NUA3200 Student Guide Exam 3 Fall 2024 PDF

**EXAM 3** **Week 7 Objectives** Medication Administration 1. Identify appropriate needle sizes and landmarks for intradermal, subcutaneous, and intramuscular injections. Intradermal: A 27- to 31- gauge, ½ inch needle is used. Inner forearm and upper back are ideal locations. The needle sho...

**EXAM 3** **Week 7 Objectives** Medication Administration 1. Identify appropriate needle sizes and landmarks for intradermal, subcutaneous, and intramuscular injections. Intradermal: A 27- to 31- gauge, ½ inch needle is used. Inner forearm and upper back are ideal locations. The needle should be inserted bevel up at 5-15 degrees Subcutaneous: A 25- to 30- gauge, 3/8- to 5/8- inch needle. Upper arm, thighs, abdomen, buttocks. The needle should be inserted at an angle of 45 to 90 degrees. Intramuscular: A 18- to 25- gauge that is 5/8- to 1 ½ inches long. Deltoid muscle, vastus lateralis muscle, and gluteus medius muscle. The angle of insertion should be 90 degrees. 2. Discuss factors to consider when administering intradermal, subcutaneous, and intramuscular (including the Z-track method) medications. Intradermal: Very small volume in these injections; be sure to watch for anaphylactic reactions; choose a site that is lightly pigmented, free of lesions, and relatively hairless; the bevel of the needle is positioned upward to ensure a bleb (a raised area of skin that indicates the injection has stayed in the dermal layer) Subcutaneous: Maximum injection volume is 1 milliliter or less; slower absorption rate than intramuscular injections. Intramuscular: Maximum injection volume is 3 milliliters; faster absorption than SQ injections because of the increased vasculature in the muscle tissue; the Z-track method is recommended to reduce tissue irritation after the injection (Z-track method is where you displace the skin and the subcutaneous tissue at the site by about 1 to 1 ½ inches with the side of your nondominant hand. Maintain this displacement throughout the injection and release it immediately after you withdraw the needle from the skin.) 3. Differentiate between vials and ampules Vials: can be multi dose or single dose; contain either liquid or dry powder that needs to be reconstituted; the instructions will be found on the lid; the top of the vial has a rubber seal into which the needle goes; air needs to be injected into the vial prior to withdrawing medication to prevent a vacuum from developing inside the vial (prevents build-up of negative pressure) Ampules: made of glass with a cap that needs to be broken off at a pre-scored mark; use a filter needle to draw up medication (prevents entry of glass into the syringe); unlike a vial, no air needs to be injected into a vial prior to withdrawing the medication 4. Identify factors to consider when choosing routes of medication. The part of the body being treated, the way the drug works within the body, and the formula of the drug 5. Describe types and components of medication orders. Routine: scheduled medications that are ordered at a certain time or frequency Standing: orders nurses can use without contacting the health care provider when certain criteria are met PRN: as needed medications, most used for pain, nausea, constipation, and indigestion One time: medications that are only ordered for a specific time and not repeated Stat: medications that need to be given within 15 minutes of the order Components: Clients full name, Date and time that the order is written, Medication name, Dose, Route of administration, Time and frequency of administration, Signature of health care provider 6. Identify the six rights of medication administration. The right medication The right dose The right client The right route The right time The right documentation 7. Discuss the nurse's role and responsibilities in medication administration. Administration: always follow the six rights of medication administration, ensure that the client receives medications safely, and evaluate the use of herbal therapies that could interfere with the medication Observation and Documentation: evaluate the effects of the medication on the client's health status; if withholding a drug, record the reason and follow the institutional policy for noting withheld doses Patient Education: open medications in front of the client and discuss the reason for giving it so that the client knows what they are taking and why; teach clients about any side effects; reinforce the importance of adherence to the medication regimen; evaluate the client's technique of self-administration; instruct the client and/or family about specific information pertaining to their medication regimen **Week 8 Objectives** Bowel Elimination-GI Tubes 1. Discuss age-related changes in the GI tract. Infancy: small stomach, decreased enzymes, rapid peristalsis, lack of control to defecate Older adult: decreased peristalsis, decreased salivation, weaker perineal muscle, missed defection signals 2. Describe factors influencing bowel elimination. - Age - Diet: fiber bulks stool. Increases peristalsis, and softens stool - Fluid intake: fluids liquify intestinal contents and ease the passage of stool - Positioning: squatting is better than supine - Physical activity: promotes peristalsis, maintains muscle tone of pelvic floor and abdominal muscles - Psychosocial: stress accelerates peristalsis, depression decreases peristalsis - Alterations in person habit: lack of mobility, personal preference, embarrassment - Medications: laxatives increase peristalsis, cathartics soften stool, NSAIDs, Antibiotics side effect can be diarrhea, opioids side effect can be slowing of peristalsis - Pain: hemorrhoids, if it hurts to have a bowel movement they will have more difficulty - Pregnancy: peristalsis is slowed - Surgery/anesthesia: slows down or stops peristalsis 3. Identify common bowel elimination problems and interventions Common problems: - Constipation - Impaction - Diarrhea - Incontinence - Flatulence - Hemorrhoids Interventions: - Diet education (increase fiber, increase fluids, fruit juices) - encourage activity/exercise - medications (constipation-laxatives/cathartics enemas; diarrhea-antidiarrheals) - establish bowel regimen - maintain privacy for elimination 4. Explain common diagnostic examinations of the GI tract. - Abdominal x-ray: includes abdomen as well as kidney, ureter, and bladder - Upper GI (barium swallow): x-ray using contrast (barium) to examine structures and movement of upper GI tract, NPO after midnight, increase fluid after exam to clear the barium out of the GI tract - Barium enema: x-ray with contrast to examine lower GI, NPO after midnight, bowel preparation, increase fluids after exam to clear the barium out of the GI tract - Ultrasound: use of sound waves to visualize organs, preparation varies depending on the organ to be visualized - Upper endoscopy (esophagogastroduodenoscopy, or EGD): viewing of upper GI tract through fiber optic scope, NPO, light sedation, important to check for return of the gag reflex after procedure - Colonoscopy: viewing of entire colon using a fiber optic scope through the rectum, clear liquids day before then NPO, bowel cleanser until stool is clear liquid, light sedation, abdominal bloating after procedure is normal - Flexible sigmoidoscopy: exam of sigmoid colon through scope/tube, NPO, prep similar to barium enema, they will not have to do complete bowel prep usually just an enema in the morning, light sedation - Computerized tomography (CT) scan: scan of body from various angles, analyzed by a computer, NPO, client needs to lie still, typically give dye by mouth and intravenously - Magnetic resonance imaging (MRI): noninvasive exam using magnets and radio waves to produce a picture a picture of the inner organs/body, NPO 4-6 hours before, nonmetallic objects - Enteroclysis: x-ray of the entire small intestine with the use of contrast, introduction of contrast into the small intestine via a nasogastric tube, 24-hour clear liquids, colon cleaning the morning of test with an enema 5. Describe the purposes for nasogastric tubes. Decompression: removal of secretions and gas from the GI tract, prevention or relief of abdominal distention, commonly used for bowel obstruction Compression: internal application of pressure by means of inflated balloon, prevents internal esophageal or GI hemorrhage, used when there is bleeding in the GI tract Lavage: irrigation of stomach, used in cases of active bleeding, positioning, or gastric dilation, overdose of medication Enteral Feeding: instillation of liquid nutritional supplements or feedings into the GI tract, used when unable to swallow safely or cannot take enough nutrition orally but has a functioning GI tract 6. Discuss nursing care for placement and care of nasogastric tubes. Prior to nasogastric tube placement: - Check order for tube placement - Asses client nares for patency - Review clients history - Sit client in high fowlers position - Measure distance from tip of nose to earlobe to xiphoid process - Lubricate the end of the tube Placement of nasogastric tube: - This can be very uncomfortable so there may be some gagging. Make sure you are giving the client time if they need it during the placement. - Clean procedure (not sterile) - Instruct the client to flex head forward and swallow gently as you advance the tube - Advance the tube until the mark on the tube is reached - Secure the tube - Verify placement (test pH of aspirated contents and check x-ray) - Assess for signs and symptoms of placement in the lung Care of nasogastric tubes: - Assess client's nares and mucosa for inflammation and excoriation - Monitor tape or fixation device frequently to ensure placement and check for irritation - Frequent lubrication of nares - Frequent mouth care - Nothing by mouth - Maintain patency 7. Describe the principles of enteral nutrition. Maintains intestinal function, decreases risk for sepsis, decreases mortality, and minimized the hypermetabolic response to trauma. 8. Discuss the complications associated with nasogastric tubes. - Pulmonary aspiration - Diarrhea or constipation - Nausea, vomiting, or both - Abdominal cramping - Tube occlusion - Tube dislodgement - Delayed gastric emptying - Electrolyte imbalances - Fluid overload - Hyperosmolar dehydration 9. Identify the nurse's role when caring for a client with a feeding tube. Keep the head of the bed at 40-45 degrees at all times, particularly in the hour after feedings are completed. Measure gastric residuals by drawing back all the gastric secretions using a syringe to assess how much feeding is left in the stomach. This should be done every 4-6 hours for continuous feedings and immediately prior to administering bolus or intermittent feedings. Flush enteral feeding tubes every 4 hours with at least 30 mL to keep the tube patent. Verify the placement every 4-6 hours by aspirating gastric contents, observing appearance, and testing pH. 10. Explain the use of other access tubes for feeding. Usually placed for long-term feeding (more than 4 weeks) to reduce the discomfort of a nasal tube and provide more secure, reliable access Gastrostomy: placement of a feeding tube through the skin and the stomach wall, directly into the stomach via a surgical procedure. Jejunostomy: placed in the jejunum, alternative to gastrostomy when the stomach is unsuitable for feeding tube or there is a higher risk of aspiration, surgical procedure. Percutaneous endoscopic gastrostomy tube: one end of this flexible silicone tube sits inside the stomach and is held in place with a balloon like tip, procedure takes 30 minutes, tube is put into stomach through a small opening in skin using a special camera or endoscope **Week 9 Objectives** IV Therapy-TPN-Fluid and Electrolyteshn 1. Discuss the purpose of intravenous therapy. The fastest route to administer fluid or medications. It can be used for maintenance or replacement of fluids or electrolytes, medication administration, blood administration, chemotherapy, and administration of radiographic dyes. 2. Describe the types of intravenous devices. Peripheral IV: placed in a smaller peripheral vein and are for short-term use (72-96 hours), try not to place these in areas of flexion (wrists and antecubital), need to be routinely flushed Central Line: end of the catheter terminates in a central vein (e.g., superior vena cava, subclavian, internal jugular); these catheters are good for: long term use, medications that are vesicants, parenteral nutrition, patients with difficult intravenous access 3. Identify methods to administer intravenous medication and/or fluid. Bolus or "IV push", secondary or "piggyback", or continuous infusion 4. Explain types of infusions. Gravity: involves dripping fluids through tubing without a pump attached to it Electronic Infusion Device: these are often referred to as IV pumps and are the most common method seen in the hospital, these will deliver an hourly infusion rate that you set electronically, use positive pressure to deliver fluid Mini Infuser: allows you to hook a syringe you've drawn up to device and slowly push medication, this is often used for medications that have to be pushed slowly 5. Employ the principles of maintaining intravenous therapy. Ensure that the system is sterile and intact. Use alcohol to cleanse the access point whenever there is a break in the system. You also need to ensure that the rate of fluid or medication is maintained. IV fluid is ordered to infuse at a specific rate and is called the infusion rate or the flow rate. Monitor the IV site and patency. Change IV tubing, bags, and dressings per hospital protocol. Monitor for complications of IV therapy. 6. Describe the types of intravenous solutions. Isotonic: Isotonic fluid has the same osmolality as body fluids and is the same concentration as body fluids. Cells will not gain or lose fluid, so it doesn't promote a shift of fluid in or out of cells. Isotonic fluid replaces extracellular volume and is used to treat dehydration. It is the most common type of IV fluid. Hypotonic: Hypotonic fluid has an osmolality that is less than body fluids and is more diluted. It moves fluid into the cells and can cause hypotension as fluid shifts from the vascular bed into the cells. Hypotonic fluid replaces extracellular volume and rehydrates the cell. It is used for dehydration or to treat hypernatremia. Hypertonic: Hypertonic solution has an osmolality that is greater than body fluids and is more concentrated. It moves fluid out of the cells and into circulation and can shrink cells. Hypertonic solution is used to correct electrolyte imbalances (e.g., hyponatremia) and when treating cerebral edema. 7. Explain complications of intravenous therapy. Phlebitis: inflammation of the vein characterized by a red streak going up the line of the IV Infiltration: occurs when the IV fluid enters the subcutaneous tissue either because of catheter dislodgement or rupture of the vein Infection: can occur at the catheter entry site and tends to occur less often than phlebitis and infiltration 8. Define total parenteral nutrition (TPN). Is a way to provide nutrition to clients when the gastrointestinal tract cannot be utilized. It is called total as it provides all the fluid and nutrients required for a client. Must be administered through a central access device which differentiates it from peripheral parenteral nutrition. 9. Identify indications of parenteral nutrition. TPN is indicated for clients with nonfunctional gastrointestinal tracts, clients on extended bowel rest, preoperative clients, or those that are in highly stressed physiological states. 10. Discuss goals for parenteral nutrition. 11. Identify metabolic complications of parenteral nutrition. - Electrolyte imbalance - Hypercapnia - Hypoglycemia - Hyperglycemia - Hyperglycemic hyperosmolar nonketotic dehydration/coma 12. Explain nursing responsibilities with parenteral nutrition. Central line: if using a solution with more than 10% dextrose (TPN), a central line is required. PPN does not require a central line, but TPN is used more frequently. Confirm the placement of the central line with an X-ray first. Collaboration: double check orders with the physician before administering anything, TPN also requires collaboration with the physician, dietician, and pharmacist IV: TPN always requires the use of an IV pump and dedicated line, check solution for particulate matter Monitoring: daily labs are required to assess whether or not the formula needs to be adjusted, PBG is required at least every six hours, you will also have to monitor for metabolic and catheter-associated complications Starting and Stopping TPN: TPN must be gradually started and gradually stopped to prevent hypo- or hyperglycemia 13. Discuss pneumothorax. May occur during the placement of a central catheter due to an accumulation of air in the pleural cavity, causing a collapse of the lung. Symptoms include sudden, sharp chest pain, dyspnea, hypoxia, or coughing. Evaluate a client for 24 hours after a central line is placed and look for signs and symptoms of pulmonary distress. A chest x-ray is completed immediately following any central line placement to monitor for the complications of pneumothorax. 14. Discuss air embolism. May occur during the insertion or removal of a central catheter or when changing the tubing or cap. It occurs when air enters the vasculature. Interventions: maintain the integrity of the closed IV system when changing caps and tubing, have the client perform a Valsalva maneuver while assuming a left lateral decubitus position during catheter insertion. When removing the line, have the client bear down when pulling out the line. 15. Discuss catheter occlusion. A catheter is occluded when there is no flow in the line or difficulty flushing the line. Interventions can be performed by attempting to flush the catheter or aspirate a clot. If still unsuccessful, follow the institution's protocol for use of a thrombolytic agent. An important way to prevent this complication is to follow policies regarding the frequency of flushing central line catheters. 16. Discuss catheter sepsis (CLABSI). The clinical manifestations of catheter sepsis may include fever, chills, glucose intolerance, or positive blood culture. Prevention of catheter sepsis is the reason why we: - Utilize sterile technique during dressing changes - Change the dressing per institution policy or when it becomes wet or contaminated - Scrub all access ports of the IV with an appropriate agent and for the appropriate time - Change IV tubing according to facility policy - Change tubing and total parenteral nutrition bag every 24 hours when TPN is infusing 17. Describe fluid intake and output. Fluid intake for healthy adults ranges from 2,200-2,700 ml. This intake is done via drinking, eating, as well as metabolizing. The average fluid output for healthy adults is also about 2,200-2,700 ml. Fluid output is excreted through the skin, lungs, gastrointestinal tract, or kidneys. 18. Identify common fluid and electrolyte imbalances. - Fluid - Fluid deficit vs. Fluid excess Electrolytes: - Sodium - Hyponatremia vs. Hypernatremia - Potassium - Hypokalemia vs. Hyperkalemia - Calcium - Hypocalcemia vs. Hypercalcemia - Magnesium - Hypomagnesemia vs. Hypermagnesemia 19. Describe causes and signs and symptoms of fluid and electrolyte imbalances. - Fluid deficit: - Postural hypotension - Tachycardia - Oliguria - Dry mucous membranes - Thirst - Restlessness and confusion - Hypovolemic shock - Fluid excess: - Sudden weight gain - Edema - Crackles in dependent portion of lungs - Pulmonary edema - Jugular vein distention **Sodium** - Hyponatremia: - Apprehension - Nausea and vomiting - Headaches - Decreased level of consciousness and possible coma - Seizures - Hypernatremia: - Extreme thirst - Dry and flushed skin - Postural hypotension - Fever - Confusion and/or agitation - Coma - Seizures **Potassium** - Hypokalemia: - Fatigue and muscle weakness - Nausea and vomiting - Cardiac dysrhythmias - Hyperkalemia: - Anxiety - Abdominal cramps and diarrhea - Muscle weakness - Cardiac dysrhythmias and cardiac arrest **Calcium** - Hypocalcemia: - Numbness and tingling of fingers and mouth - Hyperactive reflexes - Muscle twitching - Tetany - Seizures - Laryngospasm - Cardiac dysrhythmias - Hypercalcemia: - Anorexia - Nausea and vomiting - Constipation - Fatigue and lethargy - Diminished reflexes - Change in level of consciousness and confusion - Cardiac dysrhythmias - Possible flank pain from renal calculi - Pathological fractures **Magnesium** - Hypomagnesemia: - Hyperactive reflexes - Insomnia - Muscle cramps and twitching - Dysphagia - Tachycardia and hypertension - Tetany - Seizures - Cardiac dysrhythmias - Hypermagnesemia: - Lethargy - Hypoactive reflexes - Bradycardia and hypotension - Flushing and sensation of warmth - Hypoventilation - Muscle paralysis - Cardiac dysrhythmias and cardiac arrest 20. Interpret basic fluid and electrolyte laboratory values. Fluid Deficit: Increased hematocrit & Urine specific gravity\>1.030 Fluid Excess: Decreased hematocrit & BUN\