Spring 2024 Exam 1 Blueprint PDF

Feel free to edit! Good Luck! !" BSN Blue Print Nurs__3411_____ Exam__1____ Date_2/06/2024_____ Content 50 #of qts (Nursing Process / Bloom’s) IV’s (I, AS, AN / AP, AN)...

Feel free to edit! Good Luck! !" BSN Blue Print Nurs__3411_____ Exam__1____ Date_2/06/2024_____ Content 50 #of qts (Nursing Process / Bloom’s) IV’s (I, AS, AN / AP, AN) Venipuncture o Insertion (I / AP) Selecting a Vein: RBC 4 6 o Factors to consider: pt’s medical hx, age and general condition, condition of veins, type of IV fluid and medications, expected WBC S 10 duration of therapy, your skill. o Short peripheral catheters 496 1218 Therapy < 5 to 7 days Osmolality < 600 mosm/1 It 36 54 pH 5 to 9 400 P1 190 +Exploring the Options: Use the non-dominant hand or forearm. 26000 6000 NC Avoid antecubital fossa and above. Can cause pressure and break when bending arm. Use only in emergencies for quick and easy access. odium 135 145 o Start distal and make subsequent puncture proximal. o Veins of legs, feet and ankles are NOT recommended. allium 8.6 10.2 Less circulation Lowest we go is femoral; anything below is not good. tassion 3.5 5.5 Other Sites to Avoid: o Veins below a previous IV infiltration. o Veins below a phlebitis area. 41 7.35 7.45 o Sclerosed or thrombosed veins. o Areas of skin inflammation, disease, bruising, or breakdown. o An arm affected by a radical mastectomy, edema, blood clot, 02 35 45 paralysis, or infection. o An arm with an arteriovenous shunt (graft straw place; plastic 42oz 22 26 tube) or fistula (something that bends/connects; artery directly connected to vein). DO NOT use the arm on the side of mastectomy, lymph node dissection, arteriovenous shunt or fistula, or paralysis! Special Considerations for the Elderly: o Large veins and tortuous = do not use a tourniquet o Do not use hand veins. o Use the smallest gauge possible (22-24). o Strict aseptic technique o Do not slap arm to visualize veins.  o Use pumps, controllers, or burettes to control infusion volume and rate. Basilic and Cephalic veins are the 2 common veins used for PICC lines. Procedure: Starting IV o Prepare patient. o Wash hands. o Open and prepare infusion set. o Select venipuncture site. o Don gloves o Dilate vein. o Clean site o Stabilize vein. o Insert catheter and initiate infusion. o Apply dressing and label. o Label tubing. o Document o Complications (phlebitis, infiltration) (AS / K) Prevention is KEY Infiltration Scale: o 0: No symptoms o 1: skin blanched; edema < 1 in an direction; cool to touch; with or without pain. o 2: skin blanched; edema 1-6; cool to touch; with or without pain. o 3: skin blanched; translucent; gross edema > 6; cool to touch with moderate pain; possible numbness. o 4: skin blanched, translucent; skin tight, leaking; skin discolored, bruised swollen; gross edema > 6; deep pitting tissue edema; circulatory impairment; moderate to severe pain; infiltration of any amount of blood product or vesicant. Phlebitis Scale: o 0: no symptoms o 1: erythema with or without pain. o 2: pain at access site with erythema and/or edema. o 3: pain at access site with erythema and/or edema. Streak formation. Palpable cored o 4: pain at access site with erythema and/or edema. Streak formation. Palpable venous cord more than 1 inch long. Purulent drainage Local Complications: o Infiltration: fluid that leaks is non-vesicant. o Extravasation: fluid is vesicant; irritates tissue.  o Phlebitis o Mechanical: occurs where the movement of the cannula within then vein causes friction and subsequent venous inflammation; occurs when cannula size is too big for vein. o Chemical: response of intima to certain chemicals infused or placed within the vascular system. o Bacterial: caused by contamination of IV during catheter insertion or manipulation due to poor aseptic technique. o Thrombosis: blood clot blocks veins or arteries. Hematoma: a blood pool of mostly clotted blood that forms from an organ, tissue, or body space. (collection of blood). Catheter embolism: Systemic Complications: o Fluid overload: check weight; early sign is crackles; always assess the pulmonary system. Speed shock: too much fluids too fast (can cause cardiac shock from fluid overload). Can lead to CHF/cardiogenic shock. o Embolus: obstruction of artery. o Sepsis: severe reaction to an infection. Combination of symptoms occurs: Shiver fever or very cold, extreme pain or general discomfort, pale or discolored skin, sleep difficulty to around or confusion, “I feel like I might die,” shortness of breath. o Assessment Intravenous Medications: o Follow agency policies and procedures. o Observe pts closely for signs of adverse reactions. o Avoid any error in preparation of the drug and calculation of the dosage. o Vital signs before, during, and after infusion of IV drug. o Inspect and palpate the vein. o Check patency (blood return). o Check weight every day to determine fluid balance. o Gauges (sizes) (I / AP) § Bigger gauge number = smaller needle § Smaller gauge number = bigger needle § 14-16 G: trauma (those requiring large volume of fluid rapidly). § 18 G: surgery (needs to be in a large vein). For surgery, pt that has a high chance of needing blood (ex: exploratory procedure). § 20 G: surgical and blood administration.  Can be used for pts that come out of surgery and may need blood. § 22 G: medical pts § 24-26 G: infants, children, and elderly. Central lines (AN / K) o Assessment Central Venous Access Device: o Requires informed consent (consent by doctor and nurse is witness; risk factors must be answered by the doctor). o Should be placed right above the right atria, inserted into the subclavian or jugular vein. § If too far it will move around and cause dysrhythmias. o Risk for pneumothorax (absence of breath sounds). § Manifestations: Hypotension Bradycardia Desaturation of O2 SOB o Progression can see shifting of trachea. o Placement is checked by chest x-ray. o Assess site for redness, swelling, tenderness, or drainage. o Care Guidelines for CVAD o Placement of CVAD = sterile/aseptic technique o Accessing ports = sterile technique o On insertion § Document date, site, brand, gauge, and catheter length. § Use strict aseptic technique for site care. § Frequency of dressing change (7 days) Change when loose or soiled. Central line pressure monitoring o Monitor right atrial pressure: will see EKG and CVP pressures; normal is 10-20 mmHg (based on cardiac rhythms). § Low CVP with no diuretic: could indicate blood loss/hemorrhage. With diuretic: could indicate dehydration (need fluids). (Low CVP = dehydrated – give isotonic solutions because we want to replace that fluid). § High CVP: auscultate for crackles, assess for hypervolemia. (High CVP = overload – give diuretics). CVAD care and flushing  o Change catheter cap per protocol. o Use a 10 mL syringe, to flush. o Remember to flush all lumens of multiply lumen catheters. o Specially designed needles to access implanted port. o Flush with saline before and after use. o DO NOT push through if you feel resistance. Pt Teaching o No b/p on arm with PICC line. o Implanted ports can be dislodged. § Signs: Pain in neck or ear or affected side. Palpitations Swelling Difficulty accessing port. Catheter-Related Bloodstream Infection (CR-BSI) Prevention Bundle o Use checklist during insertion to make sure everything is done correctly. Tell anyone who violates the correct steps to stop the procedure immediately. o Hand hygiene thorough scrub before insertion and anyone who touches the CVAD. o Maximal barrier precautions during insertion. Patient is draped head to toe. HCP who inserts wears mask, gown, and sterile gloves. Anyone in room must wear a mask. o Traffic in and out of room must be minimized. “Stop Sign”. “Central line cart” o Chlorhexidine is used for skin disinfection. o Use preferred sites. (upper arm and subclavian) o Post-placement care requires meticulous dressing changes and care of the IV system. Keep ports and stopcocks clean; hang bags using sterile technique, vigorous scrub of catheter hub with alcohol when used. o Review daily the need/ incidence of CR-BSI increase each day the device is in place. As soon, as it is determined that the patient no longer needs the line, it should be removed. o Purpose Indications Long term therapy (pts with dialysis, osteomyelitis, etc.), infusion of vesicants and TPN. o Greater risk of complications: infection, pneumothorax, phlebitis, thrombus/air embolism. (infections and clots). o Only going to use central lines for long term therapy.  Non-tunneled: goes straight into vessel, usually done in emergency situations (short-term/not more than 1 month). Tunneled: digs under subQ and will reach subclavian vein (long-term). o Goes partially under right atria; increases risk of clots. o Higher chance of infection from opening in skin. o Ex: dialysis pt Implanted: common in chemotherapy pts. o If infiltrated = causes necrosis o Lesser chance of infection. Peripheral inserted central catheters (PICC): on arm o Osteomyelitis pts can use for 3 months (use long-term for antibiotics). o Greatest risks: infection and hematomas. Medication administration (I / AP) o IV push o Undiluted drug directly into the systemic circulation. o Given by direct venipuncture, existing IV line through an injection port, or through an injection port, or through an IV lock. o Disadvantages: error cannot be corrected after the drug has entered and the drug maybe irritating to the vessel. o Look up the maximum concentration recommended and the rate of administration. o Check the medication order for accuracy and confirm the compatibility of the drug and solution. o Prepare the medication. o Label o Wash hands and don gloves. o Identify pt o Check patency. § Cleaning is important! o Administer medication. o Flush with saline before and after medication administration. o Observe the pt closely. o Document o Bolus o IV bolus: procedure that involves placement of a prescribed medication directly into the bloodstream; given rapidly at one time. § Med usually concentrated and only a small amount of fluid is needed. § Ideal for clients who cannot tolerate a large volume of fluid. § High concentration of medications give via IV bolus = dangerous § Immediate effects. o Must confirm placement of IV line and assess prior to administering. o Can potentially irritate lining of blood vessels (phlebitis).  o Infusion o Monitoring an IV Infusion o Check pertinent data. o Ensure correct solution is being infused. o Observe flow rate every hour. o Inspect IV tubing and needle site. o Inspection insertion site for infiltration, phlebitis, and bleeding o Assess & monitor patient. o Patient teaching o Intermittent IV Medication Infusions o Medication mixed in a small amount of IV solution (50 to 100 ml) o Instilled over a short period at regular intervals (q 4 hrs, q 6 hrs, q 8 hrs) o Tandem and piggy back o Syringe pump o Volume Control Medication Infusions o Buretrol o Frequently used in children and old when volume administered is critical. IV solutions (AS, I / AN, AP) o Hypotonic o 0.45% Sodium Chloride o Used to treat hypernatremia (excess sodium) and rehydrate cells for patients with fluid imbalance. o Excessive infusion can cause decreased blood pressure, cellular edema, and cell damage. o Complications: dilution and depletion of electrolytes, hyponatremia, calorie depletion o Hypertonic o 3% - 5% Sodium Chloride - Treats severe hyponatremia, and cerebral edema o Complications: hyperchloremia, hypernatremia, loss of bicarbonate and acidosis o 10% - 50% Dextrose - Treats hypoglycemia o Major uses: hydration and providing calories, total parenteral nutrition, solvents. o Watch for signs of hypervolemia. o Do not administer peripherally. CENTRAL LINE ONLY o Use with caution in diabetic patients. o Isotonic o 0.9% Sodium Chloride (Normal Saline) -- The only solution to be administered with blood. § Used to treat metabolic alkalosis, diluent.  §Complications: hypernatremia, FVE, depletion of other electrolytes, no calories § Lactated Ringer's - Treats hypovolemia Includes sodium, potassium, calcium, and chloride. Lactate - buffer metabolized in liver to produce bicarbonate. Complications: may lead to metabolic alkalosis Contraindicated in hepatic disorders and lactic acidosis. o Used to replace fluid loss without causing RBCs to shrink or swell. Blood transfusion (I / AP) o Safety o Basic guidelines § Follow policy & procedure. § Gloves should be worn when handling blood products. § Blood should not be out of controlled refrigeration for longer than 30 minutes before initiated a transfusion. § Blood should not be stored in non-blood bank refrigerators. § No IV solution other than isotonic saline (0.9%) should be added to or administered with blood. § No IV solution should be piggy backed into the main line. § All blood components must be filtered using inline or add on filters that are appropriate for the component. § A new administration set, and filter should be used for each transfusion. § A blood filter should not be used for more than 4 hours. o Monitoring o Infiltration o Extravasation o Phlebitis o Infection o Signs of a reaction and interventions o Acute hemolytic reaction o Caused by incompatibility. o Febrile nonhemolytic reaction o Recipient sensitive to donor WBC's o Fever and/or chills without hemolysis o Allergic reaction o Caused by sensitivity of recipient to foreign plasma proteins. o Urticaria (itchy rash that appears on the skin) o Anaphylaxis (life threatening allergic reaction) o Flank pain (lower back pain) o Non cardiac pulmonary edema o Transfusion related acute lung injury. o Circulatory overload Aggravated in patients with already circulatory overload (heart failure)  o Bacterial contamination o Sepsis Immune & Hematology (AS, I, An / AN, K, AP) Types of immunity o Acquired Vs. Passive (AN / K) o Naturally acquired active: exposed to an antigen. o Artificially acquired active: receive a vaccine. getsick o Natural acquired passive: mother can pass antibodies through breast milk. o Artificially acquired passive: monoclonal antibody infusion. Assessment o Lab values in Anemias and manifestations (WBC, Hgb, Hct, Platelets) (AS, I / K, AP) o Hematocrit: Females < 36%; Males < 42% o Hemoglobin: Females < 12 g/dL; Males 55%, Hypertension, Thrombosis o Requires Phlebotomies, Hydration, Hydroxyurea to treat. Thrombocytopenia (AS, I / AN, AP) o Can result from reduced production of platelets in the bone marrow, increased destruction of platelets, or increased consumption of platelets. o Antiplatelet antibodies bind to platelets. o Can occur when immune system attacks platelets following a viral infection (or may be chronic) o Most common cause of increased platelet destruction is immune thrombocytopenic purpura (ITP) o Manifestations § Bleeding and petechiae § Nasal bleeding § Gingival bleeding § Excessive menstrual bleeding § Excessive bleeding from surgery or dental extractions § Fatal bleeding in the CNS and GI can occur when platelet count is less 150 400 than 5000/mm3. o Assessment and Diagnostic Findings § Bone marrow aspiration and biopsy used to identify platelet deficiency. § Increased megakaryocytes and normal or increased platelet production when platelet is destruction is the cause of thrombocytopenia (body tries to compensate for decreased platelets) 24 o Medical Management § Platelet transfusion may be needed to increase platelets and stop bleeding. o Nursing Management § Education on promoting safety and fall prevention. 24 hello he o Treated by: Stopping offending medications, Prednisone, IV Immunoglobulins, Splenectomy, Monoclonal antibodies, Thrombopoietin. o Avoid platelet transfusions unless there is catastrophic bleeding. Leukemia (immature cell proliferation, interventions) (I / AP) o Increase of leukocytes in the circulation o Unregulated proliferation of leukocytes in the bone marrow o Causes of leukemia § Exposure to radiation or chemicals § Genetic disorders § Viral infections § Bone marrow damage from pelvic radiation § Chemotherapy drugs o Neoplastic proliferation of the myeloid (bone marrow) or lymphoid stem cells o Leukemias are either lymphoid (stem cells that produce lymphoid) or myeloid (stem cells that produce nonlymphoid cells) o Leukemias are either chronic or acute based on the time it takes for symptoms to evolve. § Acute Myeloid, Chronic Myeloid, Acute Lymphocytic, Chronic Lymphocytic o Associated with fever, infection, fatigue, bleeding, pain, EXCESS IMMATURE BLAST CELLS Acute Myeloid Leukemia - Defect in stem cell which differentiates into ALL myeloid cells (peak is at 60 y/o) o Development of abnormal blast cells that crowd and end up resulting in anemia, thrombocytopenia (low platelet count), and low or elevated WBC counts. o Risk factors. § Males § Exposure to chemicals such as benzene or pesticides or exposed to ionizing radiation. § Prior treatment with chemotherapeutic drugs § Tobacco smoking § Blood disorders § Genetic disorders o Signs and symptoms § Symptoms due to neutropenia (low neutrophil count) = fever and infection § Symptoms r/t anemia = pallor, fatigue, weakness, dyspnea on exertion, and dizziness § Symptoms r/t thrombocytopenia = ecchymoses (bruises), petechiae (red or purple hemorrhagic spots on the skin), epistaxis (nosebleeds), gingival bleeding  § Symptoms r/t proliferation leukemic cells within organs = pain from enlarged liver or spleen, hyperplasia of the gums, bone pain from of expansion of marrow o Assessment and Diagnostic Findings § Complete blood count shows decrease in erythrocytes and platelets. § Bone marrow analysis shows excess of blast cells (hallmark of diagnosis) Medical. o Management § Induction therapy (hospitalized for several weeks due to neutropenic side effects) § Consolidation therapy is given after induction therapy to reduce recurrence of leukemia. § HSCT (hematopoietic stem cell transplant) is routinely done following induction and consolidation therapy. o Complications § Bleeding and infection (major causes of death) o Tumor lysis syndrome (from chemotherapy) - can flood the body with ions and metabolites that cause disrupted systemic function. o Keep away from plants, raw veggies and fruits and sick family. o Reverse Isolation (ex. Keep patients at end of hall) Chronic Myeloid Leukemia - Mutation in the myeloid stem cell-Extremely high leukocyte count (>100,000) but client is still considered immunosuppressed because these WBCs are immature and useless. Because of the uncontrolled proliferation of cells, the marrow expands into cavities of long bones, such as femur, and cells are also formed in liver and spleen, resulting in enlargement of these organs that is sometimes painful. o 3 stages: chronic, accelerated, and blast crisis. § Accelerated: symptoms consistent with leukemia may start to appear, such as fatigue, anemia, splenomegaly, or dyspnea. May complain of bone pain and report fever without any obvious signs of infection. § Blast crisis: most advanced phase. Exhibit signs and symptoms that are like AML than a chronic disease. Extremely high leukocytes. Patients may be dyspneic or slightly confused because of excessive leukocytes that inhibit blood flow to lungs and brain. Patient may have enlarged, tender spleen and liver. o Medical management § Goal is to obtain remission of keep patient in chronic phase for as long as possible. Mhit it § Use of TKIs has improved treatment and long-term survival for kinase patients with CML. Tyrosm potential will o Nursing Management § Educate on adherence to TKIs, side effects of this drug (fatigue, Sct asthenia (weakness), pruritus (itching), headache, skin rash, and make oropharyngeal pain), drug interactions, and safe handling. young people for  §Monitor patient for adverse signs and symptoms of therapy, such as decreased urinary output, changes in ECG, and myelosuppression. o Avoid antacids, grapefruit, large doses of acetaminophen. Acute Lymphocytic Leukemia --uncontrolled proliferation of immature lymphoblasts- o Most common in young children o Boys affected more than girls. o Clinical Manifestations § Leukemic cell infiltration in liver, spleen, bone, testes and breasts, and CNS (pain from enlarged liver or spleen, as well as bone pain) (CNS- cranial nerve palsies or headache and vomiting because of meningeal involvement) o Medical Management § Goal is to obtain remission with excess toxicity and rapid hematologic recovery. § Treatment grouped into induction, consolidation, and maintenance phases § Preventative intrathecal chemotherapy is also part of treatment plan since ALL invades CNS. o Treated by cranial radiation, Intrathecal chemotherapy. o Concern for "thrush" candidiasis (fungal infection) o Avoid spicy foods, use soft brush for daily oral care, avoid mouth wash with alcohol. Chronic Lymphocytic Leukemia - Malignant clone of B Lymphocytes. It is the progressive accumulation of the cells in the marrow and circulation. Accumulate often in the lymph nodes and spleen. o Veterans of Vietnam War exposed to Agent Orange are at risk of developing this disease. o Manifestations § Lymphocytosis (increased lymphocyte count) is always present. § Lymphadenopathy, Splenomegaly, Hepatomegaly, Lymphocytosis § Manifests as anemia, thrombocytopenia, fever, fatigue, night sweats, weight loss o Medical Management § Fludarabine o Nursing Management § IV treatment with immunoglobulins may be given to patients with infections. § Should receive pneumonia and flu vaccines. § Live vaccines should be avoided. o Treated by chemotherapy, and monoclonal antibodies. HIV  o Primarily associated with Male-to-Male sexual contact but also exists in heterosexual contact and needle sharing. o Progresses from Human Immunodeficiency Virus to acquired immunodeficiency syndrome (AIDS) Prevention & Stages (I, AN / AP, K) o Prevention § Behavioral interventions: abstinence or encouraging use of condoms. § HIV testing stop § PrEP (post-exposure prophylaxis) - taking one pill containing two HIV medications (tenofovir disoproxil fumarate 300 mg and emtricitabine 200 mg) daily in order to avoid the risk of sexual HIV acquisition in adults and adolescents aged 12 and older. Check HIV status every 3 months. § ART (antiretroviral) therapy to achieve viral suppression. § Stage 0 - early HIV infection, inferred from laboratory testing. 1500 § Stage 1 - CD4+ cell count >1,500 500 amount of virus in the body after the initial immune response subsides results in a viral set point (higher set point = poorer prognosis) Prolonged chronic stage; pt may feel well and show few symptoms. § Stage 2 - CD4+cell count: 200 - 499 cells/mm3 § Stage 3 -CD4+cell count