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
What interventions would you provide a pt w/ CAD?
Assess knowledge & understanding of disease process
* Discuss Dx, s/s, & potential complications
Explain purpose, dosage, side effects, & special effects of meds
Assess modifiable cardiac risk factors
Assess diet:
* Intake, intake of processed/canned foods
* Salt intake
Exercise:
* 150 min/week
Obesity:
* Manage caloric intake
Smoking:
* Avoid tobacco
* Avoid second hand smoke
Identify source of stress & sleeping habits
DM
What interventions would you provide a pt w/ COPD?
Ask if smoker
* if so, how many packs a day
Assess lung sounds
* Diminished
* Crackles, wheezes
* Barrek chest d/t increased anteroposterior diameter
Pulmonary hygiene, breath retraining
Meds, exercise
chest physiotherapy (CPT)
Smoking cessation
Encourage fluids, deep breathing exercises, & pured -lip breathing
Education on lifestyle changes
What interventions would you perform for a pt w/ inadequate oxygenation?
Prevent pneumonia & atelectasis by frequent position changes & deep breathing
Instruct pt to breath through the nose & gradually blow out of the mouth
Use incentive spirometer 10x/hr
* Ball rises w/ inhale
Splint when coughing
Elevated BP
* Confirmed by repeat BP findings averaging 140/90mm Hg or higher
Most serious complications include MI, HF, stroke, kidney disease & blindness
* Assess more frequently
S/s:
* Occipital headaches (more severe when arising)
* Lightheadedness, blurred vision
* Epistaxis (nosebleeds), “Silent killer”
emergency crisis: 180/100
Tx:
* Monitor vital (esp. BP)
* EKG
* Blood studies: Glucose, Hct, K, Ca, Cr, Liped profile
(Elevated Cr = kidney damage, abnorm serum lipids & lipoprotein may indicate artheroscleosis)
* CXR (May show enlargment of heart/pulmonary blood vessels)
* Education on weight reduction, smoking cessation, Na & alcohol reduction, exercise, & relaxation techs.
* Education on Dietary Approaches to Stop HTN (DASH diet - Fruit/veg, whole grains, low fat dairy)
* Medications (Beta-blocker, ACE inhibit., Thiazide/Diuretics, ect)
HTN
A patient has impaired glucose tolerance, high serum insulin hypertension elevated triglycerides low high density cholesterol and altered size and density of low density lipoproteins (LDL) cholesterol’s. Which disorder is associated with these characters?
A.) Retinopathy
B.) Neuropathy
C.) metabolic syndrome
D.) macrovascular syndrome
C.) metabolic syndrome
a medical condition associated with a group of metabolic risk factors
- obesity, diabetes (T2) , high cholesterol, hypertension, heart disease, and stroke
Precursor to Diabetes
Pts often have:
- Impaired glucose tolerance
- insulin resistance, hyperglycemia
- HTN
- Low HDLs, elevated triglycerides
- Altered size (large waist) & density of LDL
Treatment :
-weight loss, dietary & lifestyle changes
-reduce sugar & refined grains
metabolic syndrome
What is the lab value BUN an indicater for?
Kidneys ability to excrete urea (end product of protein metabilism)
* Nephrotoxic drugs, high protein diet, GI bleed, dehydration, MI, shock, burns, & sepsis
Lab value: 10-20
How will electrolytes be effected for a pt Dx w/ renal failure?
Na & K levels are elevated & Ca levels are decreased
Build up of waste in blood makes it hard for kidneys to keep correct fluid balance
Arteries in renal parenchyma become narrowed d/t artherosclerosis, HTN, nephrosclerosis, or blood components (sickled RBC,Hgb or myoglobin)
S/s:
* fluid retention/ hypovolemia
* SOB, cp or pressure
* Irregular heartbeat
* edema lower extremities
* Change in urine o/p
* systolic bp > 70mm Hg
Labs/ Tests:
* UA, BUN/Cr
* CBC
* Kidney biopsy
* GFR
* Ultrasound, CT/MRI, X-ray
Acute Renal Failure
What nursing interventions/ treatements will you anticipate for renal failure?
Fluid restriction, direct restriction
* IV fluids w/ dopamine, furosmide, or both (loop diuretics)
Restore electrolyte imbalance
* restrict Na, K & phos intake (give kayaxelate)
* Place on cardiac monitor
* Hemodialysis
* Diet individualized by electrolyte imbalance
Avoid nephrotoxic drugs
Prevent FVO
* monitor for crackles, cyanosis, increased RR, ect.
Continuous Renal Replacement Therapy
Daily weight
* Same time, same scale, same clothing types, ect.
Monitor s/s related to immobility (constipation, skin breakdown)
Kidneys damaged & cannot propperly filter blood
* progressive destruction of nephrons of both kidneys that is describes in stages 1-5
* Develops slowly
Excess fluids and waste from blood remain in body causing other problems (heart disease, stroke)
Cr clearance is important
* < 15 = stage 4, severe funtion loss
S/s:
* Elevated BUN/Cr
* Elevated serum K (hyperkalemia, hypocalcemia, high phosphate)
* Decreased GFR
* increased BP
* High LDL
* Polyuria leading to oliguria
* Change ins Sp. Grvty d/t decreased ability to concentrate urine
* hypernatremia
* Hypervolemia
Labs:
* BUN/Cr
* UA
* ultrasound, CT/MRI, X-ray
* CBC
* Metabolic panel
Chronic Kidney disease
What are the most common causes of Chronic Kidney disease?
HTN
DM
Artherosclerosis
opioid analgesic and vasodilator - PO/IV/IM
used to treat severe pain, sedation, & cancer pts
* narcotic drug derived from opium
Monitor for resp. depression
Controlled substance
morphine
Anticoagulant (blood thinner)
- PO
- vitamin K antidote
action:
- interferes with blood clotting
side effects:
- nausea, rash, anemia, ect
adverse effects:
- hematuria and hemorrhage
Lab: INR 2-3 (Give if below 2, hold if above 3)
BBW: monitor for bleeding
Warfarin (Coumadin)
How can you dx HTN?
CXR
EKG
What are some tests you could run to determine the level of HF?
BUN/Cr
Electrolytes:
* sodium (Na)
* calcium (C)
* magnesium (Mg)
EKG
CXR (Chest X-ray)
Chronic pulmonary disease/ disorder
pressure from fluid buildup and causes backflow of fluids to the right ventricle
fluid backs into venous system/ rest or body
S/s:
* coughing, wheezing
* SOB when lying flat
* dizziness
* fluid retention
* hepatomegaly
* peripheral edema
right sided heart failure
occurs when the heart loses its ability to pump blood
* prevents organs from receiving enough oxygen
* affects pulmonary (edema)
S/s: (pulmonary symptoms)
* Decreased cardiac output
* Dyspnea, orthopnea
* Wheezing
* pink sputum
* Crackles
* SOB when exercising or sleeping
Left sided heart failure
T/F - If a patient has been in atrial fibrillation for more than 48 hours, anticoagulation is needed prior to a cardioversion due to blood clot risks.
True
Rapidly progressive hypertension that can cause life-threatening damage to small arteries in major organs
Diastolic pressure is usually >140 mm Hg
life-threatening organ damage
- treatment based on severity
S/s usually don’t occur until vascular changes occur in the heart, brain, eyes, or kidneys
malignant hypertension
chaotic, rapid electrical impulses in the atria
* irregular/no P wave - has QRST wave
* 100-150 BPM
* Increases stroke risk
* most common
causes:
* HTN, MI, HF
* CHD, COPD
s/s:
* Palpitations, pulse deficit
* hypotension
* SOB, CP
* fatigue
* tachycardia
* possible stroke
treatment:
* prevent thrombi (warfarin/ anticoagulants - bleeding precaution)
* restore normal rhythm
* synchronized cardioversion/ D-fib
* Count apical pulse for 1 min
arterial fibrillation (AFib)
Your patient has a potassium level of 6, what do you do?
Give spironolactone (Aldactone)
What do you monitor for while taking lovenox?
Bleeding
D-dimer
what do you suspect is the problem with your pt complaining of being tired, weak, their skin is itchy and they have a dusky gray color to their skin?
Chronic Renal Failure
which protein choice would align with Dietary Approaches to Stop Hypertension (DASH) eating plan?
A) 12 oz ribeye steak, grilled
B) 3 oz wild salmon, grilled
C) 8 Oz hamburger w/ cheese
D) 12 hot wings w/ skin and hot sause
B) 3 oz wild salmon, grilled
Explaination: DASH diet emphasizes lean sources of protein including poultry, fish, nuts, low-fat dairy, & lean red meats.
BBW: Tendon rupture, Increased risdk when used w/ corticosteroids
can cause prolonged Q-T intervals
- danger of prolonged Q-T interval can put heart at an increased risk for cardiac dysrhythmeias (even deadly ones)
Ciprofloxacin (Cipro)
NSAID (non-steroidal anti inflammatory)
- IM, IV, nasal spray
Used for mild-moderate pain
- check BUN/Cr (Toxic to liver)
Black box warning: nephrotoxic, hepatotoxic, can cause stroke & MI, GI bleeding, Steven-Johnson’s syndrome
Do not use for pain associated with CABG
- coronary artery bypass graft
Antidote: Narcan, Mucomyst
Toradol (ketorolac)
