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NUR 3200 FOUNDATIONS > Exam 3 Study Guide > Flashcards

Exam 3 Study Guide Flashcards

1
Q

Advantages to Oral, Buccal, & Sublingual Routes

A
  • Convenient & comfortable
  • Economical
  • Easy to administer
  • Often produce local or systemic effects
  • Rarely cause anxiety
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2
Q

Hemorrhiods

A
  • Dilated engorged veins in rectum lining, internal or external
  • Signs: rectal pain, blood in stool
  • Causes: straining, pregnancy, heart failure & chronic liver disease related to incrd venous pressure
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3
Q

Nursing Responsibility in Medication Administration

A
  • Evaluate effects of med on pt’s health status
  • Open meds in front of pt and discuss reasoning
  • Teach pts about side effects
  • Reinforce importance of adherence to med regimen
  • Evaluate pt technique w/ self-admin
  • Evaluate use of herbal therapies that could interfere (garlic, ginger, & gingko interacts w/ antocoags)
  • If withholding a drug, record reason & follow institutional policy (notify HCP)
  • Instruct pt/family about purpose, action, dose, dosage intervals, side effects, food to avoid or take with med
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4
Q

Electronic Infusion Device Infusion

A
  • IV pump
  • Will deliver an accurate hourly infusion rate
  • Uses positive pressure to deliver fluid
  • Has detectors & alarms for air or occlusion in tubing
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5
Q

Impaction

A
  • Collection of hardened feces wedged in rectum, can extend to sigmoid colon
  • Signs: oozing diarrhea, loss of appetite, N/V, abdominal distention & cramping, rectal pain
  • Causes: same as constipation & incr risk if debilitated, confused, unconcscious
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6
Q

Signs of Intolerance w/ Enteral Nutrition

A
  • High gastric residuals
  • N/V
  • Abdominal cramping
  • Diarrhea
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7
Q

Extracellular Fluid Volume Excess Lab Findings

A
  • Dcrd hematocrit
  • BUN <10
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8
Q

Hyponatremia S/S (5)

A
  • Apprehension
  • N/V
  • Headaches
  • Dcrd LOC & possible coma
  • Seizures
    (Na<135)
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9
Q

Advantages to (parenteral) SQ, IM, IV, ID routes

A
  • When oral meds are contraindicated
  • More rapid absorption
  • IV: pt is critically ill, long-term therapy, peripheral perfusion is poor
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10
Q

Advantages of (mucus memb) Eyes, Ears, Nose, Vagina, Rectum, Ostomy Routes

A
  • Therapeutic effects provided by local application
  • Aqueous solutions readily absorbed & capable of causing systemic effects
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11
Q

Topical Administration

A
  • Applied locally to intact skin
  • Also applied to mucus membs
  • Ointment, lotion, paste, transdermal disk or patch
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12
Q

Maintaining IV Therapy

A
  • Ensure system is sterile & intact
  • Ensure tht rate of fluid or medication is maintained
  • Monitor IV site & patency
  • Change IV tubing, bags, & dressings per hospital protocol
  • Monitor for complications
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13
Q

PICC (peripherally inserted central catheters)

A

Enter a peripheral arm vein & extend through venous system to superior vena cava

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14
Q

Hypernatremia S/S (7)

A
  • Extreme thirst
  • Dry & flushed skin
  • Postural hypotension
  • Fever
  • Confusion and/or agitation
  • Coma
  • Seizures
    (Na>145)
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15
Q

Nursing Responsibilities Using TPN pt.1

A
  • A solution >10% dextrose a central line is required
  • Need to confirm placement of central line
  • Confirm physician orders
  • Always need to use IV pump
  • Check solution for particulate matter
  • Need to have a dedicated line
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16
Q

Subcutaneous Injection (SC or SQ)

A
  • Slower absorption
  • SQ med ex.: heparin, enoxaparin, insulin
  • Angle: 45-90 degrees
  • Needle size: 25-30 gauge (G), 3/8-5/8 inch needle
  • Max. injection vol.: 1mL or less
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17
Q

Nasal Instillation

A
  • Decongestant spray or drops
  • Have pt self-administer if able
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18
Q

Advantages to Inhalation

A
  • Provides rapid relief for local resp. problems
  • Used for intro of general anesthetic gases
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19
Q

Enteral Feeding

A
  • Installation of liquid nutritional supplements or feedings into GI tract
  • Used when unable to swallow safely or can’t take enough nutrition orally but has a functioning GI tract
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20
Q

Colonoscopy

A
  • Viewing of entire colon using a fiber optic scope through rectum
  • Clear liquids day before then NPO; bowel cleanser until stool is clear liquid, light sedation, abdominal bloating after procedure is common
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21
Q

Hyponatremia

A
  • Water excess or water intoxication
  • More water than salt

(Na<135)

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22
Q

Buccal

A
  • Placed in mouth against mucus membs in cheek
  • Alternate cheeks to avoid mucosal irritation
  • No chewing, swallowing, or liquids until completely dissolved
  • (oral)
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23
Q

Parenteral Route

A
  • Administration by injections
  • SQ, ID, IM, IV
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24
Q

Enteral Route

A
  • Administration through GI tract
  • Gastric
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25
Q

Infection

A
  • Infection at cath entry site
  • Signs: Redness, warmth, swelling, possible purulent drainage
  • Treatment: Discontinue IV, cleanse area w/ alcohol, apply new dressing, culture if needed/ordered
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26
Q

Eye Instillation

A
  • Eye drops/ointment
  • OTC meds
  • Apply oitnment along lower eyelid
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27
Q

Phlebitis

A
  • Inflammation of a vein
  • Sings: Redness, tenderness, warmth, palpable cord
  • Treatment: Discontinue IV, warm & moist compress
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28
Q

Extracellular Fluid Volume Deficit

A
  • Fluid intake less than output
  • Dcrd body fluid volume
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29
Q

Complications of NG Tubes

A
  • Pulmonary aspiration
  • Diarrhea or constipation
  • N/V
  • Abdominal cramping
  • Tube occlusion
  • Tube dislodgment
  • Delayed gastric emptying
  • Electrolyte imbalances
  • Fluid overload
  • Hyperosmolar dehydration
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30
Q

Components of a Medication Order

A
  • Pt’s full name
  • Date & time that order is written
  • Medication name
  • Dose
  • Route of administration
  • Time & frequency of administration
  • Signature of health care provider
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31
Q

Nursing Responsibilities Using TPN pt.2

A
  • Requires collaboration w/ physician, dietician, & pharmacist
  • Daily labs required to adjust formula
  • Peripheral blood glucose (PBG) are required every 6 hrs
  • TPN must be gradually started and gradually stopped to prevent hypo or hyperglycemia
  • Monitor for metabolic & cath associated complications
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32
Q

Z-Track Method

A
  • Given w/ intramuscular injections
  • Helps prevent injection going into subcut tissue
  • Use non-dominant hand to pull skin on side of injection site
  • Hold syringe like a dart at 90 degree angle
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33
Q

Gastric Tubes

A
  • Placed in stomach
  • NG tube: short-term use
  • PEG tube: long-term use
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34
Q

Hyperkalemia S/S (4)

A
  • Anxiety
  • Abdominal cramps & diarrhea
  • Muscle weakness
  • Cardiac dysrhythmias & cardiac arrest

(K>5.0)

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35
Q

pH Values

A
  • pH 0-4 indicates gastric placement
  • pH 6 indicated jejunum placement
  • pH 7+ indicated lung placement
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36
Q

Nursing Care w/ Enteral Nutriton

A
  • HOB at 30-45 degrees at all time & 1 hr after feedings completed
  • Measure gastric residuals
  • Flush enteral feeding tubes q4hr w/ at least 30ml to keep tube patent
  • Verify placement q4-6hr by aspirating gastric contents
  • When initiating feedings start slow & incr rate q8-12hr per orders if no signs of intolerance
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37
Q

Decompression

A
  • Removal of secretions & gas from GI tract
  • Prevention or relief of abdominal distention
  • Ex: bowel obstruction
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38
Q

6 Rights

A
  1. Right medication
  2. Right dose
  3. Right patient
  4. Right route
  5. Right time
  6. Right documentation
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39
Q

Compression

A
  • Internal application of pressure by means of inflated balloon
  • Prevents internal esophageal or GI hemorrhage
  • Ex: esophageal varices bleed
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40
Q

Extracellular Fluid Volume Deficit S/S (6)

A
  • Postural hypotension
  • Tachycardia
  • Oliguria
  • Dry mucous membranes
  • Restlessness & confusion
  • Hypovolemic shock
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41
Q

Intradermal Injection Sites

A

Surface of the Forearm
Upper Back Below Scapula

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42
Q

Isotonic IV Fluid

A
  • Same osmolality as body fluids
  • Cells do not gain or lose fluid
  • Replaces extracellular volume
  • Used to treat dehydration
  • Most common type of IV fluid
  • Normal saline (0.9%NS), Lactated Ringers (LR)
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43
Q

Abdominal X-ray

A

Includes abdomen, kidney, ureter, & bladder - KUB

44
Q

Jejunostomy Tubes

A
  • Placed nasally or surgically into jejunum
  • Long-term use
45
Q

Hypertonic IV Fluid

A
  • Osmolality is great than body fluids; fluid is more concentrated than body fluids, moves fluid out of cells into circulation
  • Can shrink cells
  • Used to correct electrolyte imbalances (hyponatremia)
  • Used when treating cerebral edema
  • D10W, 3-5% NS, D5NS, D5LR
46
Q

Hypercalcemia S/S (9)

A
  • Anorexia
  • N/V
  • Constipation
  • Fatigue & lethargy
  • Diminished reflexes
  • Change LOC & confusion
  • Cardiac dysrhythmias
  • Possible flank pain from renal calculi
  • Pathological fractures

(Ca>10.5)

47
Q

Focus on Older Adults (pt education)

A
  • Begin & end w/ most important info
  • Slow, low tone of voice
  • Allow enough time for understanding
  • Emphasize concrete material
  • Specific info in frequent, small amounts
  • Repeat important info
  • Teach when pt is alert & rested
48
Q

Hypermagnesemia S/S (7)

A
  • Lethargy
  • Hypoactive reflexes
  • Bradycardia & hypotension
  • Flushing & sensation of warmth
  • Hypoventilation
  • Muscle paralysis
  • Cardiac dysrhythmias & cardiac arrest

(Mg>2.5)

49
Q

Ultrasound

A
  • Use of sound waves to visualize organs
  • Preparation varies depending organ visualized
50
Q

Hypokalemia S/S (3)

A
  • Fatigue & muscle weakness
  • N/V
  • Cardiac dysrhythmias

(K<3.5)

51
Q

CLABSI Interventions

A
  • Change tubing every 24hrs
  • Do not hang for more than 24hrs or lipids more than 12hrs
  • Utilize sterile technique during dressing changes
  • Change dressing per institution policy or when becomes wet/contaminated
52
Q

Mini Infuser Infusion

A
  • Used to deliver small volumes
  • Uses syringes
53
Q

Flatulence

A
  • Bowel stretches & distends w/in intestine (passing gas) or escapes mouth (belching)
  • Sings: abdominal distention, severe & sharp abdominal pain, abdominal cramping & pain
  • Causes: immobilization, medications, general anesthesia, abdominal surgery
54
Q

Hypocalcemia S/S (7)

A
  • Numbness & tingling of fingers & mouth
  • Hyperactive reflexes
  • Muscle twitching
  • Tetany
  • Seizures
  • Laryngospasm
  • Cardiac dysrhythmias
    (Ca<8.4)
55
Q

Sublingual

A
  • Readily absorbed
  • Placed under tongue
  • Hold fluids until completely dissolved
  • (oral)
56
Q

Disadvantages & Contradictions of Oral, Buccal, & Sublingual Routes

A
  • (oral) Alts in GI function (N/V), reduced GI motility (after anesthesia or bowel inflamm), & surgical resection of GI tract
  • Pt is unable to swallow (oral)
  • Pt unconscious, confused, unwilling to swallow, hold med under tongue
  • Gastric suction
  • Irritate lining of GI tract, discolor teeth, have unpleasant taste
  • Gastric secretions destroy some meds
57
Q

Hypernatremia

A
  • Water deficit
  • More salt than water

(Na>145)

58
Q

Hypokalemia

A
  • K < 3.5
  • Decreased potassium intake & absorption, a shift of K from ECF into cells, & incrd K output
59
Q

Disadvantages to Mucous Membranes

A
  • Highly sensitive
  • Ruptured eardrum
  • Insertion of rectal & vaginal med often causes embarrassment
  • Rectal surgery or active rectal bleeding
60
Q

Oral Administration

A
  • Easiest & most desirable route
  • Contraindications: NPO, alts in GI func, aspiration risk, dcrd LOC, gastric suction or recent surgery, prior to certain tests, procedures, or surgery
  • Can’t be crushed: enteric coated, sustained release
61
Q

Principles of Enteral Nutrition

A
62
Q

Lavage

A
  • Irrigation of stomach
  • Used in cases of active bleeding, poisoning or gastric dilation
  • Ex: overdose of medication
63
Q

Constipation

A
  • Bowel movement less than every 3 days
  • Signs: difficulty passing stool, excessive straining, hard feces
  • Causes: dcr fluid intake, lack of exercise, medications
64
Q

Air Embolism Interventions

A
  • Maintain integrity of closed IV system when changing caps & tubing
  • Have pt perform a Valsalva maneuver while assuming a left lateral decubitus position during cath insertion
  • When removing line have pt bear down when pulling out line
65
Q

Intramuscular Injection SItes

A

Deltoid
Vastus Lateralis
Ventrogluteal
Upper Arm

66
Q

Positive Learning Environment

A
  • Well lit, good ventilation, appropriate furniture, comfortable temperature
  • Quiet
  • Infrequent interruptions
  • Group setting require pts to be w/in hearing distance & to allow participants to observe one another
67
Q

Interventions to Promote Bowel Elimination

A
  • Diet education: incr fiber, fluids, fruit juices
  • Activity & exercise
  • Positioning to facilitate elimination
  • Medications: laxatives/cathartics, enema, antidiarrheals
  • Establish bowel regimen
68
Q

Inflitration

A
  • When IV fluid enters the subcutaneous tissue
  • Caused by catheter dislodgment or rupture of vein
  • Signs: Edema, cool to touch, skin around cath is taut, blanched skin
  • Treatment: Discontinue IV, elevate extremity, warm & moist compress
69
Q

Non-Parenteral Route

A
  • Administration other than parenteral
  • enteral, topical, inhalation
70
Q

Computerized Tomography Scan (CT)

A
  • Scan of body from various angles, analyzed by computer
  • NPO; pt needs to lie still
  • Typically give dye by mouth & intravenous
71
Q

Extracellular Fluid Volume Deficit Lab Findings

A
  • Incrd hematocrit
  • BUN >25
  • Urine specific gravity >1.030
72
Q

Disadvantages to Inhalation

A

Some local agents can cause systemic effects

73
Q

Enteroclysis

A
  • X-ray of entire small intestine w/ use of contrast
  • Into of contrast into small intestine via NG tube
74
Q

Intramuscular Injection (IM)

A
  • Deposits med in muscle tissue
  • Faster absorption
  • Angle: 90 degrees
  • Needle size: 18-25 gauge, 5/8- 1 1/2 inches
  • Max. injection vol.: 3mL
  • Z track method recommended to reduce tissue irritation
75
Q

Factors Influencing Bowel Elimination

A
  • Age; infancy, older adult
  • Diet
  • Fluid intake
  • Positioning
  • Physical activity
  • Psychosocial
  • Alterations in personal habits
  • Medications
  • Pain
  • Pregnancy
  • Surgery/anesthesia
76
Q

Central IV

A
  • Long term use
  • Use w/ meds that are vesicants
  • Parenteral nutrition
  • Pts w/ difficult intravenous access
77
Q

Flexible Sigmoidoscopy

A
  • Exam of sigmoid colon thru scope/tube
  • NPO; prep similar to barium enema, light sedation
78
Q

Air Embolism

A
  • May occur during insertion, removal, or when changing tubing or cap
  • Air enters into the vasculature
79
Q

Subcutaneous Injection Sites

A
  • Outer posterior upper arm
  • Abdomen
  • Thigh
80
Q

Intradermal Injections (ID)

A
  • Used for skin testing; TB screening & allergy tests on the dermal layer
  • Angle: 5-15 degree
  • Needle size: 27-31 gauge, 1/2 inch
  • Very small volume
81
Q

Types of Enteral Administration

A
  • Gastric tubes
  • Jejunostomy tubes
82
Q

Indications for Parenteral Nutrition (TPN)

A
  • Nonfunctional gastrointestinal tract: bowel obstructions, ineffective absorption, fistulas
  • Extended bowel rest
  • Preoperative TPN
  • Highly stressed physiological states: sepsis, head injury, burn
83
Q

Vaginal Medications

A

Instruct pt to remain on back for at least 10 mins to allow med to absorb

84
Q

Upper GI (Barium Swallow)

A

X-ray using contrast (barium) to examin structure & movement of upper GI tract (pharynx, esophagus, & stomach)

85
Q

Advantages of Topical Routes

A
  • Provides local effect
  • Painless
  • Limited side effects
  • Prolonged systemic effects
86
Q

Hyperkalemia

A

Incrd potassium intake & absorption, shift of K from cells into ECF, & drcd K output
(K>5.0)

87
Q

Catheter Sepsis (CLABSI)

A
  • A central line associated bloodstream infection tht develops w/in 48hrs of central line insertion
  • Fever, chills, glucose intolerance, positive blood culture
88
Q

Gravity Infusion

A

Infusion of bag that needs to be above pt

89
Q

Hypotonic IV Fluid

A
  • Osmolality is less than body fluids; fluid can be more diluted than body fluids, moves fluid into cells
  • Can cause hypotension
  • Replaces extracellular volume and rehydrates cell
  • Used with dehydration or to treat hypernatremia
  • 1/4 normal saline (0.225%NS), 1/2 normal saline (0.45%NS)
90
Q

Diarrhea

A
  • Incr in # of stools, liquid, & unformed
  • Sings: frequent liquid stools
  • Causes: antibiotics, enteral nutrition, food allergies, food borne pathogens, disorders related to absorption (Cdiff, chrons, ulcerative colitis)
91
Q

Incontinence

A
  • Inability to control passage of feces and gas
  • Can affect body image & skin integrity
  • Causes: age, confusion
92
Q

Goals of TPN

A
  • To provide nutrition when unable to use GI tract
  • To move towards the use of GI tract; disuse leads to villus atrophy, cell shrinkage, movement of bacteria up GI tract - septicemia
93
Q

Magnetic Resonance Imaging (MRI)

A
  • Noninvasive exam using magnets & radiowaves to produce pic of inner organs/body
  • NPO 4-6hrs before, no metallic objects
94
Q

Measuring Gastric Redisuals

A
  • q4-6hr for continuous feedings
  • Immediately prior to administering bolus or intermittent feedings
  • Don’t assess w/ small bore tubes
  • Delayed gastric emptying is a concern if residual is >250ml for 2 consec. checks of >500ml in a single measure
95
Q

Disadvantages to SQ, IM, IV, ID routes

A
  • Risk of introducing infection
  • Expensive meds
  • Pain from repeated needlesticks
  • Bleeding tendencies
  • Risk of tissue damage
  • Higher absorption rates = higher risk of reactions
  • Cause considerable anxiety
96
Q

Extracellular Fluid Volume Excess S/S (5)

A
  • Sudden weight gain
  • Edema
  • Crackles in dependent portion of lungs
  • Pulmonary edema; high risk for resp failure
  • Jugular vein distention (JVD)
97
Q

Ear Instillation

A
  • At room temp to prevent vertigo, dizziness, or nausea
  • Straighten ear canal by pulling auricle upward & outward (adult)
  • Remain side-lying fore 2-3 mins
98
Q

Subclavian or Jugular

A

Tunneled through subcutaneous tissue before entering a central vein

99
Q

Nursing Role in Patient Education

A
  • Teach the parents/family
  • Place priority on self-management
  • ADPIE
100
Q

Disadvantage of Topical Routes

A
  • Skin abrasions at higher risk for rapid med absorption & systemic effects
  • Meds are absorbed through skin slowly
  • Med can leave oily or pasty substance on skin & clothing
101
Q

Upper Endoscopy

A
  • Viewing of upper GI tract through fiber optic scope
  • NPO; light sedation is required, important to check for return of gag reflex after procedure
102
Q

Rectal Medications

A
  • Sims’ position
  • Insert 10cm/4inches (adult)
  • Remain flat for at least 5 mins
103
Q

Hypomagnesemia S/S (8)

A
  • Hyperactive reflexes
  • Insomnia
  • Muscle cramps & twitching
  • Dysphagia
  • Tachycardia & HTN
  • Tetany
  • Seizures
  • Cardiac dysrhythmias

(Mg<1.5)

104
Q

Barium Enema

A
  • X-ray w/ contrast to examine lower GI
  • NPO after midnight, bowel preparation
105
Q

Extracellular Fluid Volume Excess

A
  • Fluid intake greater than output
  • Incrd body fluid volume

NUR 3200 FOUNDATIONS (6 decks)

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