Exam 2 Flashcards
Normal ranges for labs for a patient who is going through a pre-op assessment
-CBC
RBC 4.2-6.1
WBC 4000-11000
Hgb 12-18
Hct 37-52
Plt 150k-450k
-PT 10-12
-INR 2-3 <1.1 normal
-aPTT 60-80
Electrolyte
Pre-op teaching for a patient
Measures/treatment to reduce the chances of blood clots for a patient post-op
-early ambulation
-compression socks
-SCD
-anticoagulated therapies
S/s of opioid overdose and treatment for opioid overdose
-Respiratory depression
-treatment: Narcan/ Naloxone
Priority assessment for post-op patient in the PACU
Nurse’s role with informed consent
-review consent
-verify and clarifies facts
-confirms consent is signed, dated, and timed
-may serve as a witness
Know the reasons for surgical procedures and examples of surgeries for each
-Cosmetic: reshape normal body structure/ improve self-image (ex. Rhinoplasty)
-Curative: resolve health problems/ repairs or removes the cause (ex. )
-Diagnostic: determine origin or cause of disorder/ taking of a tissue sample (ex. Biopsy)
-Palliative: increases quality of life/ often done to reduce pain (ex. )
-Preventative: intention is that condition will not develop (ex. )
-Reconstructive: performed to improve functional ability/ abnormal or damaged body structures (ex. Total joint replacement)
-Transplant: replaces malfunctioning structure or organ (ex. Kidney, liver, heart, etc.)
Tasks for a pre-op nurse to ensure patient safety
Consider risk factors for pressure injury development
Consider priority assessments for a patient with a non-healing pressure injury
-Culture, slough, eschar, tunneling, undermining
Interventions to maintain skin integrity for a patient with a low Braden scale
-Q2 turns
S/s of wound infection
-fever, elevated WBC count, and positive blood cultures, purulent drainage
Different kinds of exudate and descriptions
-Serous drainage: the portion of the blood (serum) that is watery and clear or slightly yellow in appearance (fluid in blisters)
-Sanguineous drainage: contains serum and red blood cells. It is thick and appears reddish. Brighter drainage indicates active bleeding; darker drainage indicates older bleeding/ drainage
-Serosanguineous drainage: contains both serum and blood. It is watery and looks pale and pink due to a mixture of red and clear fluid.
-Purulent drainage: the result of infection. It is thick and contains white blood cells, tissue debris, and bacteria. It may have foul odor, and its color (yellow, tan, green, brown) reflects the type of organism present (green for Pseudomonas aeruginosa infection)
-Purosanguineous: mixed drainage of pus and blood (newly infected wound)
Different kinds of pressure injuries and descriptions
Know the difference between hypoxia and hypoxemia
-Hypoxia: decrease tissue oxygenation
-Hypoxemia: low levels of oxygen in the blood
Understanding of oxygen delivery via nasal cannula
-flow rate: 1-6L/min
-O2 concentration: 24-44%
->6L/min does not increase gas exchange because anatomical dead space is full
-Often used for chronic lung disease or long-term therapy
Oxygen delivery via nasal cannula, simple face mask, partial rebreather mask, non-rebreather mask, venturi mask- flow rates, FI02, advantages and important highlights
Priority assessment for a patient with a tracheostomy
Proper technique for tracheostomy suctioning
Client teaching of possible complications and hazards of home oxygen therapy
-highly combustible
-oxygen tanks need to be upright and secure
-must be 10ft or more away from open flames
Warning signs of lung cancer
Pulmonary
-pneumonitis or bronchitis, blood-tinged sputum, hemoptysis, purulent and copious sputum with infection or necrosis, irregular breathing (labored, painful, obstructive, with periods of shallow breathing, rapid and shallow breathing) dyspnea and abnormal lung sounds (wheezing, pleural friction rub), fremitus, use of accessory muscles, flared nares, abnormal retractions, stridor, asymmetric diaphragmatic movement an inspiration
Non- Pulmonary
-cardiac tamponade, dysrhythmias, cyanosis, bone loss density
-late symptoms: fatigue, weight loss, anorexia, dysphagia, nausea, vomiting, superior vena cava syndrome
Know names of different kinds of medication for asthma prevention and treatment (know the categories the drugs e.g. reliever drug vs. control therapy drug)
-Albuterol (reliever drug)
-Salmeterol (control drug)
S/s of COPD
Know ABG normal ranges
-pH= 7.35-7.45
-PaCO2= 35-45
-PaO2= 80-100
-HCO3= 21-28
-O2= 95-100%
Treatment for patient with COPD
Assessment findings for COPD and emphysema
barrel chest
Treatment and client teaching for cystic fibrosis
Nutrition management
S/s of someone with COPD that would need immediate attention
S/s of COVID-19 vs s/s of the flu
Covid
-fever
-chills
-cough
-SOB
-difficulty breathing
-fatigue
-muscle aches/ body aches
-headache
-new loss of taste/ smell
-sore throat
-N/V/D
-abdominal pain
Flu
-severe headache
-muscle ache
-fever
-chills
-fatigue
Weakness
-anorexia
Contraindication for receiving the flu vaccine, consider allergic reactions
-egg allergy
Risk factors for PNA
PPD description and intervention for positive PPD
-Airborne precautions
Treatment of patient with community-acquired pneumonia in the ED
-antibiotic
Interventions and patient education for pt. with TB
Medications to be given to a patient with a Pulmonary Embolism (PE)
-anticoagulants
-fibrinolytic therapy
Interventions for a patient with a Pulmonary Embolism
Managing hypoxemia
- apply oxygen, elevate HOB, and reassure the patient
-oxygen therapy
-monitor the patient for changes in status
-administer anticoagulation or fibrinolytic therapy
Managing hypotension
-IV fluid therapy used (using crystalloid solutions) to restore plasma volume and prevent shock
-drug therapy with vasopressors (norepinephrine, epinephrine, or dopamine) is used if fluid therapy does not help
Controlling bleeding
-assess for evidence of bleeding, ensure correct dosing and timing of medication, monitor lab values
Minimizing anxiety
-patient with PE struggles with anxiety, fear, and pain
-maintain proper communication with your patients
-anti-anxiety medication
-pain management
S/s of Acute Respiratory Failure
-dyspnea
-orthopnea
-hypoxia & hypercarbia
-hypoxic respiratory failure (restlessness, irritability or agitation, confusion and tachycardia)
-hypercapnic failure (decreased LOC, headache, drowsiness, lethargy, and seizures)
-effects of acidosis (decreased LOC, drowsiness, confusion, hypotension, bradycardia, and weak peripheral pulses)
Priority assessment for an intubated patient
-maintain patant airway and monitor for obstruction
Care that can be delegated to a PCA for a patient with respiratory failure who is on a ventilator
-vitals
-turning
-raise HOB
-mouth care
Physical assessment/s/s of acute respiratory distress syndrome- consider lung sounds
-hyperpnea, noisy respirations, retraction intercostally, wheezing
Know the different types of incontinence and the descriptions of each
-Stress- when urine leaks out at times when your bladder is under pressure (cough or laugh)
-Urge- when urine leaks as you feel a sudden, intense urge to pee, or soon afterward
-Mixed- stress AND urge incontinence
-Overflow (reflex)- when you’re unable to fully empty your bladder, which causes frequent leaking
-Functional- leakage of urine caused by factors other than disease of the lower urinary tract
Nursing action- providing skin care for a patient with incontinence
-check regularly, keep skin dry
-barrier cream
-changing and cleaning after incontinent episode
-checking for skin breakdown
Nursing action- providing skin care for a patient with incontinence
S/s of bladder cancer
-blood in the urine
Plan of care/interventions for patient with cystitis
Nonsurgical
-drug therapy
-fluid intake
-comfort measures such as pain relief
Surgical
(Treat conditions that increase risk for UTIs)
-removal of obstructions
-removal of vesicoureteral reflux
-removal of calculi
Urolithiasis- Intervention/management- preventing obstruction specifically
-high fluid intake (3L/day or more)
-accurate measurement of I/O’s
-drugs therapy
-nutrition therapy/ diet modification
Risk factors for bladder cancer
-GREATEST RISK FACTOR Tobacco use
-exposure to toxins such as gasoline and diesel fuel, chemicals used in hair dyes and in rubber paint, electric cable, and textile industries
-family history, Schistosoma haematobium (a parasite) infection, excessive use of drugs containing phenacetin, and long-term use of cyclophosphamide
Expected blood gas values for acute kidney injury
-metabolic acidosis
Abnormal lab values for acute kidney injury
- increase in serum creatinine by 0.3mg/dL or more within 48 hours
-increase in serum creatinine to 1.5 time or more occurring in the previous 7 days
Assessing therapeutic effect of Lasix for chronic kidney disease
-reducing extra fluid in the body
-daily weights
Assessment findings for chronic kidney disease (pg 1388)
How to safely care for an AV Fistula used for hemodialysis
-do not take blood pressure or obtain blood samples on extremities with fistula
-check pedal pulses and cap refills in the arm with the fistula
-check for bruit or thrill by auscultation or palpation over the access site
Advantages of hemodialysis
-toxins filtered and cleaned in the dialyzer
-achieves acid-base balance
-fluid balance
-maintain gas exchange
