Fundamentals Review for Final Exam (PDF)

Final Exam  Go back and review your notes and videos of the following topics.  Know Isolation kinds  Wound healing ◦ primary intention ◦ secondary intention etc.  PPE ◦ When to use it and what order for on and off  Must have a doctor’s order  Use the least restrictive...

Final Exam  Go back and review your notes and videos of the following topics.  Know Isolation kinds  Wound healing ◦ primary intention ◦ secondary intention etc.  PPE ◦ When to use it and what order for on and off  Must have a doctor’s order  Use the least restrictive that works  Not a first line intervention  Check every 15-30 minutes; release, toilet and exercise every 2 hours  Signs consent  Check circulation distal to restraints;  Client can refuse—assess their mental function; notify doctor and responsible party; document  Lock before using  Make sure base of lift is spread  Place client in center of sling  Reassure  Get training and plenty of help—do not use alone  Lock wheels  Place closest to the client’s stronger side  Don’t secure any tubing to movable parts  Odorless, tasteless, colorless, non-flammable gas (supports combustion)  Flow meter regulates rate of O2 flow; Fi02 is the percentage of concentration of oxygen  Usually ordered in Liters/minute  Chronic respiratory illnesses will require lower settings of O2 delivery (usually no more than 1-2 L/M  Long term use of oxygen requires humidification  No SMOKING signs and enforce  Know location of fire extinguishers  Never use grease, oil, vaseline, alcohol, ether or ungrounded equipment around oxygen  Breath sounds q shift; o2 sat q 4 hours.  Nasal cannula (bi-prongs) ◦ Documented as BNP or BNC ◦ Fits into nares ◦ Concentrations of 24-44% ◦ No more than 6 liters ◦ Turn O2 on before placing on patient ◦ Tubing goes over ears (may want to pad this area ◦ Nares care ◦ Assess and document skin condition around nares and around ears ◦ Use water soluble lubricant  Face mask ◦ Allows more control over lower O2 levels ◦ Concentration of 60-100% (6-10 liters)— depending on L/M ◦ Should see a fine mist with humidified O2 ◦ Adjust mask so that it fits snugly over nose and covers chin ◦ Reservoir should never completely collapse (if it does, O2 should be turned up at doctor’s order) ◦ Types  Venturi—4-10L/24-55%; very precise amounts  Non rebreather—6-15L/up to 100%  Simple—5-8L/35-55 % O2 delivery  Oxygen Tent ◦ Fine mist, constant temperature, high concentration ◦ Canopy must enclose upper torso of patient ◦ Keep patient dry and prevent chilling—change linens more frequently ◦ Temperature inside canopy should be at 70 degrees ◦ Adjust O2 flow rate to 10-12 L/M ◦ Tuck sides of canopy under mattress ◦ Parent may have to get under tent to keep child under tent  Hyperbaric chamber ◦ Delivers 100% O2 at 3 times atmospheric pressure ◦ Helps regenerate new tissue at a faster rate  Ambu bag ◦ Up to 100% concentration depending on presence of reservoir ◦ Mask must firmly cover mouth, nose to form a seal ◦ Breath delivered every 5 seconds ◦ Ambu bag may be attached to endotracheal tube (ET tube)  Application and Safety  Signs and symptoms O2 toxicity ◦ Seen more in concentrations over 50% for longer than 24-48 hours ◦ Non productive cough ◦ Substernal chest pain ◦ Nasal stuffiness ◦ NV ◦ Fatigue ◦ H/A ◦ Sore throat ◦ Hypoventiliation  Oral hygiene  Forcing fluids  TCDB  Humidification  RACE  PASS  Monitor those at risk more closely  Use call lights, brakes, and side rails appropriately  Teach home safety ◦ Grab bars ◦ Avoid use of rugs ◦ Keep floors clutter free ◦ Night light  Handwashing—single most important way to prevent transmission of pathogens— before and after client contact  Isolation ◦ Depends on how pathogen is spread  Contact—gloves, gown, goggles, mask  Enteric—gloves, gown  Respiratory (droplet/airborne)—mask  Cycle of infection ◦ Pathogen, reservoir, portal of exit, mode of transport, portal of entry, host  Sterile to sterile only  When in doubt, it is contaminated  Review sterile techniques  Factual ⚬ Subjective ⚬ Objective Rules of charting Accurate, concise, pertinent Complete and current Organized and timely Use only symbols/abbreviations approved by facility Correct spelling, English Documentation is about the client and his/her condition Good penmanship, punctuations  Ink only  No white out  Mistakes-1 line through and “error”  Verbal—includes spoken and written  Nonverbal ◦ Check for congruency  No false hopes or cliches  Acknowledge client’s feelings/concerns  Special situations ◦ Confused/agitated—calm, approach slowly ◦ Blind—don’t “sneak up” on them ◦ Hearing impaired—don’t raise your voice, face them when talking; speak clearly and distinctly  Non-invasive  No special prep  Do not require a consent form  Determine pregnancy (Last menstrual cycle)  Remove all jewelry or clothing with metal in the area being tested  Will hold breath during procedure  (E.G.) CXR, Hand, Ankle, Leg  Consent  CBC prior to test  Local anesthetic  Iliac crest (most common)  Pressure dressing—watch for bleeding; s/s of shock  Some tenderness at site expected  Intravenous Pyelogram (IVP) ◦ Kidneys ◦ Check for allergies to iodine ◦ Do before any barium studies ◦ NPO after MN ◦ May require laxative pretest ◦ Force fluids post test  Consent—usually obtained by Radiology  Respiratory difficulties after injection of dye may indicate anaphylactic reaction Consent Assess allergies to dye Keep patient flat 8 hr post test with affected extremity extended Force fluids post test Monitor insertion site for bleeding Do not remove pressure from site—feel under extremity for bleeding Other contrast media tests Renal arteriogram Lung scan Femoral angiogram  Explain  Protect self  Get help as indicated  Be sure to clean the skin appropriately  Make sure have correct collection tube and order of draw  Release tourniquet before removing venipuncture needle  Apply pressure to site posttest  Lighted instrument to direct view internal structures  All are NPO post MN and require consent form  Consent form  Bowel prep for colonoscopy  NPO after MN  NPO afterwards for Bronchoscopy and EGD until gag and swallowing reflex returned; monitor  Vital signs post procedure every 30 minutes until stable  Monitor for respiratory distress with bronchoscopy  Monitor for bleeding if polyps are removed (colon)  Do not touch the inside of the container  Label the container not the top  Mid-Stream—clean, void a little, then collect urine  Sterile—only real way is to catheterize; ◦ Foley—clean port with alcohol then collect with syringe  If C & S and antibiotics are ordered, collect specimen first  24 hour Urine—discard first; keep the last and every amount in between; keep on ice; if any lost—start over.  Sterile procedure performed by the provider  Informed consent  Position according to procedure (Review sites)  Monitor access site post procedure for bleeding along with vital signs  Monitor for respiratory distress/breath sounds with thoracentesis/hemoptysis  Empty bladder with paracentesis and a amniocentesis ◦ Uses sound waves that bounce off solid structures and produces a picture ◦ Most be done before barium studies or after a post barium laxative has been effective ◦ Non invasive ◦ Most patients must be NPO except with echocardiogram and pelvic ◦ E.G.  Pelvic/OB—force fluid pretest and don’t void  Liver—NPO  GB—NPO  Echocardiogram  No special prep  WBC--5000-10,000 ◦ Neutrophils ◦ Basophils ◦ Monocytes ◦ Eosinophils ◦ Lymphocytes  RBC—4.2-6.1million males  4.2-5.4 million females  HCT ◦ Male—42-52% ◦ Female—37-47%  Hgb ◦ Male—14-18 g/100ml ◦ Female—12-16 g/100ml  Platelets ◦ 150,000-400,000  APTT ◦ used to monitor Heparin therapy ◦ Therapeutic range in Heparin therapy is 1.5-2.5 times the control or normal ◦ Normal 60-70 seconds  PT ◦ Used to monitor Coumadin therapy ◦ Therapeutic range on Coumadin therapy is 1.5-2.0 times the control ◦ Normal—11.5-12.5 seconds  INR—international normalized ration ◦ Used in conjunction with PT for clients on Coumadin ◦ Therapeutic ranges are from 2.0-3.0 depending on client’s problem  60-110 mg/dl (normal fasting levels)  No special prep unless ordered as fasting— then must be NPO overnight  Fasting  Accuchek  Post-prandial  Gives accurate picture of blood sugar levels over previous 120 days  Can be drawn at any time; no special prep  Elevated with diabetes mellitus  Normal values ◦ Adult  4-7% ◦ Child  1.8-4% ◦ Poor diabetic control  10-20%  Recheck blood sugar frequently to make sure it’s remedied. ◦ OJ or other fruit juice ◦ Hard candy or honey ◦ Commercial glucose ◦ Glucagon by SC, IM or IV ◦ Glucose 10% or 50% IV  No special prep  Elevations seen in gout  Normal value: 3.0-7.0 mg/dl  Looking at kidney function  Elevations seen in kidney failure  Normal level: 0.6-1.2 mg/dl  Blood Urea Nitrogen  Looking at kidney function  Elevations seen in dehydration and kidney impairment  Normal level: 10-20 mg/dl  Potassium ◦ 3.5-5.0 mEq/L  Sodium ◦ 135-145 mEq/L  Triglycerides ◦ NPO 12-14 hrs ◦ No alcohol for 24 hrs prior to test ◦ High fat ingestion up to 2 weeks prior to test may elevate findings ◦ Normal findings  Male—40-160 mg/dl  Female—35-135 mg/dl ◦ > 400 mg/dl is critical  HDLs  LDLs ◦ 30-80 mg/dl ◦ 60-180 mg/dl ◦ Lower the level, the  VLDL greater the risk for heart ◦ 25-50% disease ◦ NPO ◦ NPO 12-14 hrs ◦ Smoking and alcohol can ◦ Smoking and alcohol may elevate values lower levels  Fast 12-14 hrs after eating low fat diet  No alcohol 24 hrs prior to test  Normal values ◦ Adult/elderly  < 200 mg/dl  W-D ◦ Apply wet ◦ Allow to dry ◦ Used for wound debridement ◦ Sterile procedure ◦ Discard wetting solutions after 24 hours ◦ Cleanse wound prior to placing new dressing ◦ Document condition of wound and any drainage or odor  Collect culture after cleaning wound of any old drainage  Use a sterile swab stick or syringe  Gentle washing of an area with stream of solution through and irrigating syringe ◦ to prevent further tissue damage and intro of bacteria  Promotes wound healing and comfort  Method of cleansing wound and medication admin. ◦ Most common used-NS (isotonic solution)  Irrigation principles ◦ Irrigation solution flows from least contaminated to most contaminated ◦ Cleanse in direction of least contaminated to most contaminated  Wash hands before and after  Protect self (PPE)  Uses either a syringe alone or a syringe with IV catheter or needle  Use a collection device to catch irrigation fluid  Suction before  Sterile procedure  Do not remove outer cannula  Place in Semi-Fowler’s position  Never remove the outer cannula—only the inner cannula  Rinse inner cannula with sterile saline after cleaning with peroxide  Remove only one side of the cotton tie at one time when changing ties—making sure to keep tracheostomy tube stabilized  Tie at side of neck  Auscultate lung sounds afterwards  Good oral hygiene  Nasopharyngeal/Tracheal—sterile ◦ Review procedures  Oropharyngeal—clean  Suction only when coming out  Assess respiratory status before and after  Sterile  Insert past the point of getting urine  Inflate balloon  Don’t kink the tubing  Don’t have dependent loops  Don’t allow client to lie on tubing  Don’t allow drainage bag to go above bladder  Use port to get specimen with needle/syringe  Empty at end of shift  Assess for bladder distention when no output in catheter or after removal  Large bag for nighttime  Changed every month  24 hour ◦ Collect all urine with the 24 hours ◦ Keep on ice ◦ Have client empty bladder and discard at beginning ◦ Have client empty bladder and keep at end  Midstream ◦ Clean, void a little bit, then collect in cup  Indwelling Urinary Catheter ◦ Clean port with alcohol prep ◦ Use needle/syringe to collect ◦ May need to clamp tubing for no longer than 30 minutes  Clean procedure  Types ◦ Fleets ◦ Retention ◦ SSE ◦ TWE ◦ Carmative  Steps ◦ Left Sim’s position ◦ Temperature—no higher than 105 ◦ Don’t put soap in until the water is in ◦ No higher than 18 inches ◦ Usually no more than 3 buckets without doctor’s permission ◦ Review procedure  Upright position  Always check placement and residual— follow orders. Unless otherwise ordered hold for more than 100 mL  Return residual to stomach  Flush before and after  Give bolus by gravity  Monitor weight, breath sounds, I & O  Bathing ◦ No soap on face unless specifically requested ◦ Rinse all soap from body ◦ Dry by patting—especially between skin folds and toes ◦ Use long, smooth strokes back toward the heart  Therapeutic ◦ Tepid ◦ Sitz ◦ Medicated  Monitor skin for breakdown  Includes pain and weight  Know the normals for adults  Weights ◦ Same scale ◦ Same amount of clothing ◦ Same time of day  Pain ◦ Always assess before medicating and assess post- medication for therapeutic effect ◦ Vital signs (but not temp) are usually elevated with acute pain—narcotics more likely to be prescribed for acute pain ◦ Believe the patient  6 rights  Verify order  Medication routes will affect absorption ◦ PO ◦ SL ◦ SQ ◦ IM ◦ IV  Order of  Monitor for therapeutic and nontherapeutic effects  Assess for allergies—always  Instruct on drug, dose, route, purpose, special instructions  Errors  Life threatening allergic reactions  Physician discusses the risks, benefits, etc.  Nurse responsible for witnessing signature  If client has questions, then ensure they’re answered prior to procedure or consent  Usually with invasive procedures  Do not chart in nursing notes that report was filed  Documents unusual events  Use factual information only  Definitions:  Assault – an intentional threat to cause bodily harm to another; does not have to include actual bodily contact  Assault is an act that creates an apprehension in another of an imminent, harmful, or offensive contact. The act consists of a threat of harm accompanied by an apparent, present ability to carry out the threat.  Battery – Unlawful touching of another person without informed consent  Defamation  Slander – Malicious or untrue spoken words about another person that are brought to the attention of others  Libel – A malicious or untrue writing about another person that is brought to the attention of others  Tort – A type of civil law that involves wrongs against a person or property; torts include negligence, assault, battery, defamation, fraud, false imprisonment, and invasion of privacy.  Client right  Keep door closed, no photographs  Keep client information confidential  Do not try to access records of any client that is not part of your responsibilities  Four things must be proved ◦ Duty ◦ Duty was breached ◦ Injury occurred ◦ Proximate cause—the breach of duty was the cause of the injury  Written by the American Hospital Association  List of client rights ◦ Right to information ◦ Right to refuse ◦ Right to adequate, competent care ◦ Right to have their bill explained ◦ Right to confidentiality ◦ Etc.  Delegation—transferring to a competent individual the authority to perform selected nursing task in a selected situation  Accountability—being responsible and answerable for actions or inactions of self or others in the context of the delegation process  Unlicensed Assistive Personnel (UAP)—any unlicensed personnel, regardless of title, to whom nursing tasks are delegated  Supervision—provision of guidance or direction, evaluation, and follow-up by a licensed nurse for the completion of assigned tasks delegated to UAP  Delegable task.  Patient’s needs.  Competency of UAP  Communication with the UAP  Evaluation  Tasks to delegate (right task)  Under what circumstances (right circumstances)  To whom (right person)  What information to communicate (right direction/communication)  How to supervise/evaluate (right supervision/evaluation)  Must provide clear instructions when delegating a task initially and for periodic reassessment and evaluation of the outcome  RNs delegate to other RNs, LPNs, and AP  LPNs delegate to other LPNs and AP  Only delegate tasks appropriate for the skill and education level of the nurse who is receiving the assignment  RNs cannot delegate the nursing process, client education, or tasks that require nursing judgement to LPNs or APs  Predictability of outcome  Potential for harm  Complexity of care  Need for problem solving and innovation  Level of interaction with the client  Education, training, experience  Knowledge and skill to perform the task  Level of critical thinking required to complete the task  Ability to communicate with others as it pertains to the task  Demonstrated competence  Facility policies and procedures  Licensing legislation (nurse practice acts)  Examples in ATI book page 44  Actions Increase cardiac output by increasing the force of myocardial contraction (called positive inotropic activity) Slow conduction and decrease heart rate through negative chronotropic effect Uses Heart failure Atrial fibrillation  Headache, weakness, drowsiness  S/S toxicity  Visual disturbances  Arrhythmias  GI upset and anorexia  Lanoxin—digoxin Loading dose Therapeutic drug level 0.8-2.0 ng/ml Dig toxicity—green/yellow visual disturbance, anorexia, nausea, vomiting Changes in cardiac function Monitor potassium levels—hypokalemia predisposes to dig toxicity Antidote—digibind (digoxin immune) Primacor—milrinone lactate—IV only  Nitrates ◦ Relax smooth muscles (vessels) increasing blood flow to the myocardium  Calcium Channel Blockers ◦ Slow conduction ◦ Dilate coronary arteries ◦ Depresses contractility of the heart  Nitrates ◦ Relieve pain associated with angina ◦ Prevention of anginal attacks ◦ Treatment of chronic stable angina  Calcium Channel Blockers ◦ Anginal pain ◦ Hypertension  Nitrates ◦ Headache(hallmark effect), dizziness, weakness, hypotension, flushing  Calcium Channel Blockers ◦ Dizziness, lightheadedness, fatigue, nausea, constipation, peripheral edema, hypotension, bradycardia, nasal congestion, cough  Nitrates ◦ ISMO, Imdur—isosorbide mononitrate ◦ Isordil—isosorbide dinitrate ◦ Nitro-Bid, Nitrostat—nitroglycerin  Calcium Channel Blockers ◦ Norvasc—amlodipine ◦ Cardizem— diltiazem HCL ◦ Plendil—felodipine ◦ Cardene—nicardipine HCL ◦ Procardia, Adalat—nifedipine ◦ Calan, Isoptin—verapamil HCL  Give SL nitroglycerin 1 every 5 minutes x 3—if pain still present, call doctor  Monitor vital signs—take an apical pulse  Protect safety  Monitor and document chest pain  Get a new bottle every 3 months  Keep Nitro in brown bottle  Rise slowly from lying or sitting position  Nitro should tingle or sting when used  Rotate patch sites, remove old  Keep nitro with you at all times  Hypertension  Hypertensive emergencies  Diagnosis of pheochromocytoma (alpha- adrenergic blocking drugs)  Peripheral vasodilators Hypotension, dizziness, angina, headache Hirsuitism, nasal congestion, fatigue, sodium and water retention Beta-blockers CHF, dizziness, bradycardia, arrhythmias, decreased libido, impotence, constipation/diarrhea  Anti-adrenergic drugs—centrally acting ◦ Drowsiness, sedation, headache, dry mouth hypotension, syncope fluid retention, constipation  Antiadrenergic drugs—peripherally acting ◦ Headache, fatigue, hypotension, lethargy, dyspepsia, headache  Alpha Adrenergics ◦ Headache, fatigue, hypotension, sexual dysfunction, lack of energy  ACE inhibitors ◦ Nausea, cough, hypotension, headache, fatigue  Angiotensin II Receptor Antagonists ◦ Diarrhea, abdominal pain, hypotension, fatigue, headache, lightheadedness, URI symptoms, cough  Hypertensive Emergency Drugs ◦ Dizziness, weakness, nausea/vomiting, sodium and water retention, apprehension, headache  Peripheral Vasodilators Apresoline—hydralazine HCL Loniten—minoxidil Beta Blockers—olol drugs Tenormin—atenolol Lopressor, Toprol—metoprolol Corgard—nadolol Inderal—propanolol (non-selective) Blocadren—timolol maleate  Calcium Channel Blockers ◦ Norvasc—amlodipine ◦ Procardia, Adalat—nifedipine ◦ Cardizem—diltiazem HCL  Antiadrenergic Drugs—Centrally acting ◦ Catapres—clonidine HCL ◦ Tenex—guanabenz acetate ◦ Aldomet—methyldopa  Antiadrenergic Drugs—peripherally acting ◦ Cardura—doxazosin ◦ Ismelin—guanethidine monosulfate  Alpha-Adrenergic Blockers ◦ Regitine--phentolamine  Alpha/beta blockers Coreg—carvedilol Normadyne, Trandate—labetalol HCL ACE inhibitors—pril drugs Lotensin—benazepril HCL Capoten—captopril Vasotec—enalapril Mavik—trandolapril Zestril--lisinopril  Angiotensin II Receptor Antagonists— sartan drugs ◦ Atacand—candesartan cilexetil ◦ Avapro—irbesartan ◦ Cozaar– losartan potassium ◦ Micardis—telmisartan ◦ Diovan—valsartan  Hypertensive Emergency Drugs—IV only ◦ Hyperstat--diazoxide ◦ Nitropress—nitroprusside sodium  Take blood pressure before giving meds  Monitor for adverse effects  I & O  Dangle before getting out of bed  Do not stop your drug(s) abruptly  Report adverse effects to physician  Take as directed  F/U care  Report s/s of HF (sudden weight gain, swelling, SOB)  Do not use OTC cold preparations without clearing with physician