RN Exam 1 PDF

​ Preparatory module ○​ Role of the RN in QI: ​ what can be improved and taking action to improve system ○​ Clinical judgment ○​ Critical thinking: ​ prioritize, importance of cues, respond and report ○​ Clinical reasoning ○​ Systems thinking...

​ Preparatory module ○​ Role of the RN in QI: ​ what can be improved and taking action to improve system ○​ Clinical judgment ○​ Critical thinking: ​ prioritize, importance of cues, respond and report ○​ Clinical reasoning ○​ Systems thinking ○​ Rapid response team vs Code Team: RRT for sudden changes in condition. Code- cardiopulmonary arrest ○​ Safe delegation: ​ can’t include assessment/evaluation or education ​ Can delegate down, up and lateral ​ 5 rights of delegation ​ Scope of practice/policies ○​ Failure to rescue: ​ failure to recognize changes in condition and response/report appropriately ​ ED Nursing ○​ Vulnerable populations ○​ Social determinants of health ○​ Safety in the ED ○​ Priorities of care- ​ Primary survey: bleeding, airway/c-spine, breathing, circulation, disability (GCS), expose/protect. ​ Triage: ​ 1- need physician upon arrival, cardiac arrest ​ 2-can wait about 5 minutes, cp ​ 3-can wait hours but needs full workup, abdominal pain with normal vitals ​ 4- can wait hours, need minimal care ​ 5-can wait days, needs no care ex. Med refill ​ Pts in waiting room should be rechecked every hour  ○​ Mechanism of injury: ​ The forces applied to the body and can be used to predict likely injury patterns and severity (blunt trauma, penetrating trauma). ○​ Complications of trauma: Triad of death ​ Hemorrhage, airway compromise, sepsis and hypothermia ​ Need to be warm, perfusion, oxygenation ​ Fluids, Electrolytes ○​ How ions and water move- ​ Fluids are water with dissolved or suspended substances ​ Glucose, proteins, ions, and cells ​ Electrolytes are mineral salts that dissolve in water and separate into ions (charge particles) ​ Cations include chloride, bicarbonate, and phosphate ​ Homeostasis is maintained through… ​ Diffusion (high to low) ​ Osmosis: (low to high) ​ Filtration: (high to low) ​ Active transport (ATP):( low to high) ​ Fluid distribution includes filtration between spaces ​ Kidneys ​ Vascular ​ Interstitial ○​ Homeostasis: ​ the dynamic state of equilibrium maintained by living organisms required for optimal functioning of cells, tissues, organs, organ systems and Organism. ○​ Fluid Volume assessment: ​ Intake and output measurement, physical assessment, lab work, urinalysis, daily weights (a L = 2.2lbs) ​ Sensible losses (measurable losses) ​ kidneys/urine, diarrhea, emesis ​ Insensible losses ​ Lungs, skin ○​ FVO: ​ Weight gain, ​ Hypertension ​ Tachycardia ​ Tachypnea ​ bounding pulse ​ Crackles ​ Dyspnea ​ Orthopnea ​ pitting edema (Edema = error of filtration) ​ jugular vein distention ​ Bulging fontanels and periorbital edema ​ Hemodilution ○​ Treatment:  ​ Diuresis ​ Safe removal of water ​ Electrolyte balance ​ Diuretics ​ Limit oral salt intake ​ Oral fluid restrictions (if CHF or hemodilution) ○​ FVD- ​ weight loss ​ Hypotension ​ Tachycardia with thready pulses ​ poor/tenting turgor ​ Flat neck veins ​ dry cracked mucus membranes ​ Oliguria. ​ Hemoconcentration ○​ Treatment: ​ Oral solutions ​ Salts and water ​ Not concentrated glucose ​ IV Solutions ​ 20 mL/kg bolus ​ Goal ​ PO: 64 ounces ​ Output: 720 mL clear urine ​ Isotonic- equal osmotic pressure ​ Hypotonic- lower osmotic pressure ​ Hypertonic- higher osmotic pressure ​ Fluid balance in children: ○​ When the output exceeds the intake ○​ Causes: ​ diarrhea ​ Sweating ​ Medications ​ diabetic ketoacidosis (metabolic acidosis) ​ Vomiting ​ Infections ​ Fever ​ Diuretics ​ Trauma ​ NPO status ​ burns ○​ S/S: ​ dry mucosa ​ sunken orbits ​ sunken fontanel in infants only ​ tenting turgor ​ tachycardia  ​ Hypotension ​ Thirst ​ weight loss ​ Oliguria ​ lethargy. ○​ Treatment: ​ maintaining fluid and electrolyte balance. ​ Replacing volume deficits (20 ml/kg fluid boluses) ​ use infusion pumps for accurate intake and output ​ ** potassium only once urine output is adequate** ​ treat underlying cause ​ Rehydration strategies- PO/IV fluids ​ Fluid balance in the elderly-at risk for fluid volume deficit is greater in elderly. They have a lower percentage of body water normally. They also have decreased thirst mechanism, difficulty obtaining fluids with impaired mobility or may avoid drinking adequate fluids if they have an issue with elimination, and maybe taking medications that increase fluid excretion. Electrolyte Imbalance S/S Causes Treatment Nursing priorities Normal range Sodium Hyponatremia Osmolarity Water excess, Encourage oral Seizures, decreases adrenal rehydration confusion, risk 145 Fever, excess to decrease for injury restlessness, sodium, retention hypertension, dehydration, Diuretics edema, dry kidney NS mucosa. disease, Critical S/S hypercortisolis m  AMS: seizures, priority is safety/seizure pads Potassium Hypokalemia muscle GI losses cardiac Cardiac weakness, (diarrhea, monitoring dysrhythmias, 5 diarrhea (↑ cellular Priority Nursing muscle peristalsis), damage, Intervention: weakness, GI cardiac kidney failure, cardiac changes dysrhythmias acidosis, K+ monitoring sparing Critical s/s: diuretics dysrhythmias, (Spironolacton Critical high hypotension, e), lack of potassium can arrest insulin, be from Peaked T dehydration, hemolyzed lab waves (>⅔ on adrenal QRS height), insufficiency wide QRS, (aldosterone),  bradycardia, (rhabdomyolysi cardiac arrest. s leads to cells rupturing, releases K+ and leads to increase K+) Calcium Hypocalcemia Tetany, nutrition Neuromuscular Chvostek’s/Tro deficiency, changes, 10.5 reflexes, bone tumors, anorexia, hyperparathyro constipation. idism, thiazide diuretics. Magnesium Hypomagnesemia + Chvostek Alcoholism, When giving Neuromuscular and diarrhea, magnesium IV changes, 2.6 (will need dysrhythmias, cardiac arrest dialysis), cardiac arrest. Respiratory magnesium-ba depression sed antacids (diaphragm and laxatives. cannot contract) RAAS system ​ Activated by decreased blood flow to the kidney. Result is decreased urinary output, increased arterial constriction, and increased blood volume and blood pressure. ○​ Aldosterone causes nephron distal tubules to reabsorb more sodium and water to increase blood volume ○​ Atrial Natriuretic Peptide (ANP) causes decrease blood volume and pressure by increasing glomerular filtration rate, decrease Na reabsorption, and inhibit renin, aldosterone, and ADH release  ​ Acid-base balance Condition pH CO2 HCO3- Normal ABG 7.35 - 7.45 35 - 45 22 - 26 Respiratory acidosis low high Respiratory alkalosis high low Metabolic acidosis low low Metabolic alkalosis high high ​ Causes of imbalances: ○​ Respiratory acidosis: ​ hypoventilation, head injury, stroke, overdose, anesthesia, airway obstruction, respiratory muscle dysfunction, PE, COPD ○​ Respiratory alkalosis: ​ hyperventilation, fear, anxiety, mechanical ventilation (too fast/deep), aspirin overdose, early-stage acute resp. problems. ○​ Metabolic acidosis: ​ DKA, starvation, diarrhea, excessive muscle use, acid ingestion, kidney failure, pancreatitis, liver failure ○​ Metabolic alkalosis ​ Excessive vomiting/diarrhea ​ Immune system ○​ Components: tonsils & adenoids, thymus, lymph nodes thymus, appendix, spleen, bone marrow, Peyer’s patch, cells, tissue and organs ○​ Purpose: protect body from infection/invasion  ○​ Immune response: how your body recognizes and defends itself against bacteria, viruses and substances that appear foreign and harmful ○​ Inflammatory response: part of innate immunity (inflammation) ○​ How are the innate and adaptive immune cells created? ○​ Types of immunity, which is best for long-term protection? ○​ Hypersensitivity reactions (Ig, examples, management) Type I Hypersensitivity Reaction - IgE/Mast cell – Allergies, Rhinitis, Asthma Anaphylaxis ​ Onset: Within 1 hour ​ Immune Response: Generalized, Inappropriate; may cause: ○​ Pruritus: Itching ○​ Urticaria: Hives ○​ Angioedema: Swelling (lips, tongue, periorbital) ​ Treatment: ○​ Antihistamines; decreases itching but does not stop anaphylaxis ○​ Leukotriene inhibitors: singulair ○​ Mast Cell stabilizers ○​ Allergy shots or SL therapy ○​ Always ask and avoid allergens Anaphylaxis (Type I) ​ Definition: Systemic, Severe reaction involving 2+ body systems (IgE problem). ○​ Faster onset = Worse reaction ○​ Ace inhibitors have a high risk of angioedema ○​ Urticaria: more likely to be all over body ○​ 2 or more symptoms: ​ Tachycardia, tachypnea, N/V, hives, angioedema, wheezing, stridor, ○​ Histamine: the release causes capillary leakiness, leaking plasma causing runny nose, cough, hypotension ○​ Bradykinin: causes angioedema to try and stop reaction from spreading ○​ Bronchospasm = stridor ○​ Wheezing ○​ Mast cells: N/V/Diarrhea ​ Treatment: ○​ Epinephrine (Beta 1, some Beta 2 and alpha properties): ​ Increase blood pressure and ​ Adults: 0.3 mg IM (vastus lateralis) ​ Pediatric: 0.15 mg IM ​ Repeat after 5 minutes if needed (2 mg IN also used). ​ Education: can give second dose after 5 minutes, always keep 2 with you, hold with a fist, only a rescue drug (not a treatment), ensure everyone practices, hold for 10 seconds ​ Intranasal (Neffy): 2 mg  ○​ Steroids: decrease swelling ○​ Antihistamines: benadryl helps with itching, oral shows zero effect ○​ Zantac: ○​ Inhaled Beta 2: albuterol for wheezing and bronchospasm Type II Hypersensitivity Reactions – IgG or IgM Cytotoxic - Phagocytosis – Hemolytic anemia, transfusion reactions, Goodpasture syndrome, Graft rejection, MG, ​ Onset: Hours to days ​ Examples: Autoimmune disorders like systemic lupus erythematosus (SLE). ​ Prevention: 2 RN’s to check when giving blood, monitoring transfusion closely ​ Acute Hemolytic Reaction: (transfusion reactions) 3. Type III Hypersensitivity Reactions – Immune Complex Mediated – Serum Sickness, SLE ​ Onset: 1-3 weeks ​ Examples: Serum Sickness, SLE ​ Systemic Lupus Erythematosus: ○​ Chronic progressive inflammatory connective tissue disorder ○​ Damaging to kidneys and heart, monitor fluid balance ​ Lupus nephritis: lose protein in urine ​ Causes edema and hypotension when albumin is lost through urine (not supposed to be blood) ○​ S/S: butterfly rash (increased with vasodilation), disturbed body image, joint damage and pain, swelling and pain, exacerbations and remission ○​ Teaching: Promote rest and monitor for infection. Steroids can help but can increase the risk of infection. We need to taper off to avoid the Addison-like crisis. Protect skin by avoiding sun, and infection, use lotion, no perfumes. ​ Discoid: only affects skin; skin rashes ​ Care: ○​ Skin protection (avoid sun, infections, use lotion, avoid perfumes). ○​ Promote rest and infection monitoring.  ○​ Use steroids (topical/oral); taper gradually to prevent adrenal crisis. ​ Can increase risk for infection ○​ Hydroxychloroquine: very damaging to eyes, need eye exam first and every 6 months ​ Education: ○​ Self management: prednisone taper ○​ Steroids decrease immune system and increase risk of infections ○​ Ask about allergies 4. Type IV - T Cells mediated/inflammation – MS, Crohn’s Dz, RA, Asthma, Contact dermatitis, SJS ​ Onset: days to weeks ​ Examples: SJS, Rash ​ Contact dermatitis: substance, poison ivy, local reactions to bites/stings Lyme disease ​ Cause: Borrelia burgdorferi. ​ Stages: ○​ Stage I: Flu-like symptoms, arthralgias, erythema migrans (bullseye rash, can be any rash and most common is hematoma) ○​ Stage II: Cardiac (can cause heart blocks needing pacemaker, is reversible once treated), respiratory, neurological symptoms ○​ Stage III: Arthritis, chronic fatigue, memory/thinking issues. ​ Prevention: ○​ Avoid heavily wooded areas, think underbush, walk in center of the trail ○​ Use light colored clothing, long pants and long sleeves (tuck things in) ○​ Use DEET (wash off because it is a carcinogen), wear boots or closed shoe and a hat ○​ Check yourself, kids, and pets, then bathe immediately ○​ If bitten: ​ Remove ticks with tweezers, q-tip (dish soap), tick remover ​ Report bite and any symptoms to provider ​ Takes 4-6 weeks to get tested HIV ​ Chronic infection impairing the immune system ​ Transmission: Sexual, parenteral, perinatal (blood, body fluids, placenta, delivery, breastfeeding). ​ Viral load: Viral load decreased with care. Blood tests for viral load are the amount of HIV in ml of blood. When viral count is high, the immune system is overwhelmed. ​ CD4 count ​ Stages:  ○​ Stage 0 is acute with normal lab values ○​ Stage1- chronic CD4+ >500 ○​ stage 2- worse CD4+ 200-499 ○​ Stage 3- AIDS CD4+