. vitamins & minerals & proteins are important to prevent anemia, which reduces blood oxygen carrying compacity Obesity & cardiac health - answer-obesity increases the risk of developing atherosclerosis & HTN. excess fat 72 stores in & around the heart itself reduce its effectiveness as a pump. the workload of the heart is increased by the need to perfuse the excess body tissues Exercise & cardiac health - answer-exercise improves blood circulation & delivery of oxygen to tissues & cells. it also increases metabolic demands. the body responds by increasing the heart rate & rate & depth of breathing. Tobacco use/substance abuse & cardiac health - answer-tobacco use is a major risk factor in several chronic CV conditions. Alcohol abuse causes fatty infiltration of the heart muscle, thrombi in the coronary arteries, heart enlargement & dysrhythmias Levels of prevention - answer-1. primary prevention- activities are designed to prevent or slow onset of disease. ex: eating healthy, exercising 75 P wave - answer-represents the firing of the SA node & conduction of the impulse through the atria. in the healthy heart, this leads to atrial contraction. QRS complex - answer-represents ventricular depolarization & leads to ventricular contraction T wave - answer-represents the return of the ventricles to an electrical resting state so they can be stimulated again (ventricular repolarization). U wave - answer-not always seen on the ECG, but may be detected with an electrolyte imbalance such as hypokalemia or hypercalcemia. U waves sometimes occur in response to certain meds Inverted U wave may occur with ischemia to the cardiac muscle 76 Normal sinus rhythm - answer-60-100, regular rhythm Tachydysrhythmias - answer-rates >100 beats/min Bradydysrhythmias - answer-rates <60 beats/min Ectopy - answer-extra beats Supraventricular - answer-above the ventricles Junctional - answer-within the AV node Ventricular - answer-in the ventricles All dysrhythmias have the potential to cardiac output - answer-decrease Cardiac diagnostic testing - answer-labs- lipid profile, carry fats in blood stream; LDL- low density, bad cholesterol. 77 elevated cholesterol is highly associated with CV problems. *want cholesterol to be less than 200 mg/dL* 3 lab values that indicate cardiac muscle damage - answer-1. troponin- very specific to cardiac damage. low troponin indicate there has been a blockage in the muscle that is releasing this protein. will go up if pt is having a heart attack. 2. creatinine kinase (CK)- CKMB levels will rise with heart damage. 3. myoglobin- protein released from heart muscles when there is damage. Cardiac screening - answer-1. CXR- basic chest xray tells us the silhouette/outline of heart 2. cardiac monitoring- noninvasive. 3. 12 lead EKG 4. hoitor monitor- a long term rhythm strip we use in hope to catch a change intermittently 80 IV therapy - answer-administration of fluids, electrolytes, medications, or nutrients by the venous route. IV fluids are used to: - answer-1. expand intravascular volume 2. correct an underlying imbalance in fluids or electrolytes 3. compensate for an ongoing problem that is affecting either fluid or electrolytes Isotonic fluids remain in the - answer- intravascular compartment Hypotonic fluids pull body water of the intravascular compartment - answer-out Hypertonic fluids pull body water the intravascular compartment - answer-into 81 Isotonic fluids - answer-normal blood serum osmolality is 275-295 mOsm/kg. Isotonic solutions have similar tonicity (250 to 375 mOsm/L). Therefore when infused, *they remain inside the blood vessels.* Isotonic fluids are useful for clients with - answer-hypotension or hypovolemia Commonly prescribed isotonic solutions - answer-1. 0.9% sodium chloride (0.9% NaCl) also called normal saline 2. Lactated ringers (LR) Isotonic fluid precautions - answer-Clients who have congestive heart failure must be closely monitored when they receive isotonic fluid replacement, bc they may easily develop fluid overload 82 Hypotonic fluids - answer-the osmolality of a hypotonic solution is less than that of serum (less than 250 mOsm/L) therefore when infused, these solutions *pull body water from the intravascular compartment into the interstitial fluid compartment*. Expand volume & rehydrate cells Hypotonic fluid is used for: - answer-hyperglycemic conditions, such as diabetic ketoacidosis, in which high serum glucose draws fluids out of the cells and into the vascular & interstitial compartments Examples of hypotonic fluids - answer-1. 5% dextrose in water (d5w) 2. 0.45% NaCl (1/2 normal saline) 3. 0.33% NaCl 4. 0.2% NaCl 85 Butterfly needle is commonly used for - answer- intermittent or short term therapy for children & infants for single dose medications & drawing blood Butterfly needle disadvantages - answer-bc the inflexible metal needle remains in the vein, a butterfly needle is more likely to infiltrate (damage the vein & allow fluid to leak into the interstitial spaces) than a flexible plastic catheter. Midline peripheral catheter - answer-a peripherally inserted flexible IV catheter typically inserted into the antecubital fossa & then advanced into the larger vessels of the upper arm for greater hemodilution. Midline peripheral catheter is left inserted for how long? - answer-typically 1-4 weeks. A midline peripheral catheter should be changed only when - answer-there is a specific indicator (swelling, pain) 86 A midline peripheral catheter is easily confused with - answer-a peripherally placed central line (PICC) Peripheral intravenous lock - answer-also called a saline lock, a prn adapter, & sometimes a heparin lock establishes a venous route as a precautionary measure for clients whose condition may change rapidly or who may require intermittent infusion therapy. How is the patency of a peripheral intravenous lock maintained? - answer-by injecting normal saline or a dilute heparin solution Central venous access device (CVAD) - answer- intravenous line inserted into a major vein. typically, the subclavian or internal jugular vein is used. CVADs are used to: - answer-administer large volumes of fluid or highly irritating medications, when 87 peripheral sites are unavailable, for monitoring central venous pressure, & for frequent blood draws. Advantages of central lines - answer-1. accommodates highly irritating solutions 2. central veins are accessible even if the pt is experiencing fluid depletion 3. can be left in longer than peripheral IVs 4. nutrition can be given parenterally 5. phlebitis, extravasation, & infiltration less likely to occur Disadvantages of central lines - answer-1. practitioners must have specialized training to insert 2. must obtain patients consent 3. placement must be confirmed by radiography 4. placement treated as minor surgical procedure 5. dressing changes require strict sterile technique 6. risk the catheter will float into the right side of the heart 90 intended for shorter use than a PICC line (less than 6 weeks) dont routinely replace Tunneled CVC - answer-intended for long term use. the catheter is inserted by a surgeon through a 3-6 in subcutaneous tunnel in the chest wall & then into the jugular or subclavian vein, risk of infection is less with their use than it is with PICCs or nontunneled central lines. Implanted port - answer-the catheter enters the internal jugular vein in the neck, & it may be tunneled or untunneled to a completely implanted port in the upper chest. placed by surgeons & only specially trained nurses are allowed to access an implanted port bc of risk of 91 infiltration into the tissue if the needle placement is not correct. intended for long term use Intraosseous devices - answer-designed for immediate access (within seconds) and short term use (less than 24 hrs) used to administer fluids when a peripheral catheter cannot be inserted or when a central line insertion is not advisable, but especially in emergency situations. placed into the matrix of a bone most common access site is the proximal tibia in both children & adults. sternum & head of humerus can also be used in adults osteomyelitis is a rare complication. 92 How does a nurse choose the size of the IV catheter? - answer-select the smallest diameter and the shortest length catheter that will accommodate the prescribed therapy. nurses commonly use a 20-22 gauge catheter for adult peripheral infusions. a 20 gauge will accommodate adult blood transfusions you will need the larger 16-18 gauge for rapid infusions, thick fluids, or surgical/trauma patients. the smaller 24 gauge is used in geriatric & neonates Macrodrip vs microdrip tubing - answer-1. macrodrip delivers 10-20 drops per ml of solution; select a macrodrip for most adult infusions 2. microdrip delivers 60 drops per ml; use for very slow infusion rates or for infants & children How many times should you attempt to initiate an IV? - answer-twice. do not make more than 2 attempts 95 iv catheter dislodges or tip penetrates vessel wall signs & symptoms: slowed or stopped flow, pain burning & swelling at site, blanching & coolness. blistering is a late sign. if extravasation resulted from vasoconstricting medication may see necrosis of dermis -treatment depends on severity -stop immediately -administer antidote -apply cold compress, elevate extremity IV complications & interventions: phlebitis - answer- inflammation of the vein causes: may be due to mechanical irritation, infusion of solutions that are irritating to the vessel, or sepsis 96 dextrose solutions, potassium chloride, antibiotics, and vit. c are associated with higher risk trauma to the vessel, compression of the line by client movement, or low flow rate signs & symptoms: redness, pain, warmth at site, swelling, palpable cord along the vein, sluggish infusion rate, elevated temp. slowed or stopped infusion, inability to restart flow of iv -discontinue IV & restart in new location -apply cold compress initially if site is warm & tender. then apply warm compress IV complications & interventions: thrombophlebitis - answer-thrombosis & inflammation causes: use of veins in leg for infusion, use of hypertonic or highly acidic solution, can be a result of untreated phlebitis 97 signs & symptoms: sluggish flow rate, edema, tender & cord-like veins, warmth, & erythema at site -discontinue IV infusion, restart in opposite extremity w/ new equipment -apply warm compress -consult provider IV complications & interventions: local infection - answer-causes: poor technique when inserting, leaving in place longer than 96 hours, or direct contamination signs & symptoms: redness, swelling, exudate, elevated temp -remove IV line -apply sterile dressing over site -administer antibiotics if necessary