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