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 - 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 1 1 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 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 5 1 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 and turn off O2 sources) (E- Extinguish) - PASS (use of a fire extinguisher) P: pull the pin, A: aim at the base of the fire, S: squeeze the handle, S: sweep side to side Chapter 14: Safe Patient Movement - When lifting an object, you should hold it as close to your body as close as possible - Avoid twisting and bending at the waist - Always gen help when repositioning the patient Moving patient from the gurney to the bed: - Position the bed slightly lower than the gurney, lower the head of the bed so its flat, have them tuck their chin in to their chest and cross their arms over their chest and you slide them across 7 1 tympanic temp 10 1 - Axillary temp are 0.5 degrees C or 0.9 degrees F lower than oral and tympanic temp - Temporal temps are close to rectal, but they are 0.5 degrees C and 1 degree F higher than oral, and 1 degree C and 2 degrees F higher than axillary temps What impacts body temp? - Age: A newborn will have a lower temp, 36.5 and 37.5 degrees C or 97.7 and 99.5 degrees F - Older adults have lower temps, 36 degrees C, or 96.8 degrees F - Wait 20-30 minutes to take oral temp if the patient has eaten or drunken hot or cold foods Rectal temp: place patient in sims position, use lube, insert thermometer 1- 2.5 inches for adults - Do not take rectal temp for anyone under 3 months or anyone who is at risk for bleeding Tympanic temp (Ear): adults pull up and back and children under 3 years old pull back and down Temporal temp: slide thermometer across forehead to the hairline and then touching behind the ear Nursing Intervention for hypo and hyperthermia Hyperthermia: temps is over 39 degrees C, obtain blood cultures and other specimens to check for infection, administer antibiotics but make sure to get cultures first, administer Tylenol to bring their temp down and administer fluids, prevent shivering Hypothermia: temps below 35 degrees C, provide warm blankets, warm IV fluids, increase room temp, and keeping patients head covered PULSE Assess for the - Rate: adult 60-100 beats per minute - Rhythm: pulse regular or irregular - Quality: how is the pulse on the left side compared to the right side of the body - Strength: 0 means no pulse, its absent, 1+ means pulse is diminished, 2+ is normal, 3+ is stronger than normal, and 4+ means it is bounding Radial Pulse - Take on the thumb side of the wrist, if they have a regular pulse you can count for 20 seconds and multiply by 2, and if you have irregular pulse you need to count for the full minute Apical pulse - Take it at the 5th intercostal space at the left mid- clavicular line 11 1 - If its regular you can count for 30 seconds and multiply for 2 - Pulse is irregular or if they are taking meds, you need to count for the full minute 12 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 -If the cuff is too large your reading will be low, and if the cuff is too small you’ll get a high reading -Do not take BP in the arm where there is an IV, don’t take it on the side of they have had a mastectomy, or a shunt, or fistula To estimate BP, palpate the radial pulse, inflate the cuff until the pulse disappears, then inflate the cuff another 30 mmhg, release pressure, and note when the pulse is palpable again 15 1 Chapter 28: Head and Neck Assessment Cranial Nerves: On Occasion our trusty truck acts funny very good vehicle any how (pneumonic for all 12) Some say marry money but my brother says big brains matter more (Sensory function) - Words that starts with (S) is for sensory, (M) is for motor, and (B) is for both 1) : Olfactory: controls smell 2) Optic: controls vision 3) Ocular Motor: responsible for eye movements and pupil restriction 4) Trochlear: eye movement in, down, and laterally 5)Trigeminal: controls chewing (motor and sensation) 6)Abduscense: allows the eye to move laterally 7) Facial: facial muscles and taste (anterior 2/3 of tongue) and salivary glands 8)Vestibularcochlear: controls hearing and balance 9) Glossopharyngeal: controls gag reflex, and taste (posterior 1/3 of tongue) 10) Vagus: controls pharyngeal and laryngeal muscles used for swallowing, speech, voice, gag reflex, and thoracic and abdominal viscera 11) Accessory nerve: allows shoulder and head movement 12) Hypoglossal: tongue movement When assessing a patient’s thyroid gland, it shouldn’t be visible, you can have them sip a glass of water and you can feel their thyroid gland move up and feel that it is not enlarged or any bumps Assessment of the eyes: the Snellen chart, (letter chart), have the patient stand 20 feet away from chart, this can let you know if your patient has 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 16 1 Chapter 29: Thorax, Heart, and Abdomen 17 1 Skin assessment: - When you see discoloration like Pallor, that means there is a circulation issue or they are suffering from anemia - If they are turning blue, cyanosis, this is due to hypoxia and is an emergency situation - If they are jaundice looking (yellow), this means hepatic or liver dysfunction or this happens when there is a lot of red blood cell destruction - Erythema (red color) can be due to inflammation, sunburn, or rash - Brown discoloration on the lower extremities, this means poor blood circulation back to the heart (venous insufficiency) Capillary Refill: - It should refill within 2 seconds or less (3 or 4 seconds is unexpected finding) Skin turgor - If you see tenting this means they are dehydrated or they are older Check for Edema: -Compress the skin for 5 seconds over a bony prominence in the lower extremities - 1+ is trace edema, rapid skin response (2mm) - 2+ is mild edema, 10-15 second response (4mm) - 3+ is moderate edema, prolonged skin response (6mm) - 4+ Severe edema, prolonged skin response (8mm) Primary Lesions: - Macule: flat area of discoloration, less than 1 cm wide (ex: freckle) - Patch: flat area of discoloration, more than 1cm wide (ex: birthmark) - Papule: elevated solid lesion that is under 1 cm (ex: mole) - Plaque: elevated solid lesion that is over 1 cm wide (ex: psoriasis) - Vesicle: elevated serous (clear) filed lesion that is under 1 cm wide (ex: herpes or varicella) or (ex: blister) - Nodule: firm deep lesion that is 1-2 cm wide (ex: wart) - Pustule: puss filled vesical that is under 1cm (acne) - Wheal: transient elevated irregular border, itchy, red (insect bite) Secondary Lesions: - Crust: slightly elevated lesion that is either dry blood, wound exudate, or puss (scab) - Erosion: moist, loss of the epidermis, like a ruptured vesical (blister that popped) - Scale: dry skin, that flakes (dandruff and eczema) - Fissure: linear break in the skin surface, due to skin being too dry or too moist (between the but crack like a crack in the skin) - Ulcer: loss of the epidermis and dermis with possible bleeding and scarring (round lesion over bony prominence) 20 1 Chapter 31: Musculoskeletal and Neurosensory Systems 21 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 - 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 22 1 Anticipatory grief: where someone grieves before they experience the actual loss 25 1 Complicated grief : where grief is prolonged, severe, and continues 6 months after the passing Stages of grief: 1) Denial 2) Anger 3) Bargaining 4) Depression 5) Acceptance Palliative care: comfort care, symptom relief, it can be used as the same time as treatment for conditions Hospice care: terminal illness, patients not expected to live more than 6 months Signs of impending death - Abnormal breathing (Cheyenne-stokes, apnea, death rattle) - Decreased LOC - Decreased muscle tone - Modeling of skin - Cool extremities - Decreased pule and BP - Incontinence - Decreased urine output - Decreased secretions in airway **Hearing is not impaired before death** How to prepare a body post-mortem: -remove all tubes -give belongings to family -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 26 1 - Avoid self-treating for corns or calluses - Do not apply heating pads to their feet 27 1 3 main macro nutrients that we consume in our diet: 1) Carbohydrates: provide most of the bodies energy and fiber, it provides 4 calories per gram of energy. Makes up 45-65% of our calories. Glycogen is stored carbohydrate energy in the liver and muscles, and is released in-between meals to help maintain out blood glucose levels 2) Protein: supports tissue building, metabolism, and immune function. Super important for wound healing, makes up 10-35% of our calories and provides 4 calories per gram of energy 3) Fat: provides stored energy for the body, padding and isolation, hormone production, and absorption of fat soluble vitamins, makes up 20-35% of daily calories, and provides 9 calories per gram of energy Water soluble vitamins: vitamin C and B-complex vitamins Fat soluble vitamins: Vitamins A, D, E, and K Newborn nutrition: only have breast milk or formula for their first 1 year of life. Solid foods are introduced around 4-6 months, no cow’s milk or honey until they are 1 year Older adults: slower metabolisms, decreased thirst, higher risk for dehydration, calcium and vitamin D substances to prevent osteoporosis Body Mass Index: (BMI) - The patients weight in Kg and dividing that by height in Meters squared - BMI under 18.5, they are considered underweight - BMI between 18.5 and 24.9 considered healthy - BMI between 25 and 29.9 is overweight - MBI of 30 or more is obese Nursing care for patients who have dysphasia (difficulty swallowing) - Sit them in fowlers or high fowlers - Give them 1 med at a time - Lightly stroke chin or throat to help them swallow - Always thicken thin liquids - Check for food pocketing - Encourage patient to tuck their chin when swallowing - Monitor patient during meals and have suction available - Avoid use of straws Different types of diets: - NPO (nothing by mouth) 30 1 - Clear liquid diet : water, tea, coffee, broth, clear juices, gelatin, ginger ale 31 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 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 32 1 anxiety 35 1 Chapter 43: Bowel Elimination Ways to prevent constipation: - Increase fluid intake to 2-3L a day - Increase fiber intake 25-30g a day - -Increase activity level helps stimulate peristalsis FOB test: Fetal Occult blood test - collect 3 samples of stool from 3 separate bowel movements - no urine contamination - a blue color will indicate there is blood in their stool How to administer an enema: - position patient in sims position - lubricate the tip of the enema - insert the tip 3-4 inches - open the clamp with the bag leveled to the patient’s hip - you can raise the bag slowly, 12-18 inches above the anus - if the patient is having cramping and pain you can slow the flow by lowering the bag back down How to change an Ostomy pouch: - remove the pouch carefully, use a washcloth soaked with water and gently pull back - inspect the patient’s stoma, it should be pink, red or moist - it should not be purple or pale - skin should be intact around it - you can clean it with water or soap and water - never use moisturizers on the skin - cut a hole in the skin barrier that is slightly bigger than the stoma, no larger than an 1/8th inch larger than the stoma - apply the skin barrier and the pouch Valsalva Maneuver: - when a patient bares downs or strains, it is important to advise 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 36 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 - menopause - 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 37 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 - Use the vastus lateralis (side of the thigh) for infants less than 1 year old - Ventral gluteal site is best for volume over 2mL - Deltoid site is limited to volumes up to 1 mL - Inject medications up to 90-degree angle Intradermal Injections - Use a tuberculin syringe, 26-27 gauge (the bigger the gauge the smaller the needle) - (TB shot) - use very small volumes, 0.01 -0.1 mL - insert bevel up at a 10-15-degree angle - observe for a small bubble - never massage site 40 1 Subcutaneous Injection - use a 3/8 to 5/8 needle, 25-27 gauge - if you are giving insulin, use an insulin needle which is 28-31 gauge - inject volumes up to 1.5 mL of solution - select fatty sites like the abdomen and lateral upper arms - inject at a 45-90-degree angle - obese patient use 90 degree Mixing Insulins - Never mix a long acting insulin with any other insulins - Can mix regular insulin (clear) with NPH (cloudy) - Insulin suspensions, gently rotate vile between hands don’t shake - STEPS IN MXING REG AND NPH o 1) inject air into the longer lasting insulin which is the NPH (cloudy) o 2) remove needle o 3) Inject air into the shorter acting insulin with is regular insulin (Clear) o 4) Do not remove needle, tilt the vile up and draw up the clear insulin o 5) put that down, then draw up the longer lasting insulin, NPH, (cloudy) second o *** Clear before cloudy ** o ** insert the air in the cloudy first then the air in the clear then drawing up the clear then drawing up the cloudy ** Chapter 47: Safe Medication Administration and Error Reduction All medication has a pregnancy category A, B, C, D, X - A is the safest and X is the most dangerous *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 41 1 - Name of med 42 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 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 45 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 meals to avoid vomiting - Administer a bronchodilator 30 min prior to chest physiotherapy - If you need to collect a sputum sample, you want to collect them early in the morning and ideally through coughing rather than suctioning Suctioning - Nasopharyngeal and Naso tracheal suctioning o Place patient in fowlers or high fowlers o lubricate the catheter distal 6-8 cm with water soluble lube o insert the catheter during inhalation and insert it the distance from the tip of the nose to the base of the ear lobe o apply suction intermittently while withdrawing the catheter while rotating it at the same time for 10-15 seconds o perform up to 2 passes waiting 1 minute between passes 46 1 - Endotracheal suctioning o Place patient in fowlers or high fowlers o The catheter diameter should be less than or equal to half the diameter of the endotracheal tube o Should hyper oxygenate the patient with 100% O2 prior to and in- between suctioning o Use suction pressure of 120-150 mm hg o Advance the catheter until you reach resistance and pull it back 1 cm prior to suctioning o Apply suction intermittently while withdrawing the catheter and rotating it for a max of 10-15 seconds o Never re use the catheter Tracheostomy care - Give oral care every 2 hours and trach care every 8 hours - Suction PRN - Apply O2 loosely if the O2 decreases during procedure - Use surgical asepsis - Use split gauze - Replace trach ties as needed - Secure the new ties before you remove the soiled ones - Home care they should clean with normal saline using medical asepsis and cover it when they go outside Chapter 54: Nasogastric Intubation and Enteral Feedings Inserting an NG tube: - Place patient in high fowlers position - Ahead of time agree on a signal the patient can use if they are feeling stressed during procedure - Lay a towel across patient chest - Used water based lube - Have patient sip water while inserting it - Withdrawal slightly if they gauge or choke - Check placement by checking pH of gastric contents - 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) 47 1 - Oliguria (less pee) - Decreased skin turgor - Decreased cap refill - Flattened neck veins - Dry mucous membranes - Diaphoresis 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 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 50 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 - Symptoms of hypomagnesemia: dysrhythmias, tachycardia, hypertension, tremors, seizure, decreased DTR (EVERYTHING FAST) - Causes of hypermagnesemia: kidney disease, too many laxatives - Symptoms of hypermagnesemia: hypotension, muscle weakness, lethargy, respiratory and cardiac arrest (EVERYTHING GOES DOWN) 51