Nursing Exam 2 Review Sheet PDF

lOMoARcPSD|23521333 Nursing Exam 2 Review Sheet Safe And Effective Nursing Care Of Clients Level I (Queensborough Community College) Studocu is not sponsored or endorsed by any college or university Downloaded by cristalene parag ([email protected]) lOMoARcPSD|23521333 Primary IV- Care...

lOMoARcPSD|23521333 Nursing Exam 2 Review Sheet Safe And Effective Nursing Care Of Clients Level I (Queensborough Community College) Studocu is not sponsored or endorsed by any college or university Downloaded by cristalene parag ([email protected]) lOMoARcPSD|23521333 Primary IV- Care of IV site - IV is best for care of systemic infection Infiltration - Fluid enters tissues instead of veins - Cool, pale, swelling of site (fluid cooler than body temp) - May elevate arm as intervention Phlebitis - Red, warm swelling of site - Inflammation of the vein (little red line, may be tender) - Consult physician, may lead to infection - Pull IV out if there are signs of infiltration or phlebitis If necessary to restart IV, start at different site Warm and cold(ice) soak is okay for both o Talking about patient’s comfort, constriction (cold), vasodilation (warm)  Warm (Vasodilation)  Dilates peripheral blood vessels  Increases tissue metabolism  Reduces blood viscosity  Increases capillary permeability  Reduces muscles tension  Reduces muscle spasms  Relieves pain  Prolonged heat raises cardiac output and pulse rate, lowers blood pressure and you sweat more  When on large surface it increases blood flow while decreasing other areas  Don’t put heat on pregnant woman or open wounds  Look for blisters, pain and redness  Cold (Vasoconstriction)  Reduces swelling  Decreases blood flow  Promotes comfort  Reduces muscle spasms  Reduces muscle tension  Primarily used after direct trauma, dental pain, spasms, and sprains  Look for pain, pallor, numbness and cyanosis o Must not touch direct skin  Use pillowcase, sheet o Check for circulation and damage to skin o Alternate hot and cold Downloaded by cristalene parag ([email protected]) lOMoARcPSD|23521333 o Check every 15 min o 20 min on, 20 min off Pharmacology Generic Name: Digoxin Trade Name: Lanoxin Recommended dosage: 0.125-0.5 mg/day Mechanism and Action: Increases force of myocardial contraction Therapeutic Effect: Increased cardiac output and slowing of HR Indication: Heart failure, Slow ventricular rate, Paroxysmal atrial tachycardia Adverse Reactions: Digitalis toxicity: Nausea, Bradycardia, Dizziness, Vomiting Nursing Considerations: Monitor apical pulse for 1 min, if less than 60 bpm withhold dose and notify doctor Lab Values: Evaluate electrolyte values (K, Mg, Ca) and renal and hepatic functions Generic Name: Furosemide (oral) Trade Name: Lasix Recommended dosage: Edema PO: 20-80 mg/day as single dose initially, may repeat in 6-8 hr, may increase dose by 20-40 mg Q6-8 hr until desired response. HTN PO: 40 mg twice daily Mechanism and Action: Inhibits the reabsorption of sodium and chloride from the loop of Henle and distal renal tubule. - Increases renal excretion of water, sodium, chloride, magnesium, potassium and calcium. - Effectiveness persists in impaired renal function. Therapeutic Effect: Diuresis and subsequent mobilization of excess fluid (edema, pleural effusions.) - Decrease BP Indication: Edema due to HF, hepatic impairment or renal disease. Hypertension. Adverse Reactions: Erythema multiforme, Stevens-Johnson syndrome, aplastic anemia, agranulocytosis, dehydration, hypocalcaemia Nursing Considerations: Assess fluid status. Monitor BP and pulse. - Assess for rash periodically. May cause Stevens-Johnson syndrome. Discontinue therapy if rash or if accompanied with fever, fatigue, muscle or joint aches, blisters, oral lesions, or hepatitis. Lab Values: Monitor electrolytes, renal and hepatic function, serum glucose and uric acid levels before and during therapy. Generic Name: Warfarin Trade Name: Coumadin Recommended dosage: 2-5 mg/day for 2-4 days; then adjust dose by results of INR Mechanism and Action: Interferes with hepatic synthesis of vitamin K-dependent clotting factors (II, VII, IX, and X). Therapeutic Effect: Prevention of thromboembolic events Downloaded by cristalene parag ([email protected]) lOMoARcPSD|23521333 Indication: - Prophylaxis and treatment of: Venous thrombosis, Pulmonary embolism - Management of myocardial infarction: Decreases risk of death, risk of subsequent MI, risk of future thromboembolic events - Prevention of thrombus formation and embolization after prosthetic valve placement Adverse Reactions: Bleeding, cramps, nausea, fever Nursing Considerations: Assess for signs of bleeding and hemorrhage Lab Values: Monitor PT, INR and other clotting factors during therapy. Therapeutic PT ranges 1.3-1.5 times greater than control. Normal INR is 0.8-1.2. An INR of 2.5-3.5 is recommended for patients at very high risk of embolization. Vitamin K is antagonist for Coumadin. Peak and Trough - Check trough on third administration of drug before you administer drug Check peak when you first administer drug, 1 hour Effects of Drugs/Medications - - - Therapeutic effect= desired effect o Reasons drug is prescribed Side effect= secondary effect o Unintended, usually predictable o May be harmless or harmful- Nausea Drug toxicity o Results from overdose, ingestion of external use drug o Buildup of drug in blood Drug allergy o Immunologic reaction to drug o Mild to severe reactions (anaphylaxis) SOB, rash, medication must be stopped! Drug tolerance o Need increasing doses to maintain therapeutic effect o Opioids (concern of addiction) Drug-drug interaction o One drug affecting effect of another Potentiating effect o Effect of one or both drugs is increased Inhibiting effect o Effect of one or both drugs is decreased Synergistic effect o When two drugs increase the action of one or another drug Idiosyncratic- less or more than expected or different effect than expected Downloaded by cristalene parag ([email protected]) lOMoARcPSD|23521333 Pharmacodynamics - Process by which drug changes body Pharmacokinetics - study of absorption, distribution, biotransformation, and excretion of drugs o Liver: metabolizes drugs o Kidney: excretes drugs Routes of Medication Administration - - Oral: NG tube Sublingual: under tongue Buccal: check (Nitroglycerin) Parenteral o Subcutaneous (fat) o Intramuscular (vaccine) o Intradermal (TB) o Intravenous (IV line) Topical Inhalation Vaginal Rectal Transdermal: patch Triplicate: special pad for controlled substances, has three copies. One goes to physician, one goes to pharmacist, one patient keeps Types of Medication Orders - Stat o Give immediately Single order o Give once Standing order o Routine order PRN order o Give as needed Medication Groups - Narcotic Analgesic (for pain) Downloaded by cristalene parag ([email protected]) lOMoARcPSD|23521333 - Narcotic Antagonist (blocks effects)- Narcan Non Steroidal Anti-Inflammatory- Ibuprofen Anti-cholinergic- drys up secretions, normally form surgery patients (Visterol) Sedatives and Hypnotics: Ambian Anticoagulants: Coumadin Anti-emetics: Zofran Antihistamine: Benadryl Antibiotics: Penicillin, Levaquin Anti-hypertensive: Lopressor, HCTZ Diuretics: Lasix Hypoglycemic: Glucaphage, Insulin Stool Softeners: Colace Antibiotics - When patient presents with bacterial infection Place patient on broad spectrum antibiotic Side effects: GI upset Duration: Short term 5-7 days Send specimens to lab for culture and sensitivity to know which bacteria it is and what antibiotic works o Culture and Sensitivity  Sputum  Blood  Urine Last resort is Vancomysin! Vital Signs Blood Pressure - New Normal: 110/70 - Old Normal (pre-hypertension): 120/80 - Narrow gap between systolic and diastolic is not good If a nurse assess a patient’s BP and the results are 100/60. What would be the nurse’s best action? Select all that apply. (Question from class) A. Document as normal BP B. Recognize ad pre-hypotension C. Recognize it is low D. Ask the patient if they are taking any medications E. Patient is dehydrated You are asked to take BP at your church. You take the BP of a 65 year old man and get 130/85. What would be your best response to this data? (Question from class) Downloaded by cristalene parag ([email protected]) lOMoARcPSD|23521333 A. Tell him the blood pressure is high B. Tell him to wait 5 minutes and you will re-take it C. Encourage him to follow up with his physician D. Tell him he should be careful because of his pre-hypertension How to diagnosis hypertension (must have two readings) First BP, recognize as high Second BP, doctor takes second reading Factors that affect BP - Genetics - Lifestyle o Diet, stress (raises BP), food (sodium and fats) - Smoking o Narrows vessels o Leads to impaired gas exchange Gender confirmation: male who takes female hormone supplements is more prone to female diseases than a male who doesn’t Heart Rate (Pulse) Normal pulse: 60-100 bpm Athlete normal pulse: 40 bpm The nurse takes the client’s radial pulse and gets 62 bpm. The nurse’s best action is to: (Question from class) A. Re-check the pulse because it is low B. Validate with the client’s medical record C. Check the apical pulse D. Ask another nurse to re-check the pulse Which client meets the criteria for selection of the apical site for assessment of the pulse rather than a radial pulse? (Question from class) A. A patient who is in shock B. The pulse changes with body position changes C. A client with an arrhythmia D. It is less than 24 hours since the client had surgery Respirations Normal: 12-20 breaths per min Morphine Sulfate- Analgesic Downloaded by cristalene parag ([email protected]) lOMoARcPSD|23521333 - - Short half-life Not too many side effects Cardiac drug o Morphine o Oxygen o Nitroglycerin o Aspirin Relaxes you, makes heart work better o Vasodilator Direct affect on respirations Do not administer if less than 12 respirations Temperature Normal: 98.6 degrees Febrile: 101 degrees Geriatrics febrile: 100.5 degrees Oxygenation Factors that affect respiratory function - Age Environment Lifestyle Health status Medications Stress Chronic Obstructive Pulmonary Disease (COPD) - Bronchitis and Emphysema Causes: smoking Breathing mechanics: too much O2 and they won’t breathe Risk factors: environmental factor, spinal problems Long term complications: o Oxygen Use  O2 2 liters, nasal cannula  Check pulse ox, if 89% might use 3 liters O2 Hypoxia - inadequate amount of oxygen available to the cells Common symptoms Downloaded by cristalene parag ([email protected]) lOMoARcPSD|23521333 - o Dyspnea (difficulty breathing) o Elevated Blood pressure with a small pulse pressure o Increased respiratory and pulse rates o Pallor o Cyanosis o Anxiety, restlessness o Confusion o Drowsiness Often caused by hypoventilation (decreased rate or depth of air movement into the lungs) Promoting Respiratory Function - Ensure a patient airway Positioning Encouraging deep breathing, coughing Ensuring adequate hydration Interventions - Cupping and clapping: bring sputum up Incentive spirometer: increase chest expansion and prevent atelectasis (collapse of alveoli) Delivery Systems Simple to Complex Long Term Oxygen Use Safety Precautions o Caution with COPD Oxygen delivery system Nasal Cannula- don’t go over 6L/min - Check frequently that both prongs are in the patient’s nares. - For patients with chronic lung disease, limit rate to the minimum needed to raise arterial oxygen saturation to a level that provides adequate oxygen delivery to tissues (88%-92%), and no higher; usually 2-3 L/min via nasal cannula - Disadvantages o Can be dislodged easily o Dries mucosal membrane Simple mask- 5L/min is min setting - Monitor the patient frequently to check placement of the mask. - Support the patient if claustrophobia is a concern. - Secure a medical order to replace the mask wit ha nasal cannula during mealtime. Downloaded by cristalene parag ([email protected]) lOMoARcPSD|23521333 - Used when am increased delivery of O2 is needed. - Short term use less than 12 hours because of retaining carbon dioxide. Partial-rebeather mask - 8-11 L/min - equipped with reservoir bag for the collection of the patient’s exhaled air - rebreathes 1/3 of expired air - allows for patient to inhale oxygen from the room - Disadvantages o Eating and talking are difficult o Tight seal is required o Potential for skin breakdown Non-rebreather mask- 12 L/min - highest concentration of O2 - maintain flow rates so that the reservoir bag collapses only slightly during inspiration - If malfunction, may have carbon dioxide buildup, leading to suffocation - Monitor SaO2 with pulse oximeter. Venturi Mask- precise O2 - Check that air intake valves are not blocked - Used for patients with COPD or emphysema o 2L max for COPD patients Oxygen tent - Assess for dampness of clothing, bedding, hair o Higher risk of infection - Used for children and infants mostly because they are small O2 safety - no synthetic fibers - no open fires (no smoking) - check for wounds around nose - no oils around nose Medications Bronchodilators: Albuterol - HR goes up, opens up airways - Hold for as long as possible - Goes into lungs Expectorants: Robotusen, Mucinex - makes them cough up sputum - makes sputum more mucous- like Suppressants Steroids: Pretezone - Retains water Nebulizers Downloaded by cristalene parag ([email protected]) lOMoARcPSD|23521333 Hypertension (page 134 Lab Manual) - About 80 million US adults have been diagnosed with high BP About one in three US adults has high BP Blood Pressure Category Normal Prehypertension High Blood Pressure (Hypertension) Stage 1 High Blood Pressure (Hypertension) Stage 2 Hypertensive Crisis (Emergency care needed) Systolic mm Hg (upper #) Less than 120 AND 120-139 OR 140-159 OR Diastolic mm Hg (lower #) Less than 80 80-89 90-99 160 or higher OR 100 or higher Higher than 180 OR Higher than 110 Systolic: measures the pressure in the arteries when the heart beats (when the heart muscle contracts) Diastolic: measures the pressure in the arteries between heartbeats (when the heart muscle is resting between beats and refilling with blood) Peg and NG tubes pg. 188 - Make sure patient is not flat Both end up in stomach. Main concern with patient with NG tube is ASPIRATION! For NG tubes check for placement o First check after placement and best way to check is with X-ray o 10-20 mL air, listen to air going in stomach o Check pH of gastric secretion (rarely used) - Check for residual o Pull out aspirate until you meet resistance o Goal to have 50 mL or less residual o If more than 100 mL must do further assessment o Put aspirate back in o Check residual before every feeding or 4-8 hours during continuous feedings - Patency o Put 30 mL normal water in tube to make sure liquid is going through o Do patency check before and after administration of medicine and food - Dysphasia: difficulty swallowing Enema Downloaded by cristalene parag ([email protected]) lOMoARcPSD|23521333 - introduction of a solution into the large intestine, usually to remove feces. The instilled solution distends the intestine and irritates the intestinal mucosa, thus increasing peristalsis. - long-pronged (lubricated) goes in 1 inch rectally to loosen stool. Insert when patient is in a side lying position. Ask patient to hold for a couple of minutes. - if enema does not work, might have to remove impacted feces manually Urinary Diversion - Surgical creation of an alternative route for excretion of urine Measure intake and output Clean catch or midstream Only real sterile specimen is through catheter Urinary devices o Foley catheter (indwelling urethral catheter): kept in place by balloon at the end of the catheter in the bladder o Intermittent straight catheter: catheter that is inserted several times throughout the day to release urine. Done by patient or caregiver o Urosheath or external urinary device/external condom catheter for males Nutrition pg. 169 Nutritional Terms Overweight: 10% above ideal body weight Obesity: 20% above ideal body weight Malnourished: based on lab values BMI: Body Mass Index IBW: Ideal Body Weight Macro-nutrients: Water, Carbohydrates, Proteins, Fats Micro-nutrients: Water and Vitamins Water - Regulates body temperature Excretes waste products Lubricate organs/body parts Digestion Absorption Transport for blood RDA: 8-14 cups of fluid Carbohydrates Downloaded by cristalene parag ([email protected]) lOMoARcPSD|23521333 - Brain needs glucose: drug of choice Easily obtained Absorbed by small intestine Breaks down glucose then protein then fat Protein lasts for 40 days Limit simple sugars Eat proteins with carbohydrates Simple and complex carbs RDA: 60%, 300 grams o Simple: sugar, quick hit of glucose, ends quickly though o Complex: starches and fibers Fiber - Found in vegetables, fruits, dried beans, whole grain, oats, seeds, nuts RDA 25 grams for women (19-50) 35 grams for men (14-50) Protein - - - Function o Makes enzymes/hormones o Builds muscle o Source of energy Nitrogen is the element that distinguishes protein from lipids and carbohydrates Types of Protein o Complete: protein that has all essential amino acids found in animal products, quinoa, soy o Incomplete: protein that doesn’t have all, people who don’t eat meat are recommended to have a variety of foods with each meal to increase probability to find complimentary proteins RDA o 0.36 grams for each pound of body weight o 10% = 50 grams Fats - - Function o Stores energy o Fat soluble vitamins: Vitamin E, A, K, D o Water soluble vitamins (must be replaced everyday): Vitamin C, B  People who are vegan need sources of B12 vitamin o Emergency reserve for energy RDA Downloaded by cristalene parag ([email protected]) lOMoARcPSD|23521333 - - o 20-35% of calories from fat Types of fat o Saturated Fats  Animal products  Solid at room temp  Meats, whole milk, tropical oils o Monounsaturated Fats  Plant sources  Liquid at room temp  Semi-solid/solid when refrigerated o Polyunsaturated Fats  Liquid at room temp  Liquid when refrigerated  Oils  Soybean, corn oil Cholesterol o Needed to make certain hormones o Only found in animal products o Eggs- in the yolk, Milk o Good vs. bad cholesterol o HDL and LDL  More HDL than LDL is better  Exercise raises HDL o Total cholesterol should be less than 200 o Begins breakdown in the stomach o Digested in the small intestine Calories Carbohydrates: 4 calories per gram Proteins: 4 calories per gram Fats: 9 calories per gram Alcohol: 7 calories per gram 1 pound= 3,500 calories Average Daily Calorie Needs Segment of Population Most women, some older adults, children two to six Average Adult Most men, active women, teenage girls, older children Active men, teenage boys Average Calorie Needs 1,600 2,000 2,200 2,800 Downloaded by cristalene parag ([email protected]) lOMoARcPSD|23521333 Iron - - Why we need it o Needed to make red blood cells o Vitamin C helps iron absorption Sources o Dark, leafy vegetables ex: Spinach o Iron supplements o Take on an empty stomach Calcium - - - Functions o Builds strong bone tissue o Plays a role in blood clotting, muscle and nerve functioning o Helps control high blood pressure, prevent colon cancer and promote weight loss RDA o 13-19 years: 1,300 mg/day o 19-51 years: 1,000 mg/day o 51 years+: 1,200 mg/day Osteoporosis o Bone-weakening disease o Affects 1 in 4 women over age 60. o Peak Bone Mass: 25-35 years o Bone loss starts at age 40 o Menopause: Bone loss increases to a rate of 3-5% a year o Prevention: Adequate calcium intake and exercise Hospital Diets Clear Liquids - Short term Provides sugar and fluids Limited in nutrients Reduce GI stimulation Normally right after surgery Full Liquids - Foods and liquid o Liquid at room temp ex: ice cream, yogurt Downloaded by cristalene parag ([email protected]) lOMoARcPSD|23521333 - Short term Low in protein Low in good calories Supplements Boost/Ensure Soft Diet - Minimum chewing Provides more calories than full liquids Adequate in all nutrients Dysphagia Diet - Needs evaluation by speech therapist Nectar-like food Applesauce o Add barium to applesauce to check for aspiration/food going into stomach and not lungs by x-ray Woman: 5’ 100 pounds, every inch add 5 pounds Men: 5’ 106 pounds, every inch add 6 pounds BMI - Underweight: less than 18.5 Healthy: 18.5-24.99 Overweight: 25-29.99 (10% above ideal body weight) Obese: 30-39.99 (20% above ideal body weight) Severely obese: 40 or more Waist circumference for obesity - Females, over 35 inches around waist - Males, over 40 inches around waist Nursing Interventions - Increase the appetite o Oral hygiene before meals o Clean environment o Small portions Diabetes pg. 184 Lab Manual Type 1 (Juvenile): 5-10% - Get when you’re young Downloaded by cristalene parag ([email protected]) lOMoARcPSD|23521333 - Insulin-dependent Risk factors: o Still unknown- suspect environment Treatment o Insulin o Pumps Type 2 - Impaired insulin production - Inability to enter the cells - Risk Factors: o Family history o Increase with age - Treatment o Weight management o Medications o Insulin Symptoms - - The three P’s o Polydipsia- thirst o Polyphagia- hungry o Polyuria- urine Blood Glucose Levels Diabetic Complications VERY IMPORTANT (Low Glucose) Low Glucose (Hypoglycemia) - Symptoms (early) o Feeling shaky o Headaches o Feeling hungry - Treatment o Quick source of CHO  Patient must be alert!! If not they could aspirate!  If unconscious, NPO, inject D50 by IV  15/15 rule  15 grams of carb, wait 15 min and check again (4 oz oral) Normal Glucose 70-100 High Glucose (102 Material) Downloaded by cristalene parag ([email protected]) lOMoARcPSD|23521333 Nosocomial Infections or Hospital Associated or Acquired Infection (HAIs) Health Care Associated Infections - Catheter Associated Urinary Tract Infection (CAUTI) Pneumonia: patients on ventilators are more susceptible Bloodstream Surgical Sites Urinary Tract Infection: Urine pooling in bowels Downloaded by cristalene parag ([email protected])