195 FINAL EXAM Flashcards
What are the 5 rights to delegation?
1. Right task (w/in scope)
2. Right circumstance (stable vs nonstable)
3. Right person (who can perform task w/in scope)
4. Right supervision (report back/ trust but verify)
5. Right direct & communication (be specific)
What must you make sure of when delegating to an UAP & What can you delegat to a UAP?
Is the task w/in the UAPs scope & does the UAP have the knowledge, skills, & ability to perform the task
Can delegate:
* OTC topical meds to intact skin
* OTC eye/ear drops
* Suppository meds
* Foot soak tx
* Enemas
What can you NOT delegate to a UAP?
Assessments & judgement calls
Prescription meds
Unstable Pts
* Ex -Postop pt (surgery/ procedure return), Multiple seizures
Pt education
* Ex - Discharge instructions
* TIP: You cannot delegat what you EAT
* E - educate
* A- Assess
* T - Teach
What are some ways to ensure the National Patient Safety Goals (NPSGs) are met?
Identify Pt correctly
* Use double identifier
Improve staff communication
* Give important test results to right staff on time
Use medications safely
* Label meds, take extra care of Pts on blood thinners, pass/record medications, compare meds to new meds, tell Pt to bring in up-to-date med list to Dr visits
Prevent infection
* Use standard precaution or sterile tech
Use alarms safely
* Make improvements to ensure alarms on medical equipment are heard & responded to on time
Identify Pt safety risk
* Reduce risk for suicide
Prevent mistakes in surgery
* Make sure correct surgery is done to the correct body part on the correct Pt & pause before surgery to make sure no mistakes have been made
Improve health care equality
* Health care disparities in the patient population are identified and
a written plan describes ways to improve health care equity.
“Brain attack” - medical emergency
- S/s appear suddenly
- occurs more in men
S/s:
-“worst headache ever” (Hemorrhagic)
- stiff neck (Hemorrhagic)
- loss of consciousness (Hemorrhagic)
- seizure (Hemorrhagic)
- depends on area affected (Ischemic)
- one sided weakness (unilateral; Ischemic)
- vision changes (Ischemic)
- confusion (Ischemic)
- headache (Ischemic)
- dysphagia (Ischemic)
2 types:
- Hemorrhagic: hemorrhage into brain; shows on CT
- Ischemic: formation on embolus/ thromboses that occluded an artery; does NOT show on CT
Stroke (CVA - Cerebrovascular Accident)
What neurological deficits could occur after a stroke?
Aphasia, dysarthria (communication issue)
Dysphagia (aspiration, malnutrition, check gag reflex, swallow study - swallowing trouble)
hemiplegia
unilateral neglect (patient doesn’t believe or “forgets” that side doesn’t work)
sensory impairment
What are some diagnostic tests for a stroke?
CT (fastest, determines stroke type - 1st)
-w/o contrast
MRI (2nd), ECG/EKG
EEG (later)
Cerebral & carotid angiography
Blood studies (lipid, PT/INR)
Deficient blood flow to the brain from a partial or complete occlusion of an artery (clot)
Causes:
- Thrombotic (atherosclerosis; coagulation disorder/ chronic hypoxia)
- Embolic (thrombus is endocardial layer of heart; rheumatic heart disease)
treatment:
- Thrombolytics such as tissue plasminogen activator (tPA, alteplase; acute ischemic stroke)
- digests fibrin and fibrinogen and thus lyses the clot
- platelet inhibitors and anticoagulants given if stroke is caused by thrombus or embolus (ischemic stroke) to prevent more clots (must be given after 24hrs if treated with TPA)
Ischemic stroke
Results from bleeding into the brain tissue or subarachnoid space
- the bleed causes damage by destroying and replacing brain tissue
an aneurysm is often the cause of hemorrhage
treatment:
- craniotomy: clipping the aneurysm/ removing the clot to prevent re-bleed
hemorrhagic stroke
which insulin used for sliding scale?
Rapid-acting insulin:
* Humolog (lispro)
* Novolog (aspart)
Regular/short acting insulin:
* Humulin R
* Novalin R
What is the therapeutic rang for INR for a Pt taking warfarin?
Therapeutic - 2-3
Normal - 0.8-1.2
Loop Diuretic- po, IV,IM
* potassium wasting
* Give if K is high
* Inhibits reapsorption of Na
Used for worsening crackles, new edema in the legs, edema w/ HF, rapid weight gain, pulmonary edema, hepatic disease, renal failure, & cirrhosis of the liver
Adverse reaction:
* hypokalemia, hyponatremia, hypocalcemia, hypomagnesemia
* thrombocytopenia
* orthostatic hypotension
* rash
* ototoxicity and deafness
* dehydration
Assess/monitor:
* Obtain BP before admin - notify HCP if BP < 90
* S/s of hypokalemia (weakness/fatigue, palpitations, numbness/tingling)
* Serum K, Na, & Ma levels
* monitor BUN & Cr
Pt education:
* Change positions slowly to prevent orthostatic changes, especially w/ elderly
* Increases urion O/P
Furosemide (lasix)
Thiazides
Use: Edema, HTN
Adverse reaction:
* Electrolyte imbalance
* Hepatotoxicity
* Renal failure
* Pulmonary edema
Assess/monitor:
* Obtain BP before admin - notify HCP if SBP < 90
* Presence/ resoultion of edema
* Serum electrolytes
* I/O, daily weights
Pt education:
* Notify provider before beginning any new drug/ supplememnt
* Increases urine O/P
Hydrochlorothazide (HCTZ, Microzide)
Anticoagulant/ antiplatelet - IV, SubQ
Use:
* Afib, DIC, PE in hip/knee replacement
* Venous thromboembolism prophylaxis or Tx
* Venous cath. occlusion, clots
* Warfarin bridging
Contradictions:
* Severe thrombocytopenia
* Uncontrolled active bleeding
Caution w/ severe HTN, Hx thrombocytopenia, Hepatic Disease, Major surgery
Adverse affects:
* Heparin- induced thrombocytopenia (HIT)
* Anemia, hypotension
* Thrombocytopenia
* Bleeding / hemorrhage, hematuria,ecchymosis
Assess/monitor:
* Signs of bleeding before administrating medication
* Heparin aPTT/ Antixa labs for dose titration for Pts on GTTs
* Platelets, INR (If on warfarin)
* Hgb, Hct, Liver function
Pt education:
* Rotate injection site
* Report signs of thrombocytopenia / Bleeding
Enoxaparin (lovenox)
Heart is not as effiecient as it should be
Ventricle is loaded with blood to the point where the heart muscle contraction becomes less efficient
Labs:
* CBC, MP
* Cardiac enzymes
* T3/T4, TSH
* C-reactive protein (If infection is suspected)
* B-type natrietic peptide (BNP)
* N-terminal pro b-type natiuretic peptide (NT-proBNP)
Heart Failure
What are some cardiovascular changes w/ aging & their results?
Decreased cardiac o/p:
* Increased risk of HF
* Decreased peripheral circulation
Decreased elasticity of heart muscle & blood vessles:
* Decreased venous return
* Increased dependent edema
* Increased risk of orthostatic hypotension
* Increased risk of varicosities & hemorrhoids
Increased atherosclerosis:
* Increased BP
* Increased MI
What other Dx does HTN contribute too?
CAD
Stroke
HF
PVD
Renal failure
What are nursing interventions for a pt having dysrhythmias?
Monitor vitals
Note rate, regurality, & strength of pulse
Monitor I/O
Observe & report reaction to meds
Keep stress to a minimum
* Balance rest & activity
