Chap 1: Fundamentals Of Nursing Flashcards
1
Q
Who is Florence Nightingale?
A
•She laid the foundation for professional nursing practice through her work in the Crimea in the 1850s. She later established her own nursing schools and emphasis on sanitary care
*First nurse epidemiologist
2
Q
When was the time American Red Cross was found and nursing field expanded?
A
Civil War (1860-1865)
3
Q
What was the purpose of First Amendment Act do?
A
Give financial aid for training and school
4
Q
What is the impact of Florence Nightingale on nursing?
A
Established 400 nursing training schools and improved hospital conditions.
5
Q
History of nursing
A
Follow up with professor notes and emphasis notes (not usually appeared)
6
Q
Two types of communication
A
- Verbal: speaking part
- Nonverbal: facial expression, touch, eye contact
7
Q
Phases of communication
A
- Introductory: introduction, get to know patients and the problems they are having, build the connection
- Working: work on problem (if pt have pain: think if pt have ct scan yet, look at family history, lab values, giving pain meds or surgery needed)
- Terminations: problem solved
8
Q
Use open ended questions over yes/no questions when asking pts. T or F
A
True
9
Q
ADPIE (A Delicious PIE) means in nursing care plan
A
Assessment, Diagnosis, Planning, Implementation, Evaluation
10
Q
Two types of assessment data
A
- Subjective: what pt tells you. Ex: I feel like brick on my chest, my head hurts, itchy, burning sensation, etc
- Objective: what you as a nurse can observe. Ex: vital signs, rash & lesions on arms, how big the size of the open wound, etc
11
Q
What is nursing care plan: diagnosis?
A
Basically statement of pt’s problems and causes (through signs and symptoms)
Ex: Pt has pneumonia- due to ineffective airway of clearance related to accumulation of secretions
Ex: pt has diabetes type I- due to high blood glucose related to insulin insufficient production because of autoimmune attack on beta cells of the pancreas.
Ex: pt has scabies as evidenced by papule and burrows formed in the flexion region of the hands and lab results finding of mites from the skin microscopic magnification and that physician determined it was scabies
12
Q
What is the performed steps in Planning step?
A
Planning pt care and perform intervention, basically what nurses do for treatment
Ex: if pt has pneumonia (from diagnosis) then we can perform chest physiotherapy, still obtaining oxygen saturation level and make sure pt head is elevated for better breathing, giving physician order of drug treatment (might be oral or IV), etc
13
Q
What is implementation step after planning?
A
- Perform what was planning to intervene with pt problems.
14
Q
What is evaluation step?
A
Did or goal of intervention with the problems met?
How is the pt recovery? Better or worse?
15
Q
What is functional health patterns?
A
It is the basis for a series of questions that the nurse asks the patient to develop an in-depth nursing assessment.
Include: the patient’s general health, nutrition, elimination, activity, sleep, cognition, living environment, abuse, sexuality, spiritual/cultural beliefs, coping mechanisms, hygiene, and self-perception.
16
Q
Common nutritions diets:
A
- Regular diets: no restrictions to diet or calories.
- Cardiac diets: low in sodium and fat food.
- Clear/full liquid: Ordered for patients before any GI diagnostics or after surgery. Clear liquid includes anything clear such as apple juice, tea, broth, popsicles, ginger ale, or Sprite. Avoid any liquids that are flavored or colored red for patients with gastrointestinal bleeds. Full liquids include liquid foods; there are no restrictions.
- Soft/mechanical soft diets: foods that are easy to swallow and chew include mashed potatoes, ground meats, and other easy-to-swallow foods.
- Renal diet: low in sodium and potassium food. Protein intake is also monitored.
- Malnourished pt diet: high-calorie diet and may need IV nutrition.
17
Q
Urinary & bowel function note
A
Pt who is in dialysis is anuric (little output)
No bowel movement: might be small bowel obstruction or severe constipation
18
Q
What is the average volume urinary output of adult patient every hour?
A
30mL/hr
720 mL/day or 0.7 L/day
19
Q
Why Foley catheter ordered for patients?
A
Reasons: Surgical, urinary incontinence, ICU patients, and others may require a Foley catheter during their hospital stay.
20
Q
UTI (Urinary Tract infection) characteristics
A
An infection in the urinary tract that causes burning during urination, hematuria, foul-smelling urine. Elderly patients who present with a UTI may have confusion as an associated symptom.
21
Q
Incontinence define
A
A person’s inability to control the function of urination. In many cases, briefs are worn to prevent urinary leakage.
22
Q
Constipation characteristics
A
The inability to have a bowel movement. Stool softeners, prune juice, or laxatives may be given to promote bowel movements. Common causes of constipation are pain medications, immobility, or bowel obstruction.
23
Q
Occult stool characteristics
A
Blood in the stool caused by various conditions such as hemorrhoids or ulcers.
24
Q
Diarrhea characteristics
A
Loose bowel movements that vary in severity. Can be caused by medications, food poisoning, viruses, and bacteria such as Clostridium difficile (C. diff).
25
What vital signs data include?
Temp, HR/pulse rate, respiration rate, BP, pain
26
Changes in vital signs can indicate what?
Ex: hypertension (high BP), hypotension (low BP), dehydration, respiratory distress, hypoxemia (low O2 levels), tachycardia (increased pulse), and bradycardia (low HR).
Red thermometer: rectal area, green thermometer: oral or axillary
27
What preoptic part of brain control temp?
Hypothalamus
28
Body temp assess parts
1. Oral: Many hospitals use an electronic thermometer to obtain oral temperature readings. Make sure that the patient has not had anything hot or cold to drink for 15 minutes before the assessment, as this can alter the temperature.
2. Rectal (most reliable): Never use a rectal temperature on patients who are immunocompromised (have reduced immune function)- infection complications can occur
3. Axillary
4. Tympanic
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Average normal temp
98.6 F or 37 C
30
Factors That Affect Temperature
Age, exercise, stress, illness, and infection can all affect the temperature.
31
Pyrexia define
Elevation in temp
32
Hyperpyrexia define
Intense/critical increase in temp
33
Hypothermia define
Lower temp than normal
34
What is the volume of cardiac output (SV x HR) per minute
5L/minute
SV: volume of heart pumps per beat (Volume/beats)
HR: bpm (Beats/min)
35
Pulse/heart rate ranges
Adults: 60-100 bpm (lower than 60 = bradycardia), (more than 100 = tachycardia), might need EKG to keep monitor if dysrhythmia shown
School age children: 75-120 bpm
Infants: 110-160 bpm
36
Ways to assess pulse/HR
1. Apical pulse: located between the fourth and fifth left intercostal space; it is the strongest pulse in the body and provides an accurate indication of the HR.
2. Radial pulse: located at the wrist right below the thumb (most commonly assessed).
3. Brachial pulse: in the pit of the arm, known as the antecubital fossa.
4. Femoral pulses: in a part the groin known as the inguinal area.
5. Pedal pulses: are along the top of the foot, in between the big toe and the second toe.
37
Normal respiratory rate
12-20 breaths/min
38
Factors That Affect Respirations
Smoking, stress, anxiety, exercise, temperature, infection, pneumonia, asthma, underlying physiological causes, and medications affect respiration.
39
Secret exam note
During an exam, when you are asked a priority question such as which patient to see first, always choose the answer that refers to a patient with a compromised respiratory system! Choose answers that coincide with the “ABCs” (airway, breathing, and circulation). Always help the patient who is in respiratory distress first.
40
Tachypnea & bradypnea range
Tachypnea: more than 20 breaths/min. It is caused by fever, asthma, hyperventilation, anxiety, or pain. Patients present with fast and labored breathing.
Bradypnea: less than 12 breaths/min. It is caused by pain medication or happens when a patient is sleeping.
41
BP normal number
120/80 mmHg (120 = systolic, contraction of heart), (80 = diastolic, relaxation of heart)
42
Assess BP note
The part of the cuff that goes around the patient’s upper arm should be placed over two-thirds of the length of the upper arm and cover three-fourths of the circumference of the arm, right above the antecubital fossa (middle part of the arm).
43
Korot-koff will be heard strongest when?
When cuff is inflated (systolic pressure)
44
BP measure note
BP should not be taken on the arm on the same side where patients have undergone a mastectomy or where a peripherally inserted central catheter (PICC) line is inserted.
45
Factors That Affect Blood Pressure
Dehydration, stress, medications, illness, surgery, hemorrhage, and pain.
46
What is orthostatic hypotension?
Decrease in blood pressure that occurs when patients change from a lying position to a standing position. If a patient is orthostatic, make sure you help them to stand, as a loss of balance or dizziness may occur.
47
Types of pain
•Acute pain: New onset, lasting a short time and usually affecting one area.
•Chronic pain: Experienced over a long period of time; it is constant and persistent.
•Neuropathic pain: Caused by damage to the peripheral nerves.
•Phantom pain: Postamputation, patient can feel pain in the extremity.
•Nociceptive pain: Pain in the muscles or joints.
48
Notes of pain assess
Methods of pain relief may include medications, relaxation, and touch. Pain medications ordered can be narcotics or nonnarcotic analgesics. A PCA (patient-controlled analgesic) may be ordered for patients postoperatively to better control pain. It is important to identify where the patient is having pain, have the patient use either the numeric or the FLACC (Face, Legs, Activity, Cry, Consolability) scale to rate the pain, and document.
49
Nursing interventions for the immobile patient are:
•Turning and repositioning the patient every 2 hours
•Maintaining proper skin care; applying lotion or barrier cream to affected areas
•Ensuring proper hydration by increasing the patient’s fluid intake and encouraging him or her to drink water, or through intravenous fluids
•Performing range of motion (ROM) to increase mobility and decrease the risk of contractures of the muscles •A specialty mattress, such as an air mattress, may be ordered for the patient.
•A wound care consult may also be needed for complex wounds
50
Common Complications of Immobility
Pressure ulcers, blood clots, and contractures of the extremities
51
Pressure ulcers notes:
Pressure ulcers are classified into four stages based on severity. Refer to your textbook for a visual; you will be tested on the different stages. Ulcers commonly occur on bony prominences such as the coccyx, heels, elbows, hips, and ankles. This is caused by shearing, tension, and friction on the skin.
As a nurse, your responsibility is to prevent pressure ulcers by repositioning the patient every 2 hours, applying barrier creams, maintaining dressing changes, and providing adequate hydration.
52
The four stages of pressure ulcers are:
Stage I: Reddening of the skin on the epidermal layer. Skin is intact.
Stage II: Reddening and edema of the epidermis and dermis layer. Similar to a blister. Skin is blanchable.
Stage III: Injury to the subcutaneous layer. Fat may be visible but bones, tendons, or muscles are not exposed.
Stage IV: Severe damage to all layers of the skin with exposed bone, tendon, or muscle.
A wound care consult may be needed. Dressings such as Duoderm or Aquacel may be needed.
https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/webinars/webinar6_pu_woundassesst.pdf
53
Where is the most common place for blood clot?
Calf (deep vein thrombosis)
54
Symptoms of blood clots and what can determine it?
Symptoms: warmth at the site, pain, swelling, and redness. Ultrasound can be used to determine blood clot.
55
Treatments of deep vein thrombosis or blood clot
Patients who are immobile are placed on venous thromboembolism (VTE) prophylactics such as thromboembolism-deterrent (TED) compression stockings or a sequential compression device (SCD) to prevent blood clots. The patient may also be placed on an anticoagulant (blood thinner) such as heparin or Lovenox to decrease the risk for clots. Do not place SCDs or TEDS on the leg with blood clots; this can cause the clot to travel or move. The key is anticoagulation is dissolving the clot before it moves through the vein or artery or becomes larger in size.
56
Wound care advise steps
It is important to maintain a clean and sterile environment for any open wounds. Once a sterile field is in place, clean the wound with either normal saline or sterile water, using gauze to clean in and around the wound bed. The type of dressing used will depend on the wound; the most common type is wet to dry. Check the doctor’s orders to see if packing of the wound is needed. Packing involves inserting small strips of gauze, usually ¼ inch wide, into the wound. Cover the wound with a 4-inch by 4-inch gauze and tape. Use only sterile surgical equipment when changing a dressing. At times, the physician may order ointments such as Santyl (collagenase) to be applied to the wound bed for further treatment. A Duoderm or Aquacel dressing to be placed over the wound may also be ordered. When undressing a wound, throw away the old dressing in a red contamination bag, and change gloves when applying a clean dressing. Document that the new dressing was completed. In severe cases, a wound vac is used for continuous drainage of the wound through suction, which is used for a series of days and is only temporary.
57
Oxygenation secret notes
Assessing a patient’s respiratory status is always a priority. When a patient is experiencing any respiratory abnormalities, difficulty breathing, shortness of breath, or labored breathing, you need to assess and treat immediately. On exams and tests, when any questions have to do with assessing an airway or treating a patient who has difficulty breathing, the answer always is: Assess the airway first! Oxygen saturation is used to determine the amount of oxygen perfusion through the body. The normal values are 96% to 100%. Keep in mind that a patient with a respiratory disorder may require oxygen.
58
What is Kussmaul breathing?
Deep and rapid breaths are usually seen in patients who are experiencing metabolic acidosis (excess acid in the tissues) and can be caused by chronic kidney disease or diabetic ketoacidosis.
59
What is Cheyne–Stokes breathing?
Very deep and shallow breaths. Commonly seen in patients with congestive heart failure and in terminally ill patients, as well.
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Common Respiratory Disorders:
•Chronic obstructive pulmonary disease (COPD)
•Asthma
•Pneumonia/bronchitis
61
Respiratory disorders diagnostic use
Complete blood count (CBC), chest x-ray, arterial blood gases, pulse oximetry, sputum culture, computed tomography angiography (CTA) of the chest, and many others may be used to help diagnose and treat respiratory disorders.
62
Emergency respiratory nursing intervention
When a patient is experiencing a change in respiratory status, first assess the airway and oxygen saturation. Call for help from either the respiratory therapist or team on the floor. Call the doctor for orders. If the patient is experiencing shortness of breath, place the patient in semi-Fowler’s position (an upright sitting position with the head of the bed elevated greater than 45°). Administer oxygen as ordered. A nasal cannula is commonly used to supply oxygen to the patient. When placing the nasal cannula, set the amount to 2 L, and adjust it per physician’s order. In an emergency situation, the patient may require a mask that supplies a larger amount of oxygen.
63
Nonemergent nursing respiratory intervention
1. Chest physiotherapy (Chest PT): to break up secretion in the chest so the patient can better expel the secretions. This is performed by cupping the hands and beating gently on the patient’s upper back.
2. Incentive spirometer (IS): helps the patient expand the lungs and alveoli.
3. Instructing the patient to take deep breaths and cough every 2 hours can help prevent hospital-acquired disorders such as pneumonia.
4. Nebulizer treatments and steroids may also be needed for the patient.
An early sign of a lack of oxygen is a change in mental status and low oxygen saturation levels, and a late sign is clubbing of the nails.
64
When respiratory is impaired, ABG is needed for more accurate reading of oxygen and plus co2 level in blood. T or F
True
65
PaCO2 & PaO2 means
Partial pressure of Co2 & O2 in arterial blood
66
Blood Gas Values:
•pH: 7.35–7.45
•PaCO2: 35–45 mmHg
•PaO2: 80–100 mmHg
•HCO3: 22–26 mEq/L
67
Respiratory acidosis
In this condition, PaCO2 is increased above 45 mmHg and pH is decreased (below 7.45). Respiratory acidosis can be caused by obstructive pulmonary diseases, pneumonia, hypoventilation, and asthma. Symptoms are rapid/shallow respirations, confusion, and hypoxemia. Nursing interventions are to maintain the patient’s oxygen saturation levels and airway, and treat the underlying cause. Mechanical ventilation may be needed.
68
Respiratory alkalosis
In this condition, PaCO2 is decreased and pH is increased. Respiratory alkalosis is caused by hyperventilation and stress. Symptoms are muscle twitching, deep/rapid breathing, dizziness, tingling of the fingers, and difficulty breathing. Nursing interventions treat the underlying cause and use a rebreathing mask.
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Metabolic acidosis
In this condition, both pH and HCO3 are low. Metabolic acidosis is caused by renal failure, diarrhea, diabetes, vomiting, and shock. Symptoms are fruity breath, nausea, Kussmaul breathing, vomiting, diarrhea, headache, and increased potassium. Nursing interventions are to administer intravenous sodium bicarbonate and maintain respiratory status. Ensure proper nutrition and adequate hydration. Monitor potassium levels.
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Metabolic alkalosis
In this condition, pH and HCO3 are increased. Metabolic alkalosis is caused by vomiting, excessive intake of antacids, and gastric suctioning. The symptoms are tingling, irritability, confusion, tetany, decreased respirations, and muscle cramping. Potassium is also decreased. Nursing interventions are to administer IV fluids, monitor electrolytes, increase potassium, and treat the underlying cause.
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Acid-base balance chart
Respiratory acidosis: Increase in PaCO2 (> 45 mmHg), Decrease in pH (< 7.35)
Respiratory alkalosis: Decrease in PaCO2 (< 35 mmHg), Increase in pH (> 7.45)
Metabolic acidosis: Decrease in pH (< 7.35), Decrease in HCO3 (< 22 mEq/L)
Metabolic alkalosis: Increase in pH (> 7.35), Increase in HCO3 (> 26 mEq/L)
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Electrolyte Lab Values:
•Potassium (K): 3.5–5.0 mEq/L
•Sodium (Na): 135–145 mEq/L
•Magnesium (Mg): 1.5–2.6 mg/dL
•Phosphorus (P): 2.7–4.5 mg/dL
•Calcium (Ca): 8.6–10.4 mg/dL
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Dehydration/Hypovolemia
Dehydration or hypovolemia is a loss of fluid volume. Causes of dehydration are poor nutrition or fluid intake, surgery, diarrhea, renal disease, vomiting, NGT suctioning, and diuretics. Patients may present with symptoms of increased HR, decreased BP, poor skin turgor, weight loss, low urine output, dizziness, and weakness. Treatment for dehydration is to increase oral intake and to administer intravenous fluids. Monitor intake and urine output.
74
Fluid Overload/Hypervolemia
An excess of fluid is called hypervolemia. Too much fluid can cause edema (swelling in the intravascular space), typically seen in the lower extremities and ankles, or crackles in the lungs. Hypervolemia can be caused by renal disease or congestive heart failure. Symptoms include crackles in the lungs, edema (swelling in the body), bounding pulse, weight gain, increased BP, and shortness of breath. Treatment consists of administering a diuretic such as furosemide (Lasix), discontinuing all intravenous fluids, decreasing fluid intake, monitoring strict intake and output, monitoring daily weights, and cardiac monitoring.
75
Hypokalemia
In this condition, the potassium level is below 3.5 mEq/L. Hypokalemia can be caused by vomiting, diarrhea, gastric suctioning, kidney disease, and diuretics. Symptoms include irregular pulse, heart arrhythmias, muscle weakness, and muscle cramping. Treatment includes administering oral potassium, and intravenous fluids with potassium. Oral potassium is very bitter, so mix in a cup of orange juice to mask the taste. Cardiac monitoring is necessary. Patients with hypokalemia usually have an EKG pattern with a depressed U wave. IV potassium is mixed with saline given only at a slow rate, over the course of two or more hours. Never push IV potassium, because it tends to burn and cause discomfort. Monitor the patient’s kidney status closely before administering potassium.
76
Hyperkalemia
Here, potassium levels are above 5.0 mEq/L. Hyperkalemia is caused by kidney disease, and medications such as angiotensin-converting enzyme (ACE) inhibitors are common causes. Symptoms include slow HR, weakness, cardiac arrhythmias, abdominal cramping, and muscle twitching. A peaked T wave may appear on the EKG; this cardiac arrhythmia can be fatal and must be treated immediately. Treatment includes decreasing potassium in the diet and administering sodium polystyrene (Kayexalate), a medication that decreases potassium in the blood.
77
Hyponatremia
In this condition, sodium levels are below 135 mEq/L. Hyponatremia is caused by fluid overload, edema, diuretics, burns/wounds, and administration of an excess amount of D5W. Symptoms include headache, confusion, abdominal cramping, muscle cramps, nausea, dry mucous membranes, and clammy skin. Treatment consists of administering IV fluids with sodium. Medications such as tolvaptan (Samsca) may be administered to increase sodium. Monitor sodium levels.
78
Hypernatremia
Here, sodium levels are above 145 mEq/L. Hypernatremia is caused by dehydration and an increase in salt intake. Symptoms include edema, weight gain, thirst, weakness, and fatigue. Treatment consists of monitoring sodium intake, administering diuretics to remove sodium, and monitoring daily weights.
79
Hypomagnesemia
In this condition, magnesium levels are below 1.5 mg/dL. An increase in Mg levels can be caused by alcoholism, vomiting, gastric suctioning, medications, and poor nutrition. Symptoms include increase in BP, positive Chvostek’s and Trousseau’s signs, mental status changes, and tremors. A positive Chvostek’s sign is identified by muscle contraction in the face. When the facial nerve is tapped, usually in the jaw, there is a twitch on the nose or mouth. Trousseau’s sign is identified by applying and inflating a BP cuff; a positive sign produces an abnormal spasm in the arm. Treatment consists of increasing Mg levels by administering magnesium sulfate (high-alert medication) intravenously as ordered.
80
Hypermagnesemia
Here, magnesium levels are above 2.5 mg/dL. An increase in magnesium is caused by too much Mg in the diet, renal failure, or adrenal insufficiency. Symptoms include muscle weakness, decreased HR, respiratory depression, decreased reflexes, and GI upset. Treatment consists of administering calcium gluconate intravenously. Monitor the patient’s level of consciousness and monitor for confusion.
81
Hypophosphatemia
In this condition, the phosphorus level is less than 2.7 mg/dL. Causes of decreased phosphorus are lack of nutrition, increased calcium levels, thyroid disorders, alcoholism, and poor nutrition. Symptoms include muscle weakness, respiratory depression, irritability, and positive Chvostek’s and Trousseau’s signs. Treatment consists of oral phosphorus with vitamin D as the first line of treatment.
82
Hyperphosphatemia
Here, phosphorus levels are above 4.5 mg/dL. Causes of increased phosphorus are renal disorders, thyroid disorders, and a decrease in calcium levels that increases phosphorus. Treatment consists of administering a calcium-containing phosphate binder such as Renagel and Phoslo.
83
Hypocalcemia
In this condition, calcium levels are below 8.6 mg/dL. Hypocalcemia is caused by thyroid disorders, renal failure, vitamin D deficiency, increased phosphorus, and chemotherapy. Symptoms are muscle numbness and tingling, positive Chvostek’s and Trousseau’s signs, seizures, and muscle twitching. Treatment consists of administering calcium and vitamin D.
84
Hypercalcemia
Here, calcium levels are above 10.4 mg/dL. Hypercalcemia is caused by overactive thyroid, cancer, and diuretics. Symptoms are muscle weakness, weight loss, confusion, nausea, kidney stones, and abdominal pain. Treatment consists of calcitonin, loop diuretics, and bisphosphonates such as etidronate.
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Hypotonic Solutions:
Hypotonic solutions have low osmotic pressure and are used to treat edema and hypotension. Types of hypotonic solutions are 0.45% normal saline (NS) and 5% dextrose.
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Isotonic Solutions:
Isotonic fluids are used to treat dehydration and metabolic acidosis. The types of isotonic fluids are 0.9% sodium chloride (the most commonly given fluid), lactated Ringer’s solution, and 5% dextrose in water (D5W).
87
Hypertonic Solutions:
Hypertonic solutions have high osmotic pressure and are used to treat blood loss, hypovolemia, and hyponatremia. They are usually given at a slow rate to decrease the risk of fluid overload. Types of hypertonic solutions are dextrose 5% in 0.45% NS, dextrose 5% in 0.9% NS, and dextrose 5% in lactated Ringer’s. When administering intravenous fluids (IVF), follow the physician’s orders and administer the correct rate. IVF are given through an IV site, and it is important to assess the site for redness, infiltration, or swelling.
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Intravenous lines
They allow health care professionals to administer medications, procedures, surgery, and fluids. Most hospital protocols require all patients to have IV access. An IV is best started in the distal veins of the arms and needs to be large enough to maintain the catheter. A 22-gauge needle is most commonly used. A 20-gauge needle is used for patients receiving blood products or requiring contrast. IV sites must be changed every 2 to 3 days. Complications of IVs include infiltration (swelling of the site due to fluid in the tissues) and phlebitis (inflammation of the vein). It is the nurse’s responsibility to assess the IV site and change the site if any problems occur.
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Peripherally inserted central catheter (PICC) lines
Used for patients who are on long-term antibiotics or if intravenous sites cannot be obtained. A PICC line is inserted through the cephalic or brachial vein and then advanced into the superior vena cava. A chest x-ray is used to confirm placement. A PICC line dressing must be changed every 7 days. Arm circumference is measured daily. If swelling or edema occurs in the arm, an ultrasound may be needed to see whether blood exists in the arm. Blood draws are allowed in PICC lines.
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A subclavian Port-a-Cath
A central venous catheter that goes into the vein in the chest wall and into the heart. Dressing on the port is changed every 7 days. Aseptic technique is needed when changing and accessing the port. Blood draws are also allowed. Port-a-Cath use is common with patients receiving chemotherapy or frequent transfusions.
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MEDICATION ADMINISTRATION
Nursing has three main tasks. The first is to assess the patient, the second is to administer medications ordered by the physician, and the third is documentation. It is important to know the five rights of medication administration and carefully administer medications as ordered. The five rights of medication administration are right patient, right drug, right route, right dose, and right time. Using the five rights ensures the patient’s safety and prevents you from administering the wrong medication. Medications are typically given orally, intravenously, intramuscularly, or subcutaneously. Be careful with patients who are at risk for aspiration or have difficulty swallowing; these patients may require medications to be crushed or given intravenously. Always assess, describe, and make sure the patient is aware of the medications you are administering. When administering cardiac medications, always obtain a BP/pulse and follow parameters.
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Infections
Invasions of organisms such as viruses, bacteria, and parasites that enter the body.
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Standard Precautions:
Standard precautions are used for all contact with patients. Wash hands and use gloves with all patients.
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Contact Precautions:
Contact precautions are the use of gown and gloves. Methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile (C. diff), shingles, vancomycin resistant enterococci (VRE), and E. coli in the urine are common infections that require contact precautions. When treating patients with C-diff, you must wash your hands with soap and water to prevent infection; hand sanitizer does not kill the C-diff bacteria. Pregnant women or caregivers who have not had or been vaccinated against chickenpox (varicella) should not care for patients with shingles. Always throw gowns away before exiting the room, and wash your hands thoroughly.
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Droplet Precautions
These require the use of gown, gloves, eye shield (if preferred), and mask. An N95 mask is needed and fitted by size. Patients who have TB or Ebola require droplet precautions. A negative pressure room is also needed. Droplets are found in secretions such as cough or other bodily fluids.
Ex: Adenovirus, flu, streptococcus, whooping cough (pertussis), rhinovirus, pneumonia, mumps, meningitis, mycoplasma pneumonia
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Airborne Precautions:
These require the use of gown, gloves, and mask. A regular surgical mask can be worn. Patients who test positive for influenza require airborne precautions.
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Surgical experience
There are three main phases of the surgical experience: (a) preoperative, (b) intraoperative, and (c) postoperative.
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Preoperative Phase
The preoperative phase begins with the decision to consent to surgery and ends when the patient is transferred into the operating room. Before any procedure, it is important to have the patient sign consent for surgery, and to ensure that all lab work has been completed, vital signs are stable, and the patient understands the surgical procedure. The nurse’s role in preparation for the day of surgery is to make sure all the consents are signed, prep the patient for surgery, assess vital signs and labs, remove jewelry, prepare the bowel/bladder (making sure the patient voids before going to surgery), ensure all preoperative medications are given, and make sure all the patient’s questions are answered. It is very important to administer BP medications and antibiotics prior to surgery. Beta blockers must be given if it is within parameters. If the BP is low, the surgeon should be contacted. Patient education is important, and the patient must be taught what to expect preoperatively, intraoperatively, and postoperatively. Preoperatively, you need to discuss the procedure and educate the patient on ways to avoid complications postoperatively. Some of the main points that need to be addressed with patients to prepare them for the postop phase are to turn and reposition in bed every 2 hours in order to increase circulation, and to apply SCDs and TEDs in order to decrease the risk of blood clots. Encourage the patient to cough and deep breathe, and consider using an incentive spirometer to increase lung expansion and decrease the chances of developing hospital-acquired pneumonia. Preventing complications is vital, and educating patients is important for a speedy recovery.
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Intraoperative Phase
This phase begins with the patient being transferred from preop to the operating room and ends in the postanesthesia care unit (PACU). In this phase, the surgeon performs the procedure. Nurses play many roles in the intraoperative phase. In the operating room, there is a scrub nurse and a circulating nurse to help assist the surgeon with any needs. They help with handing and counting all the instruments and materials used. They also help monitor the patient during the surgical procedure. The intraoperative phase ends when the surgical procedure is completed.
100
Postoperative Phase
The postoperative stage begins when the patient arrives in the PACU and ends when the patient is placed in a medical–surgical unit. The postoperative phase is a critical phase where the nurse must monitor for any postop complications or any acute changes. The PACU nurse is responsible for maintaining the patient’s airway, assessing the wound or incision, controlling pain, monitoring urinary output, assessing vital signs, and assessing for any changes in the patient’s mental status. It is the nurse’s responsibility to convey any changes to the surgeon immediately. The most common postsurgical complications are shock, hemorrhage, pneumonia, wound infections, and blood clots. In the preoperative phase, postop teaching was completed, with the goal of helping the patient understand these complications and learn how to decrease the chances of complications by using the numerous preventive measures. Once the patient arrives on a medical–surgical unit, it is the floor nurse’s responsibility to continue to assess for postop complications and any changes that might occur.
101
BLOOD TRANSFUSIONS
Blood transfusions are needed for the patient with a decrease in hemoglobin and hematocrit. Conditions such as sickle cell disease, cancer, GI bleeds, and anemia can all cause a decrease in these levels. Blood transfusion is administered to increase these levels. A consent form must first be signed, there must be a physician’s order, and all complications must be explained. A cross-match is needed. The blood is prepared and refrigerated until transfusion. An IV site is needed. Two nurses are needed to check the blood. Obtain vital signs before the transfusion, 15 minutes into the transfusion, and after the transfusion. If the patient has an abnormal temperature, Tylenol may be given before the transfusion. Assess for a reaction to the blood. Sit in the room for 15 minutes once the transfusion has started. If a reaction occurs, call the physician immediately and stop the blood.
102
Dehydration can lead to both low BP and high BP. T or F
True
Low blood pressure: dehydration causes blood volume to decrease and if too dehydration, body can go to shock state
High blood pressure: can happen in case where too much vasopressin (ADH- no peeing, retaining water) is being released because of high solutes in blood from dehydration
103
Pyuria define
A condition in which you have pus in your pee. UTIs are the most common cause, but other causes include STIs, viral infections and chronic use of some medications. The most common symptom is cloudy, foul-smelling pee.
104
Equipments used for standard precaution
105
Contact precautions equipment & nursing consideration
106
Droplet precautions equipment and nursing consideration
107
Airborne precautions equipment and nursing consideration
108
Neutropenic precautions equipment and nursing consideration
109
Contact transmission disease examples
110
Droplets transmission disease examples
111
Airborne transmission disease examples
112
Review the Physiology of the Renin-Angiotensin-Aldosterone System (RAA):
- Renin (Kidney Enzyme) converts angiotensinogen (plasma protein) into angiotensin I
- ACE converts that to angiotensin II. Angiotensin II is a vasoconstrictor and it stimulates
aldosterone release from the adrenal cortex.
- Aldosterone causes Na+ reabsorption and K+ secretion (increases volume).
