Nursing 100 Final Study Guide examination, Exams of Nursing

Download Nursing 100 Final Study Guide examination and more Exams Nursing in PDF only on Docsity! 1 Nursing 100 Final Study Guide examination Chapter 10: Medical and Surgical Asepsis - Hand Hygiene: Use antimicrobial soap and water when your hands are visibly soiled, before you eat, after using the bathroom, and after contact of bodily fluid. Scrub your hands for 15 seconds - Alcohol based product use 3-5ml of the product - Stand 3 feet away from those coughing - Keep nails short - No gel polish because it increases risk of microbes - Remove jewelry from hands and wrist - Never shake linens - Clean the least soiled area first and the worst last How to set up a sterile field: - Position it so the top flap is facing away from you and open it away from you - Open the right flap with your right hand and the left flap with the left hand and the last flap open towards you - If you need to use a sterile solution, remove the bottle cap and place it face it up on a clean surface not the sterile surface, hold the bottle so that the label is against your palm, and you want to pour 1-2 ml out, and then pour the solution on the site - Do not cough, sneeze, or talk over sterile field - The 1 inch outer edge of the sterile field is not sterile - Any object help below the waste or above the chest is considered contaminated - Any objects that need to be added to the sterile field should be added 6 inches above and dropped into - Never turn your back or reach across a sterile field 1 1 - Any sterile field item that comes in contact with moisture is not considered sterile Chapter 11: Immunity Nonspecific innate immunity vs. Specific Adaptive Immunity Nonspecific innate immunity: our bodies defense mechanisms or barriers that respond immediately to all antigens Ex: skin, mucous membranes, stomach acid Specific adaptive immunity: your body produces antibodies in response to a specific antigen to through the actions of B and T lymphocytes. It requires more time, but in the future the immune response will be more specific and effective through this specific adaptive immunity Active Natural immunity: the body produces antibodies in response to exposure to a life pathogen. Ex: when you get exposed to a cold virus and get sick, your body produces antibodies that when you exposed to that same cold virus again, your body can really defend it off more quickly. 2 1 many forms. Serous exudate or drainage which is clear, sanguineous drainage is bloody, serous sanguineous, may be pink tint, it is in-between, purulent drainage contains leukocytes and bacteria 3) This is when damaged tissue is replaced by scar tissue Lab tests that indicate an infection 1) WBC count should be between 5,000 and 10,000… it is over 10,000 there is an infection 2) Left shit in the WBC count means when you are fighting off a bad infection and your immune system is working really hard, when it gets overwhelmed it starts releasing immature WBC’s… releasing immature WBC’s because we are overwhelmed by an infection 3) ESR- Erythrocyte sedimentation rate is a good indicator that there is inflammation in the body 4) CRP- C- reactive protein is a good indicator that there is inflammation in the body 5) Positive culture result- indicate infection, you want to collect all the culture before the patient starts any antibiotics Precautions: 1) Standard precautions are used for ALL patients, hand hygiene, use alcohol based antiseptic rather than soap and water unless your hands are visabily soiled, always use face masks whenever there is splashing of bodily fluids, clean cloves whenever you touch anything in the room, and use a moisture resistance bag for soiked items and proper sharps disposal 2) Air borne precautions: Measles, Varicella (chicken pox) TB (MTV is airborne) the room must have negative airflow . Any 5 1 visitors must wear a N95 mask 3) Droplet precautions: Influenza, Pneumonia, Putrescence, Sepsis, Mumps, Bacterial meningitis, rubella….. patient will get a private room and caregivers and visitors will need to wear masks 4) Contact precautions- impetigo, scabies, mersa, Cdiff, other enteric infection, RSV, wound infections … usually given a private room, visitors and caregivers need to wear gowns and gloves Herpes Zoster: This is shingles, it is caused by the reactivation of chicken pox, if you had chicken pox as a kid you are at risk - Risk factors: compromised immune system, stress, fatigue, and poor nutrition Chapter 12: Patient Safety How to prevent falls? 6 1 - Patients with orthostatic hypotension advise them to get up slowly - Provide our patients with regular toileting for those that require assistance - Round on patients hourly - Put frequently used items in reach - Always position the bed in the lowest position and lock the breaks - Don not put up all 4 side rails, leave at least 1 side down Seizures - During seizures make sure you lower the patient to the floor or the bed and turn the patient on to their side - Loosen any restrictive clothing - Do not restrain patient or put anything in their mouth - Note the onset and duration of the seizure - After the seizure take patients vital signs, do neurological check, implement seizure precautions Restraints - Physical restraints like a vest, belt, or mittens - Chemical restraints like sedatives or psychotics - If you can’t calm the patient down, in an emergency the RN can place the patient in restraints but you must get a prescription from the doctor in the next hour - Orders can be written for up to 4 hours for adults - Remove restraints one at a time and check every 2 hours - Always use the least restrictive restraint like mittens - Apply restraints so that 2 fingers can fit between the restraint and the patient - Always use a quick release knot Fire Safety - Use acronym RACE (rescue: do a horizontal then a lateral evacuation) (A: alarm) (C- contain, close doors and windows 7 1 - Modified Trendelenburg: where the patient lies flat where their legs are elevated above their heart, this is good for hypovolemic shock Chapter 15: Security and Disaster Plans Triage: Class 1: gets a red tag, patients who have an immediate threat to life, breathing issues, hemorrhaging wound, major burns Class 2: Yellow tag: patients who have a major injury that requires prompt attention like a bone fracture Class 3: patients who have a minor injury who do not require immediate attention, like a sprain or a cut Class 4: Black tag, is for patients who are expected to die 10 1 During tornadoes: close shades on the windows and move patient away from windows, place blankets over patients who are bed bound Chemical exposure: undress the patient and irrigate them profusely with water, if they have dry chemicals on them brush the chemicals off clothing and skin Hazardous material: locate the safety data sheet, water is the universal antidote for most hazardous materials Bomb threat: keep the caller on the phone as long as possible, listen for background noise Chapter 26: Data Collection and General Survey -Assess and data collection for an older adult: should be gathered during multiple shorter sessions instead of one long session - Allow for more time for response to question and position changes - Make sure patient has sensory aids in place - Reduce environmental noise Physical assessment: Inspection, palpation, percussion, auscultation (normal order for everything except abdomen) Abdomen is inspect, auscultate, percuss, palpate Inspection is where we use our eyes to assess for size, shape, color or symmetry Palpation: using touch to assess for temperature, size, texture, tenderness… always assess the most tender areas last, use the dorsal surface of the hand that is the best for assessing temp 11 1 Percussion: tapping different body parts Auscultation: Listening for sounds like bowl, lung, and heart sounds What is included in a general survey? - Physical appearance (age, race, gender, LOC, signs of substance abuse, signs of distress) - Body structure (height, weight, nutritional status, posture) - mobility (gait, range of motion) - behavior (mood, speech, grooming) - Vital signs (temp, pulse, Respiration rate, Bp, O2) Chapter 27: Vital signs TEMP - Normal range orally for an adult is between 36-38 degrees C or 96.8-100.4 degreed F) - Rectal temp is usually o.5 degrees C higher or 0.9 degrees F higher than oral and tympanic temp 12 1 Calculating pulse deficit - Pulse deficit is the difference between the apical pulse and the radial pulse - It is most likely zero differences - If they are different there is a heart problem Tachycardia - Heart rate over 100 BPM - Due to: fever, exercise, meds, pain. Hyperthyroidism, stress, hypovolemia Bradycardia - Heart rate under 60 BPM - Due to meds, could be an athlete, hypothyroidism, hypothermia RESPIRATIONS - Normal range is between 12 and 20 breaths per minute for adults - Assess for the rate and the depth (shallow or deep), rhythm (regular or irregular respirations) - Chemoreceptors in your body detect when C02 levels rise in the blood, this ca respiratory control center in your brain to increase your respiratory rate - When taking respiratory rate: place patient in semi-fowlers position, place your hand on their abdomen, if its reg count for 30 and multiply by 2, irregular count for 1 minute Ventilation: exchange of 02 and Co2 between the environment and lungs Diffusion: is the exchange of 02 and C02 between the alveoli and the red blood cells in the blood stream Perfusion: is the exchange of 02 and C02 between the red blood cells in the blood stream and your body tissues What increases respiratory rate? -anxiety 15 1 -smoking -anemia -high altitude -illnesses What decreases respiratory rate? - Opioid and sedative meds - Older age When taking a patients SpO2 saturation a normal range is between 95- 100% - COPD is normal to have ranges in the low 90’s BLOOD PRESSURE - Normal ranges: Systolic is under 120 AND diastolic is under 80 16 1 - Prehypertension: Systolic is 120-139 OR Diastolic is 80-89 - Stage 1: Systolic is 140 to 159 OR Diastolic 90 to 99 - Stage 2: Systolic is greater than 160 OR diastolic is greater than 100 Hypotension is their systolic is under 90 You want to take BP reading over 3 separate occasions on different days over a couple weeks is how to assess for hypertension When taking someone’s BP if they have Orthostatic hypotension , you want to take it when they are supine, lying flat, have them sit up and wait a couple minutes then take their BP again, then have them stand wait a couple minutes and take it again - If there systolic BP decreased 20 mm hg or more, when changing position or if there diastolic BP decreases 10 mm hg or more with a 10-20 % increase in Heart rate this means they could have orthostatic hypotension BLOOD PRESSURE -Pulse pressure is systolic BP minus Diastolic BP -If the pulse pressure is elevated it can lead to increased risk for cardiovascular disease -The cuff width should be 40% or the arm circumference and the bladder should surround 80% of the arm circumference 17 1 impaired far vision (Myopia). The Rosenbaum eye chart checks for presiopia, impaired near vision and you hold the chart 14 inches away from the patient Ichihara test: color vision Extra- Ocular movement of the eyes: - Corneal light reflex test - Cover, uncover test - Six cardinal gaze by having patient follow your finger - PERRLA When patients get older they will have decreased vision, yellowing of lenses, issues of glare and darkness, hearing loss is common, thickening of tympanic membrane, decreased sense of taste, gum disease, tooth loss, decreased salivation and pallor gums, increase vocal pitch, decreased sense of smell Chapter 29: Thorax, Heart, and Abdomen 20 1 Encourage female patients to do monthly breast exams, it is best to do them after your period Lung assessment: Percussion, you are expected to hear resonant, if you hear dullness (abnormal) this can indicate a tumor or pneumonia, if you hear Hyperresonan t , this can indicate a pneumothorax or emphysema. Auscultation of the lungs: - When listening over the tracheal area , you should hear bronchial sounds - When listening over the large airways , you should hear bronchovesicular sounds - When listening over the peripheral areas of the lungs, you should hear vesicular sounds Abnormal findings: - If you hear crackles, this means there is fluid around the lungs - Wheezes sounds like whistling musical sounds - Rhonchi are like rumbling sounds - Pleural friction rub is a grating, rubbing sound Heart Assessment: - S1 sound is the sound of the mitral and tricuspid valves closing (LUB) - S2 sounds is the sound of the aortic and pulmonic closing (DUB) - Thrills are vibrations associated with murmurs and other cardiac abnormalities (someone who has a fistula) - Bruitt (brewee) is swishing sounds associated with obstructive blood flow like a narrowed artery - The point of maximal impulse (PMI) is the apical pulse, it is located at the left mid- clavicular line at the 5th intercostal 21 1 space Auscultation sites for the heart: -Aortic: listen to the right of the sternum at the second intercostal space - Pulmonic: listen to the left of the sternum at the second intercostal space - Erbes point: listen to the left of the sternum at the third intercostal space - Tricuspid: listen to the left of the sternum at the fourth intercostal space - Mitral (apical): listen to the left mid-clavicular line at the fifth intercostal Abdominal assessment: - Should hear high pitch clicking and gurgling - What is not expected is loud growling sounds or no bowel sounds after listening for 5 minutes - Percussion of the abdomen: should expect tympani sounds (drum like sounds), dullness over liver area is expected (right upper quadrant) - Palpation: if they have a tender area you always want to palpate the tender area last Chapter30: Integumentary and Peripheral Vascular Systems 22 1 Joint Movements: -Flexion: decreases the angle between two body parts - Extension: increases angle between two body parts - Abduction: movement away from the midline (away from stomach) -Adduction: movement of an extremity towards the midline (toward stomach) - Dorsi-flexion: toes are brought closer to the shins - plantar flexion is pointing your toes towards the ground - Eversion: sole of the foot goes away from the midline of the body (toes point out) -Inversion: sole of the foot tilts towards the midline of the body -External rotation: rotate a joint outwardly -Internal rotation: rotate a joint inwardly Spinal Curvatures: - Unexpected findings: o Kyphosis: exaggerated curvature of the thoracic spine (common in older adults) o Lordosis: exaggerated curvature of the lumbar spine (common in pregnancy and toddlers) o Scoliosis: exaggerated lateral curvature Levels of consciousness: 1) Alert: they are responsive, open their eyes spontaneously, and can answer questions appropriately 2) Lethargic: can open their eyes and respond to questions but they fall asleep easily 3) Obtunded: responds to light shaking, but it very confused and slow to respond 4) Stuporous: the patient barely responds to painful stimuli 5) Comatose: patient is unresponsive, may see abnormal posturing like - Decorticate: arms are flexed and internally rotated, legs are extended and internally rotated 25 1 - Decerebrate: the head is arched back and the arms and legs are both extended (worse indicated more brain damage) Romberg test: think of an uncooked ramen noodle, very stiff and straight and that’s how you want you patient to stand, it is a balance test where you have your patient close their eyes and stand with their feet together and arms by their side Chapter 32: Therapeutic Communication Responses to patients: - Wrong ways to communicate: o Never ask “why” o Never offer your opinion o Don’t get false reassurance o Don’t ask close-ended questions o Don’t change the subject if something difficult comes up o Don’t say, “I know how you feel” 26 1 - Right response: o Open ended questions, “tell me more” o “Can you share with me how your feeling” o Offering of self, like personal information but return the focus back to the patient asap Chapter 33: Coping Three stages of GAS: (general adaptation syndrome) 1) Alarm reaction stage , “fight or flight” HR increases, BP increases, and Cortisol is released and you get a boost of adrenaline 2) Resistance stage: body works to normalize hormone levels and vital signs while still responding to the stressor 3) Exhaustion stage: prolonged stress results in the body no longer able to respond to the stressor. Results in fatigue, illness, and depression Chapter 35: Cultural and Spiritual Nursing Care - Orthodox Judaism: require kosher kitchens, no meat with dairy (cheeseburger), no pork, or shellfish - Islam : Do not drink alcohol, no pork, fast during Ramadan, women requires a female provider, pray 5 or more times a day - Jehovah witness : does not accept blood products, right to autonomy - Mormons : no caffeine or alcohol - Catholics : fast during lent Ethnocentrism: the belief that one’s culture is superior to all others 27 1 -lay body supine -put dentures in -soiled linens removed -calm environment -lights dimmed Chapter 37: Hygiene - Foot care: diabetic patients are at high risk for foot sores and injuries - Apply moisture to the feet but not between the toes - Patient should wear cotton socks, not synthetic - When they are cutting their nails, cut straight across not into a curved shape - Check shoes for objects that can cause injury - Avoid self-treating for corns or calluses - Do not apply heating pads to their feet 30 1 Oral Hygiene with unconscious patients: - Have suction available - Never put fingers in their mouth - Position the patient on their side with their head facing towards you, allows secretions to drain out - Denture care: remove upper dentures by pulling down and out and lower dentures by pulling up and out, store them in water in a cup Chapter 38: Rest and Sleep Sleep cycles: - 4 stages of NREM o stage 1 : very light sleep, where vital signs and metabolism start to decrease, awakens easily, feels relaxed and drowsy (only a few minutes long) o stage 2: deeper sleep, 10-20 min long, vital signs and metabolism continue to decrease o stage 3: beginning of deeper sleep, difficult to awaken patient, lasts between 15- 30 min o stage 4 : deepest sleep, provides physiological rest, vital signs are very low, difficult to awaken someone, sleep walking and talking happen, and this lasts 15- 30 min - REM SLEEP o helps provide cognitive restoration, vivid dreaming, difficult to awaken people, vital signs can vary, lasts for about 20 min, as we cycle the REM portion gets longer and longer, about 90 minutes after falling asleep Sleep Hygiene 31 1 - Exercise regularly but not 2 hours before bed time - Avoid alcohol or caffeine 4 hours before bed time - Fluids should be limited - Engaging in muscle relaxation exercises - Light carb snack before bed time - No TV or screen time Sleep apnea: greater than 5 cessations lasting longer than 10 seconds per hour during sleep, resulting in decreased arterial oxygen saturation levels. If you have this you wear a C-pap mask Chapter 39: Nutrition and Oral Hydration 32 1 - Full liquid diet: water, tea, coffee, broth, clear juices, gelatin, ginger ale, milk, pudding, soup, ice-cream, sherbet, fruit juice, vegetable juice - Soft diet: no raw vegetables, no gassy foods, no raw fruits, no foods that cause gas, no course breads or cereals - Puree diet: if they have had oral facial surgery, or their jaw is wired shut, or other chewing difficulties - Mechanical soft diet: patients with no teeth, foods that require minimum chewing - Low-residue diet: GI disorders like IBS, foods low in fiber and easy to digest, dairy products, and eggs. Chapter 40: Mobility and Immobility How to prevent respiratory complications with patients - At higher risk for pneumonia, teach our patients to turn, cough, and breathe deeply every 2 hours - Use an incentive spirometer - Encourage patients to increase fluid intake to 2,000 ML a day or more unless they are on fluid restrictions - Reposition patient very 2 hours Patients with pulmonary embolism - Blood clot moves up to the lungs, it’s a medical emergency - Symptoms include: dyspnea, chest pain, increased heart rate, decreased BP, bloody sputum - Notify provider right away, place in high fowlers, administer o2, monitor vitals, get ABG test, administer thrombolytics and anti- coagulates Chapter 41: Pain Management Different types of pain: - Acute pain: temporary, protective and resolved within tissue 35 1 healing, their vital signs may show anxiety, tachycardia, hypertension, diaphoresis - Chronic pain: lasts longer than 6 months, does not alter their vital signs but it does cause fatigue, depression - Idiopathic pain: chronic pain of an unknown origin, often associated with depression - Nociceptive pain: due to tissue damage or inflammation, symptoms include aching, throbbing, and the pain is localized, treat this with opioid or non-opioid meds. There are 3 types of nociceptive pain: - 1) somatic: in bones, joints, muscles, skin, or connective tissue - 2) Visceral pain : in internal organs such as the stomach or intestines, may cause referred pain - 3) cutaneous pain : pain in the skin or subcutaneous tissue -Neuropathic pain: due to damage of the nerves, like phantom limb pain, usually symptoms of burning, pins and needles. Treat this pain with antidepressants, anticonvulsants, and muscle relaxers 36 1 When assessing a patient’s pain: - do a full assessment - L: Location - Q: Quality - I: Intensity (scale 0-10) - T: Timing of pain (when did it start) - S: Setting (how does it affect the patients ADL’s) - Ask if there are any other associated symptoms with the pain - Find out the aggravating or relieving factors (what makes it get better or worse) Analgesics: - Non-opioid analgesics: for mild to moderate pain, when giving acetaminophen (Tylenol) it is important to not exceed over 4g’s a day - Opioid analgesics : use for moderate to severe pain, side effects include constipation, sedation, respiratory depression, hypotension, urinary retention, nausea and vomiting (bring vital signs down) Naloxone is the antidote, if their resp. rate drops below 8 breaths per minute give them naloxone. Chapter 42: Complementary and Alternative Therapies -Acupuncture - Homeopathic medicine - Naturopathic medicine - Chiropractic medicine - Massage therapy - Biofeedback - Therapeutic touch Natural products and herbal remedies: - Some can interfere with other medications - Garlic, ginger, ginseng, can actually cause 37 1 patients not to bare down when they are having a bowel movement, it can lead to hypotension, bradycardia Diarrhea: dehydration and fluid and electrolyte imbalances and metabolic acidosis, also skin break down around the anus Symptoms of dehydration: - increased pulse rate - hypotension - poor skin turgor - elevated temp - dry mucous membranes 40 1 Chapter 44: Urinary Elimination Incontinence: - Stress incontinence is where you have a small amount of urine leak out due to abdominal pressure when you laugh, sneeze, or cough - Urge incontinence: inability to reach the bathroom onetime due to an overactive detrusor muscle - Overflow: urinary retention from bladder over distention and frequent loss of small amounts of urine due to obstruction of the urinary outlet or an impaired detrusor muscle Patient Teaching for Incontinence: o Encourage patients to maintain a toileting schedule, Kegel exercises, reducing caffeine and alcohol If your patient has a Urinary output of less than 30 ML per hour you must call the doctor The amount of fluid that a patient takes in should roughly equal the urine output If a 24-hour urine collection is ordered, it is important to discard the first void, and collect all urine for 24 hours, and keep urine on ice and make sure it does not get contaminated Foley catheter: clean the insertion site with soap and water 3 times a day, keep the collection bag below the level of the bladder and make sure the tubing is not kinked UTI ’s: -female places you at higher risk - Foley or indwelling catheters - uncircumcised males 41 1 - me nop ause - frequent intercourse How to prevent UTI’s - Females: encourage them to wipe front to back - Catheter care is important - Uncircumcised males make sure they are cleaning under foreskin - Patient should drink 2-3L of fluid daily - Cranberry juice can decrease the risk Chapter 45: Sensory Perception Hearing loss: - Make sure when your speaking to the patient you are facing them - Try lowering vocal pitch - Do not shout at patient 42 1 - Infants and the elderly have decreased metabolism - First-pass effect is where some meds are inactivated through the first pass of the liver and must be administered through a parental route - Poor nutrition can decrease metabolism 4) Excretion - Where medications are eliminated from the body mainly through the kidneys - Kidney dysfunction can impair excretion of meds leading to toxicity Therapeutic Index (TI) - Compare the minimum effective concentration, the minimum amount of drug that you need it to be affective to the level at which it is toxic - Meds that have a higher TI are safer - Meds that have a low TI, there is barely any room that the meds can reach toxicity - Like Vancomyasen has a very low TI Half-life - The amount of time it takes medication to be reduced by 50% in the body - Meds that have a short half-life leave the body quickly Medications Mode of Action - Agonist: meds that activates a receptor in the body - Morphine is an opioid agonist that activates opioid receptors in the body causing the side effects - Antagonists: medication that blocks the receptors in the body, reverses the effects of meds Medication administration principals and guidelines Oral Meds: 45 1 - Do not give Oral meds if: decreased LOC, lack of gauge reflex, dysphasia, vomiting - Place patient in high fowlers position, don’t mix meds with a large amount of food - Never crush enteric coated or extended release - For liquid meds, you should make sure that the base of the meniscus (lowest point of medication) is at the level of ordered dose Sublingual Medications: - Place tablet under the tongue Buccal Medications: - Place it between check and the gums, patient should not eat or drink until med is completely dissolved Transdermal Medications: - Patches, make sure you wash the skin with soap and water and dry thoroughly - Place patch on a non-hairy area - Rotate sides where you put the patch on 46 1 - Use gloves Optic Drop medication: - Rest your dominant hand on the patient’s forehead - Drop the meds into the patient’s conjunctival sac without touching the eye with the dropper - Wait 5 minutes between different eye drops Ear drops - Lay the patient on their unaffected side - Pull the auricle up and bac for adults and down and back for children - Instill the drops and apply gentle pressure to tragus - Patient should remain on the side for 2-3 minutes Inhalers: - Meter-dose inhaler you shake it - Dry-powder inhaler don’t shake it - either one you want the patient to put their mouth around it, take a slow deep breath and hold their breath for 10 minutes then exhale - if the patient is getting a corticosteroid inhaler the should rinse their mouth out after to prevent getting fungal infections Medication Admin through a NG tube and Gastronomy tube - Important to verify two placements - Use an x-ray to verify - Administer each medication separately - Dissolve tablets in 15-30 mL of sterile water - Flush the tube before and after each medication with 15-30 ML of water - At the end flush with 15-30mL of water Intramuscular Injections: (IM) - Use a 1- 1.5-inch needle that is 18-27 gauge 47 1 *most meds are dangerous during pregnancy * Types of prescriptions - Routine or Standard prescription : given on a regular schedule, you want to give them within 30 min from the time its ordered (30 min before or after the scheduled time) - Single or one-time prescription: given once - Stat: given to the patient immediately - Now order: given once within 90 minutes of the prescription - PRN: as needed, make sure the prescription has the dose, frequency, what conditions it could be administered - Standing prescription: can be given for specific circumstances on specific units Components of a prescription: - Patients name - Date and time of prescription - Name of med 50 1 - Strength and dose - Route - Time and frequency - Quantity - number of refills - providers signature 10 rights of safe medication administration 1) patient 2) medication 3) dose 4) time 5) route 6) documentation 7) patient education 8) right to refuse 9) right assessment (before and after administration) 10) right evaluation Error Prone Abbreviations - Never use MS or MS4 for morphine - Never use MGso4 for magnesium sulfate - Never use decimal points without a leading zero (0.5 instead of .5) - Do not use trailing zero - Do not use U or IU for units - QD or Q. for daily - Sc or SQ for subcutaneous Medication Admin: - Always identify allergies for meds prior to administration - Always question unclear or inappropriate prescription (multiple pills or vials for single dose) - Prepare meds for 1 patient at a time - Only administer meds that YOU prepare not another nurse - Double check high alert meds with a second RN like heparin and 51 1 insulin - Complete an incident report for any med errors - never reference incident report in the chart 52 1 Older adults: - Increased gastric pH - Decreased GI emptying time - Decreased blood flow - Decreased kidney function lowers their ability to excrete toxins - Decreased protein binding sites and albumin levels - Decreased body water content and muscle mass - Increase fat - Polypharmacy (taking many meds at once) Chapter 52: Specimen Collection for Glucose Monitoring When taking a patient’s blood glucose: - Clean the patients finger with warm water or soap, not alcohol - Warm moist towel to increase circulation - Place hand in a dependent position - Pierce the outer edge of the finger tip - Hold the lancet perpendicular to the skin and rotate sides - Wipe away the first drop of blood - Hold the test strip next to the next drop of blood - Don’t ever smear the blood on the strip When taking blood glucose level: - If it is over 200 that could be hyperglycemia - If it is less than 70 it could be hypoglycemia - Test for ketones in urine if their blood glucose is really high Chapter 53: Airway Management Symptoms of hypoxemia - Early: o Restlessness and irritability o Tachypnea o Tachycardia o Increased BP 55 1 o Pallor o Abnormal breathing (use of accessory muscles, nostril flaring) - Late: o Decreased LOC o Bradycardia o Dysrhythmias o Bradypena o Decreased BP o Cyanosis 56 1 OXYGEN LEVES SHOULD BE BETWEEN 95-100% FOR MOST PATIENTS - COPD PATIENT WILL HAVE LOWER O2 LEVELS (89-91%) When you’re giving a patient oxygen, you want to use the lowest Liter flow you can that will correct their hypoxemia Different O2 masks: - Nasal Cannula: you can use this if the patient requires 1-6L per minute if you are at a flow rate of 4 L or more you need to use humidification. - Simple face mask: 5-8 L per minute of O2 - Partial re-breather mask: 6-10 L per minute, make sure the reservoir bag is 1/3 – 1/2full on inspiration - Non-rebreather mask: 10-15 L per minute, is important to keep the reservoir bag 2/3 full and asses the flap and valve hourly - Venturi Mask: delivery of 4-12L per minute, offers the most precise 02 deliveries - Aerosol mask or face tent is good for patients who have facial trauma or burns and it provides high humidification Symptoms of Oxygen Toxicity - Non-productive cough - Substernal pain - Nausea, and vomiting - Fatigue - Headache - Sore throat - Nasal congestion Chest Physiotherapy - Use of percussion, vibration, and postural drainage to loosed respiratory secretions - Important to schedule treatment 1 hour before or 2 hours after 57 1 - Confirm placement with X-ray Nursing Care of enteral feeding tubes - Verify tube placement with X-ray - Verify the presence of bowel sounds before feeding - Check pH it should be between 0-4 - Discard bags and tubing every 24 hours - Measure gastric residual every 4-6 hours - Return the residual that you draw out back into the stomach - Hold feeding for residual amounts that over hospital policy (500mL) 60 1 - Flush feeding tube with 300 mL of water every 4 hours and feeding solutions should be at room temp When the patients are getting enteral feeding - Elevate the head of the bed to 30 degrees or more during the feeding and 30-60 minutes after the feeding - Refrigerate it up to 24 hours - Only fill feeding bags with only 4 hours’ worth of formula - Slowly increase volume and rate to the desired level Chapter 55: Pressure Ulcers, Wounds, and Wound Management Phases of wound healing: - 1st stage: Inflammatory stage lasts 3-6 days, during this time you have vasoconstriction, clot formation, hemostasis, phagocytosis of microorganisms - 2nd stage: Proliferative stage which lasts 3-24 days, you have replacement of lost tissue with granulation and collagen, wound becomes smaller, wound resurfacing - 3rd stage: maturation stage: 1 or more years, there is remodeling and strengthening of the tissue Wound Healing - Primary Intention: where the wound edges are approximated, and pulled together by staples or stitches (less scarring) - Secondary Intention: wound edges are apart, longer healing time, and more scarring and increased risk of infection - Tertiary Intention: wound is left open to address infection concerns and then closed at a later time What delays wound healing - Older age - Decreased immune function 61 1 - Impaired nutrition - Decreased profusion - Smoking Appearance of wounds: - You want a wound to look beefy and red - Yellow in the wound means puss - Black means escar and the wound needs to be debrided Wound drainage - Serous drainage: clear or pale yellow and watery it is the serum of the body - Sanguineous is bloody it contains both serum and red blood cells - Serosanguinous is both clear and blood 62 1 - Oliguria (less pee) - Decreased skin turgor - Decreased cap refill - Flattened neck veins - Dry mucous membranes - Diaphor esis LAB VALUES: -blood will be fairly concentrated -increased hematocrit -hypernatremia -urine will have increased urine specific gravity - Weigh patient daily - Report urine output less than 30mL per hour - Assist patient with ambulation Fluid Volume Excess - Tachycardia - Tachypnea - Hypertension - Bounding pulses - Weight gain - Dyspnea - Edema - Crackles - Jugular vein distension Nursing Care: - Weigh daily - Restrict fluids - -administer O2 as ordered - -Prevent skin breakdown 65 1 Chapter 58: Electrolyte Imbalances Sodium (Na) - Normal (136-145 mEq/L) - Functions: maintains fluid balance, important for nerve and muscle function - Hyponatremia (less than 136): GI losses, Diuretics, Skin losses (sweating), Edema, Hyperglycemia Symptoms of Hyponatremia: tachycardia, hypotension, confusion, (common with elderly patients with UTI’s), fatigue, nausea, vomiting, headache - Hypernatremia: water deprivation, kidney failure, Cushing’s syndrome, excess sodium intake - Symptoms of hypernatremia: tachycardia, muscle twitching, GI upset, edema 66 1 Potassium: K - Normal levels: 3.5-5.0 meq/l - Function: maintains intercellular fluid balance, nerve function, muscle and heart contractions - Causes of Hypokalemia: less than 3.5, GI losses, diuretics, skin losses, metabolic alkalosis - Symptoms of Hypokalemia: dysrhythmias, muscle weakness, cramps, constipation, hypotension - Causes of Hyperkalemia: over 5.0, uncontrolled diabetes, diabetic ketoacidosis, kidney failure, metabolic acidosis, salt substitutes - Symptoms of Hyperkalemia: dysrhythmias, muscle weakness, numbness and tingling, diarrhea, confusion Calcium (Ca) - Normal levels: 9.0-10.5 - Function: bone and teeth formation, clotting, nerve and muscle function - Hypocalcemia causes: diarrhea, vitamin D deficiency, hypoparathyroidism - Symptoms of hypocalcemia: positive trousseaus sign or Trouvesks sign, muscle spasms, numbness and tingling in lips and fingers, GI upset - Causes of Hypercalcemia: hyperparathyroidism, long term steroid use, bone cancer - Symptoms of hypercalcemia: constipation, decreased Deep tendon reflexes (DTR), kidney stones, lethargy Magnesium (Ma) - Normal Levels: 1.5-2.5 - Function: nerve and muscle function, bone formation, biochemical reactions in the body - Causes of hypomagnesemia: GI losses, diuretics, mal nutrion, alcohol abuse 67