Final

Question 1

Focused neuro assessment

Answer 1

• pupils (PERRLA)
• cranial nerve function
• motor function
• sensory function
• reflexes

Question 2

PERRLA

Answer 2

pupil assessment

pupils
equal -> assess size prior to testing, 20% of people naturally have asymmetrical pupils (physiological anisocoria”
round
reactive to light
accommodation

Question 3

average pupil size

Answer 3

2 - 8 mm

size varies, depending on light

Question 4

dilated pupil

Answer 4

> 8 mm

aka “blown out”

unilateral or bilateral

Question 5

constricted pupil

Answer 5

<2mm

aka pinpoint, small

unilateral or bilateral

Question 6

unilateral dilation

Answer 6

could mean
- brain hematoma
- brainstem herniation
- migraine
- compressed cranial nerve #3 -> pt may have limited ocular movement, ptosis (dropping of the eyelid) , diplopia (double vision)

Question 7

bilateral dilation/ fixed pupils

Answer 7

• midbrain injury
• poor prognosis if > 24 hours or GCS <3

Question 8

bilateral dilation/ sluggish pupils

Answer 8

• eye diseases
• illicit substances (amphetamines/ cocaine/ LSD/ MDMA)
• post-seizure

Question 9

bilateral constriction

Answer 9

• brain trauma (pons CVA)
• opioids/ narcotics
• medications (clonidine, benzos)
• environment toxins
• eye trauma
• diseases (neurological-syphilis, diabetes, MS)
• heat stroke

Question 10

unilateral constriction

Answer 10

• Horner’s syndrome
  -iris inflammation
• adhesions
• medication (pilocarpine)

Question 11

cranial nerves

Answer 11

there are 12 pairs of cranial nerves that send signals between your brain, face, neck, and torso

some are sensory -> allow you to taste, smell, hear , and feel

some are motor -> allow you to make facial expressions, blink your eyes, vocalize, and swallow food

some have both functions

Question 12

mnemonic for cranial nerves

Answer 12

on occasion our trusty truck acts funny, very good vehicle any how

olfactory (CN I)
optic (CN II)*
oculomotor (CN III)*
trochlear (CN IV)*
trigeminal (CN V)
abducens (CN VI)*
facial (CN VII)
vestibulocochlear (CN VIII)
glossopharyngeal (CN IX)*
vagus (CN X)*
accessory (CN XI)
hypoglossal (CN XII)*

Question 13

mnemonic for remembering what cranial nerves are sensory or motor or both

Answer 13

some say marry money but my brother say big brains matter more

olfactory (CN I) sensory
optic (CN II) sensory
oculomotor (CN III) motor
trochlear (CN IV) motor
trigeminal (CN V) both
abducens (CN VI) motor
facial (CN VII) both
vestibulocochlear (CN VIII) sensory
glossopharyngeal (CN IX) both
vagus (CN X) both
accessory (CN XI) motor
hypoglossal (CN XII) motor

Question 14

dermatomes

Answer 14

sensory function on the body can be assessed by testing dermatomes

dermatome is an area of skin

is associated with a single spinal nerve

31 pairs of spinal nerves, but only 30 dermatomes

some meds such as local anaesthetic and anti seizure drugs can prevent the transmission of nerve fibres from entering the spinal cord

Question 15

how to test dermatomes

Answer 15

• have pt close their eyes
• check pain sensation (gently touch skin with a sharp object) and light touch sensation ( soft object) and ask pt if it feels soft or sharp
• test bilaterally

Question 16

are there dermatomes on your face

Answer 16

no

the sensory innervation of the face is primarily provided by the trigeminal nerve (CN V), a cranial nerve, rather than spinal nerves

Question 17

the 7 cervical dermatomes

Answer 17

C2 to C8 (C1 nerve has no dermatome)

C2 = back of head
C3 = lower head and neck
C4 = lower neck and upper shoulders
C5 =upper shoulders and collar bones
C6 = lateral forearm and thumb
C7 = upper back, back of arms, index/middle fingers
C8 = lower back, inner arms, ring/little finger

Question 18

the 12 thoracic dermatomes

Answer 18

T1 to T12

T1- Upper Chest/Back, Inner arms
T2 - Upper Chest/Back
T3 – Upper Chest/Back (just above nipples)
T4 – Upper Chest/Back (level of the nipples)
T5 – Mid-Chest/Back
T6 – Mid-Chest/Back
T7 – Mid-Chest/Back
T8 – Upper Abdomen/mid-back
T9 – Upper Abdomen/mid-back
T10 – Abdomen (Level of umbilicus) and mid-back
T11 – Abdomen and mid-back
T12 – Lower abdomen and mid-back

Question 19

the 5 lumbar dermatomes

Answer 19

L1 to L5

L1 – Lower back, hips & groin
L2 – Lower back, front & inside of thigh
L3 – Lower back, front & inside of thigh
L4 – Lower back, front of thigh and calf, knee,
medial malleolus
L5 – Lower back, front & outside of calf,
top & bottom of the foot, and toes 1-3

Question 20

the 5 sacral dermatomes

Answer 20

S1 to S5

S1 – Lower back, back of thigh & calf, Toes 4 & 5, and the outer ankle bone
(lateral malleolus)
S2 – Buttocks, back of thigh & calf, heel, genitals
S3 – Mid-buttocks, genitals
S4 – Perianal region/skin
S5 – Perianal region/skin and area immediately next to the anus

Question 21

1 coccygeal dermatome

Answer 21

located directly over the coccyx

Question 22

assessing motor function

Answer 22

balance:
- gait -> smooth, coordinated arm movement, effortless?
- sensory ataxia -> Romberg test

coordination:
- finger to finger test
- heel to shin test
- rapid alternating movement

muscles:
- strength
- symmetry

Question 23

cerebellar ataxia

Answer 23

a movement disorder characterized by poor coordination, primarily due to damage or dysfunction in the cerebellum, a part of the brain that controls coordinated movements

Question 24

sensory ataxia

Answer 24

a type of ataxia, a neurological condition causing impaired coordination and balance, specifically due to loss of sensory input from the body’s position sense (proprioception)

problem with sensory nerves

Question 25

proprioception

Answer 25

the body's ability to sense its position and movement in space.

Question 26

reflexes

Answer 26

an instantaneous and involuntary response to stimulus sensory info is directly relayed to motor neurons in the spine -> before the brain gets involved normal reflex indicates functional pathway between sensory and motor neurons deep tendon reflex (DTR) is tested using a percussion hammer -> compare bilaterally

Question 27

triceps reflex

Answer 27

spinal cord level = C7 and C8

Question 28

biceps reflex

Answer 28

spinal cord level = C5 and C6

Question 29

Brachioradialis reflex

Answer 29

spinal cord levels = C5 and C6

Question 30

patellar reflex

Answer 30

spinal cord level: L2, L3, and L4

Question 31

achilles reflex

Answer 31

spinal cord level = S1 to S2

Question 32

plantar reflex

Answer 32

spinal cord level = L2, L3, and L4

Question 33

how to score reflexes

Answer 33

in a normal response, the muscle will shorten, causing movement 0 absent 1+ diminished 2+ brisk = normal 3+ very brisk 4+ clonus, or repetitive contraction of the muscle abnormal reflexes may be due to disruption in sensory and/or motor nerves

Question 34

causes of abnormal reflexes

Answer 34

- peripheral neuropathy - nerve compression - trauma or lesions (brain, spinal cord, or nerves) - medications - hormone imbalances - electrolyte imbalances - nutrient deficiencies (thiamine!!) - disease

Question 35

underlying conditions that can cause a stroke

Answer 35

- tumor - infection - brain swelling - congenital abnormalities

Question 36

right brain damage

Answer 36

- paralyzed left side (hemiplegia) -left side neglect - spatial-perceptual deficits - tends to deny or minimize problems - rapid performance, short attention span - impulsive, safety problems - impaired judgement

Question 37

left brain damage

Answer 37

- paralyzed right side (hemiplegia) - right side neglect - impaired speech - language (aphasias) - impaired right-left discrimination - slow performance, cautious - aware of deficits, depression, anxiety - impaired comprehension related to language and math

Question 38

seizures

Answer 38

a sudden onset of uncontrolled electrical activity in one or more areas of the brain may accompany other disorders or occur spontaneously without apparent cause S+S - changes in LOC - changes in emotion - loss of muscle control - sensory changes - loss of bladder/bowel - resp changes - staring or rapid blinking

Question 39

how to classify seizures (ILAE guidelines)

Answer 39

1. where seizures begin in the brain 2. the level of awareness during a seizure 3. describing the other features of the seizure (movements/automatisms)

Question 40

focal seizure

Answer 40

onset is in one area on one side of the brain

Question 41

generalized seizures

Answer 41

involves both sides of the brain at the onset

Question 42

unknown onset of seizure

Answer 42

onset is not know, this may be determined later

Question 43

focal to bilateral seizure

Answer 43

starts in one side or part of the brain and spreads to both sides

Question 44

focal aware

Answer 44

awareness remains intact, even if the person is unable to talk or respond during a seizure

Question 45

focal impaired awareness

Answer 45

awareness is impaired or affected at anytime during a seizure

Question 46

awareness unknown

Answer 46

not always possible to know if a person is aware or not (seizures occur at night, person lives alone)

Question 47

generalized seizure awareness

Answer 47

presumed to affect a person's awareness of consciousness

Question 48

focal motor seizure

Answer 48

body movement occurs -> twitching, jerking, or stiffening or automatisms -> lip licking, chewing, rubbing hands, walking/running, laughing/crying

Question 49

focal non-motor seizure

Answer 49

changes in sensation, emotions, thinking, or experiences

Question 50

generalized motor seizure

Answer 50

"generalized tonic clonic" describes seizures with stiffening (tonic) and jerking (clonic) previously known as grand Mal seizures

Question 51

generalized non-motor seizure

Answer 51

primarily absence seizures (previously petit mal) involves brief changes in awareness, staring, and may present with automatisms -> lip licking, chewing, rubbing hands, walking/running, laughing/crying

Question 52

seizure phases

Answer 52

prodromal phase : - presides seizure with signs -> headache, confusion, mood/behaviour changes - can occur several days or minutes prior to seizure early ictal/aural phase - sensory warnings prior to the seizure -> vision changes, smells, auditory sensations, fear, panic, nausea, deja vu - an aura (specific type of seizure) is a focal seizure ictal phase - seizure activity, loss of awareness, repeated movements, convulsions, tachycardia, trouble breathing postictal phase - rest and recovery -> nausea, muscle weakness, exhaustion, fear, fatigue, decreased LOC

Question 53

status epilepticus

Answer 53

a state of constant seizure or when seizures recur in rapid succession without return to consciousness between seizures NEURO EMERGENCY - can involve any type of seizure - brain uses more energy than is supplied - neurons become exhausted and cease to function - permanent brain damage can result

Question 54

tonic-clonic status epilepticus

Answer 54

most dangerous seizure complication -> can cause ventilatory insufficiency, hypoxemia, cardiac arrhythmias, hyperthermia, and systemic acidosis

Question 55

trauma during seizures

Answer 55

can cause severe injury or death

Question 56

social stigma of seizures

Answer 56

interferes with values of self-control, conformity, and independence may experience depression, anxiety, anger, and problems with relationships depression is common and can lead to impaired daily function, sleep deprivation, and increased seizure activity can lose drivers licence -> must be seizure free for 6 months before getting licence back

Question 57

diagnostic tests and treatment for seizures

Answer 57

- history and physical exam - seizure history - EEG, blood work, CT, MRI, lumbar puncture - medication - vagal nerve stimulation -> thought to interrupt the synchronization of epileptic brain wave activity - surgery - counselling - special diet -> keto, replace glucose as an energy source in the brain

Question 58

triggers for seizures

Answer 58

- stress - excessive excitement or stimulation - excessive fluid intake - low blood sugar in diabetics - sunlight, heat, humidity - flickering lights - poor nutrition - illness, fever, allergies - lack of sleep - withdrawal for meds, drugs, alcohol - missed medication

Question 59

seizure safety precautions

Answer 59

- padding lining the bed rails - mitigate triggers if possible - bedside safety check -> suctioning, oxygen

Question 60

actions during ictal phase

Answer 60

- ensure safety -> remove hazards - ensure patent airway - stay with client until seizure has passed - observe and time seizure activity - place in lateral position is possible - apply O2 as needed - establish IV and administer medication as ordered - suction as needed - assist with ventilation if pt doesn't breath after seizure - DO NOT insert anything into the mouth or restrain pt - call a code blue is warranted

Question 61

actions during the post ictal phase

Answer 61

- monitor -> VS, LOC, GCS - assess, reassure, and re orient the pt -> use a calm and quiet voice, monitor for hypoglycemia, keep lights low and staff to a minimum in the room - document

Question 62

nursing assessment during ictal phase

Answer 62

- abnormal resp rate, rhythm, sounds, apnea - airway occlusion - HTN, tachycardia, or bradycardia - excessive salivation - length of ictal phase

Question 63

nursing assessment during post ictal phase

Answer 63

- any precipitating factors -> abnormal CR, MRI, EEG, CBC, electrolytes, tox screen, history - bitten tongue, soft tissue damage - cyanosis - bowel/urinary incontinence - diaphoresis - weakness, paralysis, ataxia - neuro vitals

Question 64

oral suctioning

Answer 64

- removes secretions that obstruct airway - facilitate ventilation - obtain secretions for diagnostic purposes - prevent infections that may result from accumulated secretions suctioning an adults the suction should be set at 100 to 150 mmHg a suction attempt should only last 10 to 15 seconds and should allow 30 seconds to 1 min intervals between each suction

Question 65

alcohol use disorder (AUD)

Answer 65

a medical condition characterized by an impaired ability to stop or control alcohol use despite adverse social, occupational, or health consequences

Question 66

alcohol and neurotransmitters

Answer 66

neurotransmitters in the CNS are heavily suppressed by alcohol consumption alcohol inhibits the excitatory receptors (glutamate) or the CNS and enhances the inhibitor receptors (GABA) of the CNS when pt stops using alcohol, neurotransmitters must readjust again to regain the sensitivity needed to correctly function -> the brain has an excitatory overload, causes the symptoms of withdrawal

Question 67

short term effects of alcohol on the CNS

Answer 67

- initial relaxation - decreased inhibition - lack of coordination - impaired judgement - slurred speech - anxiety or agitation - hypotension - bradycardia - bradypnea

Question 68

long term effect os alcohol on the CNS

Answer 68

- wernickes encephalopathy - Korsakoff's syndrome - impaired cognition - decreased psychomotor skills - impaired abstract thinking and memory - sleep disturbances - depression/labile (easily changed) mood - attention deficit - seizures

Question 69

the CAGE tool

Answer 69

1. have you ever felt you ought to CUT down on your drinking? 2. have people ANNOYED you by criticizing your drinking 3. have you ever felt bad of GUILTY about your drinking? 4. have you ever had a drink in the morning (EYE-OPENER drink) to steady your nerves or get rid of a hangover?

Question 70

mild to moderate symptoms of alcohol withdrawal syndrome

Answer 70

- tremors - anxiety - N/V - headache - tachycardia - diaphoresis - irritability - confusion - insomnia - nightmares - HTN

Question 71

severe symptoms of alcohol withdrawal syndrome

Answer 71

- profound confusion - agitation - aggression - fever - seizures - tactile disturbances - auditory and or visual hallucinations - excessive diaphoresis - tachycardia. tachypnea - tremors - hypertension

Question 72

CIWA for alcohol scale

Answer 72

standardized assessment tool used to asses and monitor symptoms caused by alcohol withdrawal assess 10 most common symptoms not appropriate for all populations -> language barrier, cognitive impairment, decreased LOC, delirium is somewhat subjective the score is used to determine amount of med to administer

Question 73

10 most common symptoms of AWS

Answer 73

1) Nausea and Vomiting 2) Tremor 3) Tactile disturbances 4) Auditory disturbances 5) Paroxysmal sweats 6) Visual disturbances 7) Anxiety 8) Headache 9) Agitation 10) Orientation/clouding of sensorium

Question 74

stages of alcohol withdrawal

Answer 74

6 to 12 hrs -> minor withdrawal symptoms 12 to 24 hrs -> alcoholic hallucinosis = visual, tactile, auditory hallucinations 24 to 28 hrs -> withdrawal seizures = generalized tonic-clonic seizures 48 to 72 hrs -> alcohol withdrawal delirium, hallucinations (mainly visual), disorientation, agitation, diaphoresis

Question 75

withdrawal seizures

Answer 75

increased risk for -> long history of alcohol use -> > 40 years old seizures usually occur about 24hrs after the last drink - it is different for everyone - can occur as soon as 2 hrs after the drink or up to 48hrs - usually occur in a cluster of 1-3 seizures - generalized tonic-clonic 30 to 50% of people experiencing seizures will progress to delirium tremens

Question 76

delirium tremens (DTs)

Answer 76

includes hallucination's, agitation, disorientation, and profuse sweating increased risk in pt - heavy, prolonged alcohol use - history of previous DT or withdrawal seizures - age >30 - concurrent illness and co-morbidities - more severe withdrawal symptoms at presentation - presence of alcohol withdrawal symptoms while blood alcohol level is still elevated - occurs prior to detoxification occurs 48-72 hours after last drink

Question 77

kindling phenomenon

Answer 77

with each episode of alcohol use and alcohol withdrawal (even mild) -> the brain becomes more excitable and sensitive to effects of alcohol withdrawal with each episode of alcohol withdrawal - clinical manifestations become more severe - people become increasingly likely to experience seizures and DT

Question 78

challenges during alcohol withdrawal

Answer 78

hypovolemia/ dehydration - alcohol is a diuretic - N/V - poor appetite due to gastritis (inflammation of the stomach lining) - not drinking enough water - diaphoresis malnutrition/electrolyte imbalances - gastritis = malabsorption of vitamins (thiamine) and nutrients - alcohol can cause pancreatitis - not consuming proper nutrition - low levels of electrolytes - malnourished pt are at risk for Refeeding syndrome

Question 79

thiamine (B1) deficiency

Answer 79

it is common in people who drink excessive amounts of alcohol thiamine is essential for energy metabolism -> it converts cards into glucose beriberi is a disease caused by thiamine deficiency

Question 80

dry beriberi

Answer 80

effects the central and peripheral nervous system can lead to wernicke's encephalopathy - acute/sudden syndrome requiring urgent treatment - swelling causes damage to nerves and blood vessels in the brain - ataxia, confusion, nystagmus (rapid eye movement) - if left untreated can cause Korsakoff's syndrome Korsakoff's syndrome - irreversible, significant short-term memory impairment - inability to learn new things or retain new info - some loss of long-term memory - aphasia - lack of insight - confabulation

Question 81

wet beriberi

Answer 81

effects the heart and circulatory system

Question 82

nursing role with alcohol withdrawal

Answer 82

early and accurate assessment - history of substance use on admission - CAGE questions recognition and management os S+S - neuro assessment - CIWA provided meds for comfort - manage nausea and GI symptoms supportive nursing care - environment - approach - change bedding if diaphoretic - encourage nutrition and fluids

Question 83

labs and tests for AWS

Answer 83

- glucose -> alcohol can cause hypoglyceima - ECG -> alcohol can cause heart damage and causes autonomic hyperactivity which can cause arrhythmias - CBC and lytes - Liver function tests -> AST, ALT, GGT, bilirubin - total protein and or albumin - lipase

Question 84

leading causes of spinal cord injuries

Answer 84

- motor vehicle accidents - falls

Question 85

how to classify a spinal cord injury

Answer 85

- mechanism of injury - level of injury - degree of injury

Question 86

mechanism of spinal cord injury

Answer 86

traumatic - motor vehicle accident -fall - sporting activity - violent accident non traumatic - tumor - inflammation - infection - birth defect

Question 87

level of spinal cord injury

Answer 87

skeletal level - vertebrae and ligaments damaged - the high the injury, the more body parts effects - cervical = tetraplegia -> all 4 limbs/trunk affected - thoracic and lumbar = paraplegia -> lower limbs and trunk affected neurological level - lowest segment or normal motor and sensory function (bilateral)

Question 88

degree of spinal cord injury

Answer 88

complete - spinal cord is completely severed - complete loss of mobility and sensation below the injury incomplete - incomplete or partial cord severance - some movement and/or sensory below the level of injury

Question 89

primary and secondary injury in SCI

Answer 89

neurological damage results from both primary and secondary injury primary injury occurs immediately and secondary injury occurs over hours to day the inflammatory process happens during the secondary injury phase - is important because is removes pathogens, debris, and promotes wound healing - but the substance produced can accumulate and become toxic, causing damage to otherwise health/intact spinal cord tissue the extent of a spinal cord injury is not immediately clear

Question 90

diagnostic studies for SCI

Answer 90

- CT-> used initially to assess stability of injury, location, and degree - MRI is the gold standard - comprehensive neuro exam

Question 91

nursing care for SCI

Answer 91

immediately - maintain pantent airway - adequate ventilation - adequate circulating blood volume treat system and neurogenic shock to maintain BP remember that the extent of injury is initially unknown

Question 92

thoracic and lumbar SCI

Answer 92

- less intense than cervical injuries - respiratory compromise not as severe - bradycardia is not a problem - specific problems treated symptomatically

Question 93

SCI above C4 impact on the resp system

Answer 93

- total loss of respiratory muscle function - mechanical ventilation is required to keep pt alive - artificial airway -> direct access for pathogens - paralysis of abdominal and intercostal muscles -> ineffective cough - pulmonary edema -> neurogenic and fluid overload

Question 94

SCI below C4 impact on the resp system

Answer 94

- diaphragmatic breathing if the phrenic nerve is functional - hypoventilation common with diaphragmatic breathing - paralysis of abdominal and intercostal muscles -> depends on level and degree of injury, risk of ineffective cough

Question 95

SCI at T5 or higher impact on the CV system

Answer 95

- neurogenic shock!! - bradycardia -> drugs like atropine may be necessary to increase HR - peripheral vasodilation -> hypovolemia, decreased venous return -> decreased CO = hypotension, may need to use IV fluid or vasopressor to support BP - cardiac monitoring is necessary

Question 96

SCI impact on the urinary system

Answer 96

acute SCI and spinal shock - urinary retention is common - bladder to atonic and over distended - insertion of indwelling catheter required -> start intermittent catheterization ASAP post SCI -> 80% of people require bladder management - bladder can be = spastic (above T12), or flaccid (below T12) - recommend fluid intake 1800-2000 mL/day - bladder volume should not exceed 500mL - empty bladder regularly

Question 97

spastic bladder

Answer 97

- SCI above T12 - voiding reflex is intact - increased bladder muscle and sphincter tone - messages are blocked to the brain resulting in frequent involuntary bladder emptying - may have incomplete bladder emptying

Question 98

flaccid bladder

Answer 98

SCI below T12 - voiding reflex not intact - decreased loss of bladder muscle and sphincter tone - bladder will continue to fill -> will leak urine once too full - unable to empty bladder voluntarily

Question 99

SCI above T5 impact on the GI system

Answer 99

most problems associated with hypo motility - constipation - paralytic ileus - gastric distension - stress ulcers meds like metroclopramide may help with motility H2 receptor blocker and PPIs will help with ulcers

Question 100

SCI above T12 impact on the GI system

Answer 100

reflection (spastic) bowel - cannot voluntarily relax anal sphincter - constipation - signals between colon and brain are disrupted - bowel incontinence when rectum is full

Question 101

SCI below T12 impact on the GI system

Answer 101

areflexic (flaccid) bowel - decreased peristalsis - loose sphincter -risk for constipation with bowel incontinence

Question 102

SCI impact on the skin

Answer 102

- lack of mobility and sensation causes skin breakdown - pressure ulcers!!! - can lead to infection or sepsis

Question 103

SCI impact on thermoregulation

Answer 103

poikilothermia - inability to maintain core temp - SNS interruption prevents peripheral temp sensation from reach the hypothalamus - sweating and shivering does not occur below level of injury - can lead to hypo or hyperthermia

Question 104

SCI impact on metabolic needs

Answer 104

nutritional needs are much greater than expected for an immobilized person implement a positive nitrogen balance and high protein diet - prevents skin breakdown and infection - decreases the rate of muscle atrophy - if the pt needs NG suction -> may lead to metabolic acidosis, watch electrolyte levels until suctioning is discontinued and they are back to a normal diet

Question 105

SCI impact on peripheral vascular system

Answer 105

DVT is common during the first 3 months -> pt may be asymptomatic, complete DVT assessments pulmonary embolism is the leading cause of death in SCI

Question 106

surgical and drug therapy for SCI

Answer 106

- decompression - realignment - anterior and/or posterior stabilization with instrumentation - steroids - vasopressors meds under research - neuroprotective drugs - antibodies - stem cells

Question 107

nonoperative stabilization for SCI

Answer 107

- traction or realignments - focus on stabilization of injured spinal segment and decompression - eliminates damaging motion at injury site - intended to prevent secondary damage

Question 108

cerivcal spin immobilization

Answer 108

traction -> use only in A+O pts halo vest SOMI brace

Question 109

thoracic/lumbar spin immobilization

Answer 109

Jewett brace -> limits forward flexion TSLO brace -> controls spinal flexion, extension, rotation

Question 110

autonomic dysreflexia

Answer 110

may occur in SCI higher than T6 massive uncompensated CV reaction mediated by SNS occurs in response to sustained stimulation below T6 -> common precipitating factor is distended bladder or rectum

Question 111

S+S of autonomic dysreflexia

Answer 111

- HTN (normal SBP for tetraplegia is 90-100) - blurred vision - dilated pupils - throbbing headache - diaphoresis above injury level - bradycardia - piloerection (hair standing up) - flushed skin above injury level - spots in visual field - nasal congestion - anxiety - nausea vasodilation above injury, vasoconstriction below

Question 112

autonomic dysreflexia nursing interventions

Answer 112

- elevate HOB at 45 degrees or sit pt fully up - assess cause - remove stimulus - notify MRP if symptoms don't resolve if bladder distension is the cause - catheterize or if there is a catheter in place, check for blockages if stool impaction is the cause - a digital rectal exam should be performed only after application of an anesthetic ointment to decrease rectal stimulation and to prevent an increase in symptoms

Question 113

what can cause blood volume to increase in the brain

Answer 113

- hematoma - hemorrhage - metabolic/physiological factors - vascular anomalies

Question 114

what can cause brain volume to increase in the brain

Answer 114

- cerebral neoplasm - abscess - cerebral edema

Question 115

what can cause CSF volume to increase in the brain

Answer 115

- CSF secreting tumors - hydrocephalus

Question 116

factors that influence ICP

Answer 116

- BP - cardiac function - body positon - temp - blood gases - thoracic and abdominal pressures

Question 117

S+S of ICP

Answer 117

- changes in LOC (early sign) - ocular signs - headache - vomiting late signs - changes in VS -> cushings triad - decreased motor function

Question 118

cushings triad

Answer 118

- decreased HR - irregular respirations - widened pulse pressure

Question 119

nursing care for a pt with ICP

Answer 119

- monitor GCS - monitor neuro function -> cranial nerves - VS - resp function - monitor abd distention - monitor for pain and anxiety - monitor opioid and sedative use - monitor ABGs - monitor fluid and lytes - monitor ICP - normal = 5-15mmHg - keep HOB at 30 degrees - protection from injury -> seizure

Question 120

types of head injuries

Answer 120

scalp lacerations - most minor - blood loss and infection skull fractures - closed or open - inter cranial infections and hematoma head injury - diffuse injury - focal injury

Question 121

mild brain injury

Answer 121

GCS of 13-15

Question 122

moderate brain injury

Answer 122

GCS 9-12 significant cognitive impairment following injury often requires CT and admission to hospital

Question 123

severe brain injury

Answer 123

GCS 3-8 contusions, intracerebral lacerations, intracranial hemorrhage CT scan of brain and admission to hospital

Question 124

concussion

Answer 124

- client may or may not lose consciousness - brief disruption of LOC - amnesia of the event - headache - manifestation are short - client usually discharged home

Question 125

post concussion syndrome

Answer 125

- 2 weeks to >2 months - persistent headache - lethargy - personality and behavioural changes - shortened attention span, decreased short term memory - changes to intellectual ability - may require CT and admission to hospital

Question 126

diffuse axonal injury

Answer 126

- 12 - 24 hours to develop - decreased LOC - increased ICP - decerebrate or decorticate posturing - global cerebral edema - severe DAI remain in a persistent vegetative state

Question 127

focal brain injuries

Answer 127

- laceration -> active tearing of brain tissue - cranial nerve injuries - contusion -> frequently occurs near the site of a skull fracture, bruising of the brain tissue with in a focal area

Question 128

order of the meninges

Answer 128

dura arachnoid pia

Question 129

nursing interventions for head injury

Answer 129

- ensure patent airway - spinal stabilization if needed - monitor VS - monitor LOC, GCS, neuro status, S+S of ICP - ensure IV access and monitor fluid intake - assess for CSF rhinorrhea or otorrhea

Question 130

VAD selection

Answer 130

based on duration of therapy less than 7-10 days = PVAD 7 days to a month = non tunnelled CVAD more than a month, less than a year = PICC > year or long term = tunnelled CVAD or IVAD

Question 131

PICCs

Answer 131

- a CVAD that is inserted into a peripheral vein - inserted using an ultrasound at the bedside - after insertion the location of the tip needs to be verified via chest x-ray - may be valved (no clamp) or non valved (with clamp)

Question 132

femoral non tunnelled CVAD

Answer 132

not common avoid using in adult pts

Question 133

non tunnelled CVADS

Answer 133

- used for short term and emergent therapy - placed in the jugular or subclavian vein - inserted surgically -> tip placement needs to be verified be X-ray - are sutured in place - requires a sterile dressing

Question 134

tunnelled CVADs

Answer 134

- placed in the subclavian or jugular vein - the proximal end is tunnelled subcutaneously from the insertion site and brought out through the skin at an exit site - they have a dacron cuff on the tunnelled portion of the catheter that is placed under the skin just above the exit site -> granulation tissue will grow onto the cuff and create a seal -> keeps out infection - once healed no dressing is needed ** requires a heparin flush solution to maintain potency** - can be left in place indefinitely if there isn't any infection, blockage, or thrombosis

Question 135

IVAD

Answer 135

- no dressing required when not being used - needs an aseptic dressing when accessed - accessed using the huber needle ** requires a heparin flush solution (5mls) to lock the line* further education is needed to access and de-access an IVAD

Question 136

assessing an IVAD

Answer 136

- watch for dislodging of the catheter tip -> pt may report neck or ear pain, gurgling sounds, palpitations - watch for signs of port dislodgment -> free movement of the port, swelling, difficulty accessing - usually flushed at least every 8 weeks when not in use - requires heparin flush solution to maintain patency

Question 137

CVAD tip position

Answer 137

never use a CVAD until the tip position is confirmed via chest X-ray the tip of the catheter should be located within the lower third of the superior vena cava

Question 138

CVAD lumens and incompatible meds

Answer 138

you can administer multiple incompatible medications at the same time when using a CVAD that has multiple lumens each lumen is treated as a separate catheter

Question 139

CVAD indications

Answer 139

- giving IV fluids and blood products - giving meds - giving vesicants (chemo) - giving irritant medications - giving solution with extreme pH values - giving hypertonic solutions like TPN - obtaining venous blood samples - monitoring central venous pressure - dialysis access medications and solutions that are associated with phlebitis or tissue necrosis when infused peripherally are preferred to be given through a CVAD

Question 140

administering TPN through a CVAD

Answer 140

- CVAD is always used for TPN - an in-line filter is required for TPN - needs its own dedicated line -> the white port of a multi-lumen CVAD may be the port used for TPN - solutions need to be checked with another RN prior to hanging to ensure solution matches daily dr orders - solution needs to be changed every 24hrs

Question 141

drawing blood from a CVAD

Answer 141

- blood lab results are not as accurate with direct fresh blood access - it is best to use the largest lumen each toe -> if using a multi-lumen CVAD, leave the red one for blood - change the needleless cap if there is blood in the cap

Question 142

IV manifolds

Answer 142

are used to allow compatible medication to infuse simultaneously in the same lumen of an IV

Question 143

nursing actions for pt with a CVAD

Answer 143

1. ensure asepsis with all central lines and venous access ports 2. assess site for redness, drainage, swelling, pain, tenderness, warmth, numbness, parasthesia -> Q1h for continuous infusion, Q shift for saline/heparin locked, for non-tunnelled CVADs ensure sutures in place 3. ensure patency -> flush -> if the line not flushing properly or unable to aspirate, notify the IV team, and label line "do not use" 4. assess CVAD dressing to prevent infection 5. check the external length of a PICC catheter to ensure correct placement -> measure at least every 24 hours, every drsg change and prn -> if over 2cm difference report to MRP or IV team RN ASAP CVAD external length is not usually measured

Question 144

CVAD complications

Answer 144

- infection - air embolism - occlusions - phlebitis, infiltration, extravasation - catheter fracture - catheter embolism - PE - catheter migration - pneumothorax/hemothorax - arrhythmia

Question 145

treatment of catheter related infection or sepsis

Answer 145

local - warm, moist compress and culture of drainage from site -> remove catheter if indicated systemic - IV fluids, abx, sepsis protocol, and catheter removal if indicated -> send catheter tip to the lab

Question 146

S+S of sepsis

Answer 146

- shivering, fever, very cold - extreme pain or general discomfort - pale or discoloured skin - sleepy, difficult to rouse, confused - " I feel like I might die" - SOB

Question 147

lactate

Answer 147

a metabolite of glucose produced by tissues in the body under conditions of insufficient oxygen supply is normally cleared by the liver and kidneys blood lactate concentration in unstressed pt is 1 to 1.5 mmol/L critically ill pts lactate is often elevated to >2 mmol/L when lactate levels reach >4mmol/L -> need for immediate resuscitation and ICU admission

Question 148

air embolisms

Answer 148

there must be a pressure gradient between the vascular space and atmospheric pressure; and there must be a direct line of access to the blood vessel severity of the embolism depends on the volume of air, pt position, and rate of entry anything >50mL of air is considered potentially lethal

Question 149

air embolism S+S

Answer 149

- sudden onset dyspnea, breathlessness, tachypnea, wheezing, continued coughing - altered LOC, agitation, irritability, anxiety - shoulder and chest pain - lightheadedness, hypotension - JVD

Question 150

air embolism treatment

Answer 150

- close, fold, or clamp existing catheter - occlude the puncture site of a catheter that has been removed - place the client in trendelenburg left lateral decubitus position -> left side, head flat, feet up, right side uppermost -> moves air into the right atrium and lower right ventricle until it slowly absorbs - oxygen, VS, attempt to aspirate air from the catheter - notify MRP

Question 151

how to position pt during CVS insertion and removal

Answer 151

place pt in trendelenberg position to insert ensure catheter exit site is lower than the height of the pt heart when removing, have the pt lie flat for 30 mins post CVC removal

Question 152

CVAD thrombotic occlusions

Answer 152

a thrombus that has attached to the CVAD and has also adhered to the vessel wall S+S - pain in the extremity, shoulder, neck, or chest - edema in the extremity, shoulder, neck, or chest - engorged peripheral veins in the should, neck, or chest wall tx - thrombolysis therapy - systemic anti-coagulation with or without CVAD removal

Question 153

intraluminal clot (catheter thrombosis)

Answer 153

there is resistance upon aspiration and decreased ability to infuse fluids

Question 154

fibrin tail (catheter thrombosis)

Answer 154

resistance upon aspiration as the tail gets "sucked back" over the opening and no resistance when flushing because the tail gets pushed aside by the positive pressure acts as a one-way valve that permits infusion but not withdrawal of fluid from the catheter

Question 155

mural thrombus (catheter thrombosis)

Answer 155

depending on the location of the thrombus, may or may not be symptomatic upon syringe assessment can result in partial of complete occlusion of the vein S+S - swelling - pain - tenderness - engorged vessels

Question 156

fibrin sheath

Answer 156

inability to aspirate and resistance or inability to infuse fluids fibrin sheath creates a "sock" over the end of the catheters or its whole length

Question 157

chemical occlusions

Answer 157

occurs suddenly during administration due to a drug, mineral, or lipid residue precipitate risk factors - recent infusion of incompatible drugs - meds with high-risk for precipitation - high concentrations of calcium and phosphorous in parenteral nutrition solutions S+S - line is difficult to flush -vary depending on type of occlusion tx - depends on cause - consult with pharmacist

Question 158

mechanical occlusions

Answer 158

- kinked tubing - cracks or leakage in CVAD - constriction of CVAD due to improperly placed sutures - catheter tip migration - closed clamps - client position

Question 159

infiltration vs extravasation

Answer 159

Infiltration involves the leakage of a non-vesicant (non-irritating) solution, while extravasation involves the leakage of a vesicant (irritating or tissue-damaging) solution

Question 160

catheter embolism

Answer 160

S+S - palpitations - arrhythmias - dyspnea - cough - thoracic pain not associated with pt diagnosis prevention - don't withdraw a catheter through a needle during insertion - never use a VAD for power-injection that are not rated for the purpose - the size of the flush syringe should be appropriate for the type of CVAD and its intended use intervention - when removing, inspect the catheter for damage and possible fragmentation - notify MD and treat symptoms - Save catheter and report per agency policy

Question 161

pulmonary embolism

Answer 161

S+S - apprehension - pleuritc discomfort - dyspnea - tachypnea - cyanosis - cough - tachycardia - chest pain prevention - never irrigate the catheter if the IV is not flowing - use in line filters where applicable - throughly inspect meds and solution containers for particulate matter tx - place client on strict bed rest in semi-fowlers - notify MRP - monitor VS - give O2 - assess CVC for patency -> give emergent meds - document

Question 162

when to give IV push meds

Answer 162

- the volume is less than 20mL - the rate is appropriate for staying at the bedside to monitor - the med is approved this way by pharmacy - LPNs do not give meds by IV push due to the higher risk involved - when given into a CVAD, the vessel is much larger and some meds can be given by IV push

Question 163

venous air embolism placement

Answer 163

lay pt on left side in trendelenburg position forces are to move into the right atrium, preventing CV collapse

Question 164

arterial air embolism

Answer 164

keep client in supine flat position

Question 165

catheter migration

Answer 165

cause - improper suturing - insertion site trauma - changes in intrathoracic pressure - forceful catheter flushing - spontaneous S+S - sluggish infusion or aspiration - edema of chest or neck during infusion - pt reports gurgling sound in ear intervention - assist with removal and new CVAD placement - fluoroscopy to verify position

Question 166

PICC complication (arrhythmia)

Answer 166

cause - line advances into the right atrium irritating the heart S+S - palpitations or pounding in the chest - tachycardia/bradycardia -chest pain - SOB - weakness, fatigue interventions - - meds -> antiarrhythmic, anticoagulant, anti-platelet - vasovagal manuvers - cardioeversion -- pace maker - heart surgery

Question 167

assessing PICC external length

Answer 167

with a visible 0 - measure from 0 to insertion site without a visible 0 - measure from the hub to the insertion site

Question 168

IV med rights

Answer 168

in addition to the 10 med rights 1. dilution -> does the med need to be diluted 2. compatibility -> is it compatible with other fluids/meds in the same IV line 3. rate/duration -> how long is the med administered over if using a pump 1. right infusion device 2. right protocol 3. right program settings

Question 169

labelling med syringes

Answer 169

- drug name - dose/volume - route - 2 pt identifiers

Question 170

aspirating IVs

Answer 170

also aspirate CVADs and PICCs don't aspirate PVADs

Question 171

checking compatibility

Answer 171

assume not compatible if a med is not listed on the parenteral manual

Question 172

drug speed shock

Answer 172

complication from IV push - a systemic reaction caused by the rapid injection of a med into the circulation - results in toxic level of medication in the plasma S+S - flushed face - headache - chest tightness - irregular pulse - syncope -shock - cardiac arrest /

Question 173

when to document on the I/O

Answer 173

if giving flushed or med volume greater then 20mL

Question 174

PICC lines

Answer 174

a central line inserted into a peripheral vein don't take BP on the arm with the PICC tip rests in the distal superior vena cava (the lower third) heparin flushes are no longer needed for PICCs

Question 175

power injectable

Answer 175

a type of PICC line (power PICC) purple central venous catheter that allows power injection of contrast media for scans have a max rate of 5ml/second lumens are usually 18 gauge usually non-valved

Question 176

what syringe to use when flushing lines

Answer 176

always use a 10mL or greater syringe to decrease risk of catheter damage not applicable when using power-injectable lines

Question 177

when to change PICC dressings

Answer 177

transparent dressing = every 7 days and PRN gauze = every 2 days securement device = every 7 days and PRN needleless cap = every 7 days and PRN

Question 178

when should you remove fluid from a mini bag when adding medication?

Answer 178

if the volume of the additive is >10% of the volume of the bag, you have to remove the volume of the med from the mini bag 50mL = add less than 5mL 100mL = add less than 10mL

Question 179

what needle should you use to inject med into a mini bag

Answer 179

use a non-filter needle if using a filter needle to draw up med from an ampule or vial, must switch to a non-filter needle

Question 180

tandem infusion

Answer 180

a tandem infusion is a second IV line connected to the primary line at the lower port below the pump -> need 2 pumps the med can be given intermittently or at the same time as the primary infusion, both bags can infuse at the same time is compatible

Question 181

documenting a heparin drip

Answer 181

- MAR - Dr order page - VAD record - I/O - NN as needed

Question 182

colostomy

Answer 182

transverse and descending are more common when the colon (large intestine) is brought through the abdominal wall ascending colostomy is rare

Question 183

cecumstomy

Answer 183

the beginning part of the colon is brought to the surface rare -> seen in spina bifida

Question 184

ileostomy

Answer 184

when the ileum is brought through the abdominal wall

Question 185

urostomy

Answer 185

is used for urine and ill conduit is made -> 15-20cm segment of the ileum is converted into a conduit and ureters are anastomosed to one end

Question 186

colostomy indications

Answer 186

emergency or temporary - bowel obstruction - abdominal trauma - perforated diverticulum permanent or temporary - obstructing colorectal cancer

Question 187

colostomy types of drainage

Answer 187

depends on where it is in the colon semi-liquid to pasty, semi-formed or formed stools

Question 188

bowel resection

Answer 188

diseased or damages section of bowel is removed doesn't necessarily results in the creation of an stony -> might be able to rejoin the bowel through anastomosis

Question 189

creation of end ostomy

Answer 189

single stoma to drain decal matter can be in the small or large intestine

Question 190

hartman's procedure

Answer 190

an ostomy surgery - distal portion of the bowel left in place - may be reversed at a later time stage 1 = creation of the ostomoy stage 2 = reversal of the ostomy

Question 191

loop ostomy

Answer 191

bowel is not completely cut through -> a loop of bowel is brought to the skin usually temporary in loop colostomies there are 2 opening -> the proximal drains stool and the distal drains mucous

Question 192

loop ostomy with bridge

Answer 192

right after surgery the pt will have a bridge or rod to prevent the stoma from slipping back into the abdomen the rod is usually removed after 3-7 days

Question 193

double barrel stoma

Answer 193

similar to a loop ostomy but the bowel has been cut into 2 sections

Question 194

colostomy nursing care

Answer 194

assessment of stoma - should be pink, red -> very vascular, will bleed easily - first 72 hours post-op, necrosis is most likely to occur - increased swelling 4-6 weeks after surgery assessment of peri-stomal skin - protect the skin and stoma from trauma and effluent - choice of pouching systems and protection products - empty bag when 1/3 full or full of gas to prevent leaks - change the system every q3-5 days -> depends on what pouch pt is using, stool - change either before breakfast or 1-2 hours after a meal - provide pt education

Question 195

diet with colostomy

Answer 195

- don't need to make major changes to diet - avoid gas producing foods -> broccoli, beans, cabbage - increase fluid intake, the more of the bowel removed the more fluid intake needed

Question 196

ileostomy indications

Answer 196

temporary - protect distal anastomosis in post op low anterior resection permanent - UC - chrohn's

Question 197

ileostomy drainage

Answer 197

post op - 1200-1800 mL/day bilious output later - 800mL/ day

Question 198

ileostomy nursing care

Answer 198

assessment - ins and outs and fluid/ electrolytes -> dehydration is common assessment of stoma - same as colostomy assessment of peri-stomal skin - stool from an ileostomy is extremely irritating to skin, if leaking needs to be changed daily

Question 199

ileostomy

Answer 199

- low residual diet initially -> limit high fat dairy and red meat, raw veggies, popcorn, things with lots of seeds - insoluble fibre-containing foods introduced slowly - avoid gas producing food, eggs, beer, sodas goal to return to a normal nutritious diet increase fluid intake to replace lost fluids -> 2/3 L per day monitor for electrolyte imbalances -> may need to increases intake of potassium and sodium foods

Question 200

considerations for ostomies

Answer 200

- chew food well - avoid using straws - avoid gum - ascending and transverse colostomies have a strong odour requiring control, ileostomy have less odour - avoid foods that cause odours

Question 201

urostomy indications

Answer 201

- cancer of the bladder - neurogenic bladder - congenital anomalies - stricutres - trauma to the bladder - chronic infections with decreased renal function drain urine and or mucous

Question 202

urostomy nursing care

Answer 202

assessment of peri-stomal skin - skin requires meticulous care due to irritating urine monitor I/O, increase fluid intake to keep urine dilute and minimize the formation of kidney stones minimize odor - empty frequently, change pouch every few days - cleanse night drainage bag with soap and water, and then vinegar and water -> hang to dry

Question 203

osotomy documentation

Answer 203

complete each time pouch is changed for all ostomies - volume, colour, and consistency of drainage - condition of peri-stomal skin - stoma size (in mm) - stoma shape - stoma colour - stoma height - products used - presence of stents, catheters, rods, or bridges - pre and post op pt teaching

Question 204

folliculitis (stoma complications)

Answer 204

inflammation of the hair follicles -> bumpy, red rash usually due to a staph infection often due to shaving rather than clipping hair, or when removing the ostomy appliance pulls hair out

Question 205

candida albican infection (stoma complication)

Answer 205

- yeast infection - reddened, moist, tender - may have patchy white areas - treat with anti fungal med

Question 206

stenosis (stoma complications)

Answer 206

- narrowing of the stoma or intestinal lumen - may result in bowel obstruction - minor stenosis may be manage with low residual diet and increased fluids - serious stenosis requires surgery

Question 207

closed ended pouch

Answer 207

used for sigmoid colostomies where the stool is well-formed, and the person may only have 1 bowel movement per day or less

Question 208

stoma cap

Answer 208

can be used for people who have formed bowel movements at specific times of the day -> sigmoid colostomy can be used when bathing, swimming, or during intimacy

Question 209

ostomy irrigation

Answer 209

goal is to train the bowel to empty at the same time every day habituation of the bowel takes 3 to 6 weeks not all clients can be managed with irrigations

Question 210

high enema

Answer 210

30 to 45 cm above the anus

Question 211

regular enema

Answer 211

30cm above anus

Question 212

low enema

Answer 212

7.5 cm above anus

Question 213

cleansing enema

Answer 213

promotes complete evacuation of the rectum by stimulating peristalsis with large volumes of fluid hypertonic = saline sodium phosphate (fleet enema) -> retain 5-10mins hypotonic = tap water -> retain 15 -20 mins isotonic = normal saline, safest option -> retain 10-15mins soap suds -> Castile soap and tap water -> retain 10-15mins

Question 214

carminative enema

Answer 214

- Magnesium, glycerine, and water to stimulate peristalsis and expel flatus

Question 215

oil retention enema

Answer 215

lubricates the rectum and colon feces absorbs the oil and becomes softer and easier to pass

Question 216

medication enema

Answer 216

abx, antihelminitic (kills worms), kayexalate (reduces high serum potassium levels)

Question 217

return flow enema

Answer 217

expels flatus and relieve abd distension 100-200 mL fluid in/out of the rectum, repeated 5-6 times

Question 218

when to do a rectal exam

Answer 218

before giving an enema or suppository be gentle, use well lubricated glove, careful not to puncture the rectal mucosa if there is no stool in the rectum an enema or suppository will probably not have a successful result

Question 219

potential enema complications

Answer 219

- mucosal irritation - puncture of the colon - dehydration - fluid electrolyte imbalance - circulatory overload - decreased bowel/sphincter tone with overuse

Question 220

how to position pt to give enema

Answer 220

on left side with right knee flexed

Question 221

considerations during manual fecal disimpaction

Answer 221

the vagus nerve is stimulated in the rectum so HR must be monitored before, during, and after the procedure caution with elderly pt who are particularly susceptible to changes in autonomic tone, could trigger syncopal or near-syncopal episodes

Question 222

contraindications to bowel protocol

Answer 222

- ileostomy - blood in stool or rectum - absence of bowel sounds - complete bowel obstruction - diarrhea -impaction

Question 223

criteria for insertion of a rectal tube

Answer 223

- all options for diarrhea have been considered - fecal incontinence bag/appliance use has been attempted and unsuccessful - 3 episodes of feral incontinence of liquid stool in a 12 hr period, or skin breakdown, or presence of a surgical site/dressing - pt not mobile - liquid or semi-liquid stool anticipated for longer than 36 hours

Question 224

contraindications for a rectal tube

Answer 224

- lower large bowel, rectal, anal surgery in the last year - rectal or anal injury, severe hemorrhoids, strictures, or stenosis - fecal impaction - peds pts

Question 225

droplet/contact precautions

Answer 225

gown gloves mask eye protection

Question 226

AGMP precautions

Answer 226

N95 needed

Question 227

focused resp assessment

Answer 227

- general appearance - colour - resp rate/rhythm/depth - resp effort/dyspnea - tracheal position/thorax - chest expansion/symmetry - cough/sputum production - breath sounds - adventitious sounds - O2 sat - oxygen therapy

Question 228

adventitious sounds

Answer 228

- crackles (aka rales) -> coarse and fine - death rattle - pleural friction rub -> creaking floors - rhonchi -> upper airway wheeze - stridor -> high pitch, upper airway, only on inspiration - wheeze -> musical, inspiration and expiration

Question 229

abnormal respiratory sounds

Answer 229

cheyne stokes breathing -> alternating between deep and shallow breathing , brain injuries, neurological kussmaul breathing -> deep and rapid, DKA or metabolic acidosis agonal or guppy breathing -> irregular, long pauses, gasping, not effective, end of life, last breaths

Question 230

titration of oxygen algorithm

Answer 230

maintain O2 sat at 92% and above if lower, increase O2 if greater than 96% try to wean oxygen down

Question 231

low flow O2

Answer 231

inspiratory flow not met -> will be breathing in RA as well ventilatory pattern influences FiO2 -> more variable percentage measured in L/min -> titrate by 1-2 L include: NP, simple mask, non-rebreather

Question 232

high flow O2

Answer 232

inspiratory flow met/exceeded ventilatory rate doesn't effect FiO2 -> more predictable measured in % -> titrate by 5-10% some are humidified single or double flow -> 1 or 2 flow meters, increases amount of O2 delivered to pt. includes: aerosol/ stars wars/ Venturi/ trash masks/ face tent/ T-piece/ airvo/ optiflow

Question 233

AquaPak Humidified O2 system

Answer 233

air entrainment port -> 28-98% FiO2 patient specific connects to corrugated tubing replace prefilled sterile water bottle as needed change tubing Q7days

Question 234

aerosol mask

Answer 234

administers a specific FiO2 -> determined by air entrainment port on aquapak corrugated tubing collects moisture exhalation ports allows air from the room if oxygen were to be inadequate

Question 235

Star Wars mask

Answer 235

regular aerosol mask with two 6 inch pieces of corrugated tubing to be used as reservoirs less air inhaled from the exhalation ports generally requires a double flow system ensure flowmeter(s) set as directed by RT

Question 236

trach mask

Answer 236

placed around the neck and tracheostomy to ensure adequate oxygen/humidification delivery single or double flow imprecise FiO2

Question 237

T-piece

Answer 237

attached to an endotracheal tube of trach tube 6inch reservoir tubing attached to the other side of the T precise FiO2 single or double flow

Question 238

nursing care for oxygen therapy

Answer 238

label equipment with pt name and date clean face mask and prongs assess straps -> change when soiled observe for pressure sores complete resp/cardio assessment as per dr orders, per protocol, or PRN ensure adequate sterile water and assess setting levels for high flow O2 assess tubing for excess h2o and empty as needed

Question 239

high flow O2 and eating

Answer 239

NP at 6L may be needed have the mask available for in-between bites

Question 240

optiflow and airvo

Answer 240

high flow oxygen delivery systems used for pt with profound hypoxemia and/or mucocilliary clearance difficulties heated and humidified gas at 37 degrees can provide both low and high flow O2 nasal, mask, or trach interface

Question 241

benefits of optiflow and airvo

Answer 241

not considered AGMP more comfortable pt can eat and drink precise oxygen concentration decreased WOB promotes ciliary movement and secretion clearance

Question 242

airvo ranges

Answer 242

flow range = 2-60 L/min FiO2 range = 0.21 to 1.20 (21% to 100%)

Question 243

optiflow ranges

Answer 243

flow range = 10 -60 L/min FiO2 range = 28% to 100%

Question 244

optiflow and airvo monitoring

Answer 244

resp and cardio assessments/ vital sign Q4h and PRN for the first 24 hours after 24 hours monitor as determined by the team monitor for change in WOB, oxygenation -> if declining changed notify RT, CCN, or MRP monitor FiO2 setting, flow rate, temp, and sterile water bag at least every 4 hours humidifier should be on "invasive mode" unless the client has a trach or aerosol mask on RT or CCN are the only ones who can titrate, initiate (with dr orders) and discontinues it (with dr orders)

Question 245

e-sized cylinders

Answer 245

are often used in acute care as a transport oxygen cylinder

Question 246

how to calculate how long an O2 cylinder will last

Answer 246

PSI that is in the tank x the conversion factor divided by the L/min the client requires

Question 247

oropharyngeal airway

Answer 247

only use in pt with altered LOC -> can stimulate the gag reflex do NOT tape airway in place mouth care every 2 hours or as per protocol may be suctioned PRN remove and assess the mouth every 8 hours

Question 248

inserting an oral airway

Answer 248

1. don gloves 2. measure the oral airway from the centre of the mouth to the angle of the jaw or corner of mouth to earlobe 3. smiley face up until it reaches the soft palate then rotate 180 degrees

Question 249

nasopharyngeal airway

Answer 249

tolerated better by more alert pt than the oral airway inserted into the nare provide frequent oral and nasal care reposition the airway in the other care every 8 hours if required

Question 250

inserting a nasal airway

Answer 250

1. don gloves 2. measure the nasal airway from pt earlobe to the tip of the nostril 3. ensure the diameter of the airway is not larger than the nostril 4. lubricate airway with water soluble jelly 5. insert along the floor of the nostril with a slight twisting action, aim towards the back of the opposite eyeball

Question 251

assessment and management of a trach

Answer 251

focused respiratory assessment note the character of the secretions from the trach presence of drainage on the trach dressings or ties note the appearance of the incision/new stoma -> redness, swelling, purulent discharge, odour

Question 252

bedside safety equipment for trachs

Answer 252

- suction - oxygen equipment with humidification - two replacement trach tubes -> one the same size, one smaller - obturator and spare inner cannula - 10 mL syringe - tracheal dilators or forceps - sterile gloves - water-soluble lubricant - spare ties - normal saline nebula - manual resuscitation device with appropriate airway and mask * if jaw wired shut, have jaw cutters available at bedside

Question 253

when would you need a chest tube?

Answer 253

- when pressure placed on the lung interferes with expansion - when negative pressure needs to be restored - when air or fluid needs to be drained - may be used in chronic conditions

Question 254

pleural space

Answer 254

where chest tubes are usually inserted -> in-between the membranes that line the lungs upper anterior thorax for pneumothorax lower lateral chest wall for fluid

Question 255

assessing pt with chest tube

Answer 255

prioritize chest tubes during QPA advanced resp assessment advanced cardio assessment pain -> give PRN analgesic deep breathing and coughing every 2 hours -> may be contraindicated in lobectomy assist with range of motion/mobilizing as needed

Question 256

assess chest tube insertion site

Answer 256

look at the site q4h is the dressing dry and secure? no air leaks? palpate and listen for subcutaneous emphysema

Question 257

assess chest tube drainage system

Answer 257

- ensure closed drainage system - ensure all connected are taped and secure as per policy - tubing is free from kinks or compression - no dependent loops - drainage system below level of chest - drainage system properly secured - blue clamp is OPEN - check for tidaling. with respirations - ensure suction control dial is set to ordered level -> usually 20cm - check for bubbling in air leak monitor - record date/time/amount of drainage on the outside of the chamber - record the amount/characteristic of drainage on the fluid balance sheet

Question 258

chest tube bedside safety equipment

Answer 258

- 2 clamps -> non toothed or padded - waterproof tape do not clamp chest tube unless ordered by MRP, changing chamber, checking for leaks, or the tube is dislodged

Question 259

if chest tube is disconnected from drainage system

Answer 259

EMERGENCY 1. have pt exhale 2. double clamp and/or submerge the end in 2cm of sterile water 3. clean ends with alcohol and reconnect immediately 4. unclamp

Question 260

is chest tube is pulled out

Answer 260

EMERGENCY 1. cover insertion site with a gloved hand and call for help 2. cover site with sterile gauze and tape -> have pt exhale 3. only tape top and sides -> leave bottom open 4. cal MRP

Question 261

if chest tube has an air leak

Answer 261

begin at dressing and clamp momentarily -> work towards the drainage chamber in 20 to 30 cm increments each time you clamp check the water-seal/air leak monitor to see if bubbling stopped once bubbling stops will tell you wear the leak is

Question 262

clots blocking chest tube and bright red drainage

Answer 262

do not strip or milk the tubing may need to change drainage system notify MRP if needed bright red drainage may indicate active bleed -> monitor amount of drainage and VS -> notify MRP

Question 263

inter dermal injections

Answer 263

into the dermis low blood supply, slow absorption can administer very small amount of liquid -> 0.1 mL needle length 1/4 to 1/2 inch, and 25 to 27 gauge

Question 264

TB

Answer 264

airborne transmission can be latent or active TB most common in lungs, can infect other areas like brain, kidney, spine tx includes combination of oral antibiotics for >6 months isolation until no longer contagious if going for a test, pt must wear a surgical mask

Question 265

3 types of sputum collection

Answer 265

C&S -> identify organisms and drug sensitivities cytology -> identify origin, structure, function, and pathology of cells, often requires serial collection of 3 early morning speciments AFB (acid-fast bacillus) -> requires serial collection often for 3 consecutive days, test for TB

Question 266

how to collect sputum

Answer 266

- collect in the morning, before eating - offer mouth care, but not mouth wash - don gloves - pt takes deep breath and cough - need 15 - 30 mL

Question 267

goals of diabetes management

Answer 267

- promote well being - reduce symptoms - prevent acute complication of hyperglycemia and hypoglycemia - delay the onset of and progression of long term complications

Question 268

fasting blood glucose (FBG) levels

Answer 268

no caloric intake for at least 8 hours < or = 6 mmol/L is normal 6.1 to 6.9 mmol/L is pre diabetes = or > than 7.0 mmol/L is diabetes

Question 269

hemoglobin A1c levels

Answer 269

glycated hemoglobin measured to determine the average blood glucose levels over the last 3 moths < 5.5% is normal 5.5 - 5.9% is risk of diabetes 6.0 - 6.4% pre-diabetes 6.5% and greater is diabetes

Question 270

random plasma glucose

Answer 270

without regards to meals < 11.1 mmol/L is normal

Question 271

nova machine levels

Answer 271

4 (3.3) to 7.0 mmol/L is good 5-8 is the target range in hospital 6-10 is target range for critically ill

Question 272

hypoglycemia S+S

Answer 272

- blood glucose <4 - cool, clammy skin - rapid HR - heart arrhythmias, faintness, dizziness - nervousness, tremors, shaking - hunger - emotional changes - numbness of fingers, toes, mouth - slurred speech, unsteady gait -changes in vision - seizures, coma symptoms are similar to someone who is intoxicated

Question 273

causes of hypoglycemia

Answer 273

- insulin overdoes or sulphonylurea overdose or response to recent change in dose - missed or inadequate meal - unexpected exercise - error in timing of dose

Question 274

hyperglycemia S+S

Answer 274

- blood glucose greater than 11 - polyuria - polydipsia - polyphagia - weakness, fatigue - blurred vision - headache - N/V - abdominal cramps - glycosuria

Question 275

causes of hyperglycemia

Answer 275

- inadequate doses of insulin - infection - stress - surgery - meds -> steroids, benzos - variation in nutritional intake - receiving PN or EN - critical illness

Question 276

blood glucose monitoring (BGM)

Answer 276

should be done within 30 mins before a meal (ac meal) or 2 hours after a meal (pc meal) whole blood is used -> capillary, venous, arterial if pt is on anticoagulants hold pressure for 5 mins after using lancet

Question 277

BGM test strips

Answer 277

are good for 180 days after opening

Question 278

BGM QC vials

Answer 278

are good for 90 days after opening

Question 279

BGM results on the Nova

Answer 279

normal = 3.3 to 7.0 mmol/L critical low = <2.6 mmol/L critical high = > 25 mmol/L

Question 280

cloudy and clear insulin

Answer 280

cloudy is usually longer acting insulin clear is often shorter acting, but can also be longer acting aspart and regular insulin are always clears NPH is cloudy glargine is clear you can mix 2 insulin's together -> typically 1 short acting and 1 long acting you need to draw up the clear insulin before you draw up the cloudy insulin

Question 281

basal insulin

Answer 281

required to cover rise in blood glucose between meals and overnight calculation depends on weight -> estimated dose is 1/2 of TDD includes long acting and intermediate acting insulins -> NPH, degludec, and glargine

Question 282

bolus insulin

Answer 282

required to cover rise in glucose due to meals may use the pre-admission meal dose usually 1/2 of TDD divided equally among the 3 meals aspart

Question 283

insulin correction dose

Answer 283

is used alone q4h is pt is NPO -> no regularly scheduled basal doses

Question 284

ISF

Answer 284

insulin sensitivity factor the higher the ISF the more sensitive the client is to insulin -> requires less insulin 1 = need more to do less 4 = need less to do more ISF 4 = 4 units of 1 unit of insulin will decrease blood sugar by 4 mmol/L

Question 285

ISF calculation

Answer 285

100 divided by the TDD

Question 286

SC med administration

Answer 286

is absorbed more slowly than meds given by the IM route require a dr order prior to administration of the med via sc route this route is not recommended for severe, uncontrolled, escalating pain due to slow absorption

Question 287

insulin pen needle size and length

Answer 287

needle sizes = range from 29 - 32 needle length = determined by assessment of pt adipose tissue -> typically is 4mm - 12mm (5/32 to 1/2 inch) angle of insertion is usually 90 degrees for insulin pen

Question 288

volume of SC medication

Answer 288

only small doses 0.5 to 1ml of water-soluble meds should be given subcu up to 2mL is safe

Question 289

angle of insertion for insulin pen

Answer 289

usually 90 degrees pinching is only necessary when using a longer needed on someone slim to prevent IM injection

Question 290

SC site selection for insulin

Answer 290

lateral outer upper arms anterior and lateral thigh, butt, abdomen pt should rotate injection site within the same body part to provide better consistency of the absorption of insulin -> 2.5 cm away from last injection site abdomen has the quickest absorption for insulin

Question 291

disinfection for a SC injection

Answer 291

disinfection of the site is not usually required -> in home most people don't alcohol swab -> in hospital alcohol swabs are usually used

Question 292

cloudy insulins

Answer 292

always mix insulin suspensions gently roll x10 and invert 10x

Question 293

1 mL to 3 mL syringes

Answer 293

are typically used for subcut and IM injections

Question 294

determining needle length and gauge

Answer 294

length of needle is dependent on assessment -> client weight and size, location of injection site needle gauge is determined by -> viscosity of med, location of injection, type of injection

Question 295

syringes with meds

Answer 295

must be labelled with -> 2 patient identifiers -> name of med -> dose and volume -> route

Question 296

Subcut injections

Answer 296

usually less than 1 mL is injected via SC (safe up to 2mL) syringe size = usually 1-3mL needle size = usually 25G and 5/8 long administer at a 45 degree angle is 2.5cm of tissue can be grasped administer at a 90 degrees angle if 5 cm of tissue can be grasped rotate administration site to minimize tissue damage, maintain absorption, and avoid discomfort administer anywhere there is enough subcut tissue to pinch an inch

Question 297

SC heparin injections

Answer 297

should be injected at least 5cm away from the umbilicus heparin is injected at 90 degrees assess abdomen for trauma prior to selecting injection site -> abdomen is preferred injection site as it absorbs slower due to fat, but other site can be used heparin requires a IDC

Question 298

LMWH profiled syringe

Answer 298

comes in a spring loaded pre-filled safety syringe with the needle attached -> there is an air bubble in the barrel dont prime it and remove the air bubble -> if you have to remove some of the med ensure you add the bubble back

Question 299

insulin syringes

Answer 299

are in units instead of mLs needles come attached usually 26 -31 gauge and 1/4 to 1/2 inches long insulin is absorbed more quickly in -> abdomen -> then arms -> them thighs and buttocks

Question 300

drawing up long acting and short acting insulins

Answer 300

air into cloudy (long acting) air into clear (short acting) draw up clear draw up cloudy

Question 301

mixing 2 insulins into 1 syringe

Answer 301

NOT ALL INSULINS CAN BE MIXED when inserting air into vials make sure not to touch solution with the needle IDC must be done after drawing up the clear dose, and then again after drawing up the cloudy must get the accurate dose when drawing up the second vial, if you have to push some back into the vial -> you have to restart entire process

Question 302

priming a subcut butterfly

Answer 302

add an additional 0.36mL is first dose when initiating a SCBF to prime the line

Question 303

inserting a SCBF

Answer 303

make sure to swab with chlorhexidine insert at a 30-45 degree angle make sure you label it with the med, concentration and date

Question 304

IM injections

Answer 304

fairly quick absorption from muscle tissue muscles can accept more fluid and irritating meds that should nit be given via subcut usually 1-3mL syringe usually 21-23G and 1/2 to 1 1/2 inch needle -> length is determined by the site and weight of pt and gauge is determined by viscosity of liquid obese clients may need up to 3 inches inserted at a 90 degree angle site is determined by med and volume

Question 305

ventrogluteal

Answer 305

preferred IM site in adults landmark identifiers: - greater trochanter - iliac crest - anterior superior iliac spine typically up to 3mL - some cases 5mL can give in side-lying, supine, or prone positions

Question 306

deltoid

Answer 306

IM injection site lateral aspect of the arm landmark identifiers: - acromion process -> injection 3-5cm below - axilla -> in between these 2

Question 307

vastus lateralis

Answer 307

side of the leg typical up to 3mL - up to 5mL is ok landmark identifiers: - arterial lateral aspect of the thigh -> the middle third, hand above the knee below the hip -> go in the middle of that - greater trochanter - lateral femoral condyle

Question 308

rectus femoris

Answer 308

anterior aspect of the thigh up to 3mL, max 5mL landmark identifiers: - anterior aspect of the thigh - anterior superior iliac crest - patella this location may cause considerable discomfort

Question 309

dorsogluteal

Answer 309

DO NOT ADMINSTER HERE risk of sciatic nerve damage

Question 310

risks of IM injections

Answer 310

- pain - bleeding - abscess - cellulitis - tissue necrosis - granuloma - muscle fibrosis - contractures - hematoma - injury to blood, vessels, bone, nerves

Question 311

audible abdominal vascular sounds

Answer 311

in addition to regular bowel sounds -> bruits are sometime heard during auscultation, could indicate an aortic aneurysm, but also don't always indicate disease

Question 312

EN

Answer 312

administration of nutrients directly into the GI tract it is the preferred method for providing nutrition and should be used when the pts GI tract is functional considered an advanced directive -> could be ethical complications

Question 313

S+S of malnutrition

Answer 313

- mental confusion, irritability, unable to concentrate, listless - lack of appetite and interest in food - changes in skin colour - dry, scaly skin, brittle, pale nails, dry, dull, sparse hair - swollen and bleeding gum, decaying teeth -eyes dry, sunken, hollow cheeks - fatigue low energy - distended abdomen, enlarged liver - weight loss - poor immune function

Question 314

abnormal blood results in malnutrition

Answer 314

decreased: - albumin/pre albumin and total protein - Hgb/Hct (if anemic) - iron/components - lymphocytes (increased during infection) - blood glucose - K+ and calcium - BUN and CR (increased if hypovolemic from dehydration) - serum vitamin and mineral levels Increased - liver enzymes -> liver damage

Question 315

re-feeding syndrome

Answer 315

this occurs in malnourished pt who are fed with high carb loads carbs in the feed can cause a large increase in the circulating insulin level -> results in rapid and dramatic fall in phosphate, potassium and magnesium -> increases extracellular volume body tries to switch from catabolic to using exogenous fuel sources -> increase in oxygen consumption -> increased resp and cardiac workload -> can lead to multiple organ failure, resp or cardiac failure, arrhythmias, rhabdomyolysis, seizures, coma feeds should be started slowly and electrolytes closely monitored and adequately replaced to avoid this

Question 316

pulmonary aspiration

Answer 316

signs - increased SOP - productive cough - sputum - difficulty swallowing to prevent - ensure head of bed is elevated with a continuous tube feed is running and for 1 hour after and intermittent feed

Question 317

aspiration risk factors

Answer 317

- head of bed less than 30 degrees - impaired LOC - neurological deficits - poor oral health - Mal-positioned feeding tube - age over 60 - delayed gastric emptying

Question 318

tx of aspiration

Answer 318

- stop feed immediately and notify MRP - lower head of bed and put client on left side to prevent further seepage of formula into lungs - suction as needed - monitor O2 sat and administer O2 if needed - anticipate order for urgent chest x-ray

Question 319

short-term feeding tubes

Answer 319

required for short term feeds -> 4-6 weeks nasogastric tubes - inserted down the nose and into the stomach - requires intact gag and cough reflex to protect airway - must have adequate gastric emptying - can be hard bore and soft bore hard bore : Salem sump - larger tube, double lumen - 12 to 18 fr - may be used for suction as the smaller vent lumen allows for inflow of air Levin - single lumen - needs to be changed weekly - often used with anti-reflux valve soft bore: - most common for EN - usually 6-12 fr - smaller, more flexible, less irritating - may have weighted tip - stylet to help with insertion - need to be changed monthly naso-enteric tubes - inserted into the small intestine - used in pt with increased risk of aspiration

Question 320

anti-reflux valve

Answer 320

prevents gastric reflux or leakage through the vent lumen or a double lumen nasogastric tube allows the passage of air into the vent lumen with atmospheric pressure exceeds stomach pressure -> when stomach pressure exceeds atmospheric pressure, the valve prevents flow of fluids through the tube

Question 321

complication of nasal tubes

Answer 321

- aspiration - misplacement of tube - nasal pharyngeal irritation and pain - sinusitis, sore throat, epistaxis - perforation -> rare - inadvertent lung placement - intracranial placement

Question 322

long term feeding tubes

Answer 322

G-tube or J-tube - usually used for more than 6-8 weeks - placed surgically or by laparoscopy through the abdominal wall into the stomach or jejunum - usually longer NPO time before starting feeds - larger incision PEG tube or PEJ tube - used for more than 6-8 weeks - smaller incision - uses an endoscope to visualize the inside of stomach, puncture made through skin, insert tube through puncture - shorter NPO time - has a catheter that has an external bumper - has an internal inflatable rendition balloon to maintain placement

Question 323

complications of G/PEG and J?PEJ tubes

Answer 323

- peristome infection - leakage - accidental tube removal - tube blockage - tube fracture - peritonitis - aspiration pneumonia - bleeding

Question 324

long term feeding tube balloon volume checks

Answer 324

don't check volume for the first 4 weeks after insertion use a slip tip to avoid damage remove all of the old water, measure and discard with a new syringe draw up appropriate amount of water and re-inflate balloon to prescribed level

Question 325

closed feeding systems/ continuous drip

Answer 325

- usually used when pt does not tolerate bolus feeds - 1000 - 1500mL - hang time up to 48 hours - are essential when feeding are administered into the small bowel - tubing change with bag change - usually run using a pump - always start at slow rate and increase as tolerated

Question 326

open system/ bolus or intermittent feed

Answer 326

- used when pt can tolerate - 250mL tetra packs or cans, or dry powder - usually 300 - 500mL given several times per day - given over at least 30mins - must be given only in the stomach - open system bags and tubing need to be rinsed with tap water, drained, and hung to dry following intermittent feeds change bag and tubing, and syringes/bowels/cups every 24 hours change attachments weekly

Question 327

labelling feeding systems

Answer 327

- client info -date and time - initials - enteral feeding formula type, rate, strength, and amount

Question 328

EN formula hang times

Answer 328

tetra pack -> 8 hours reconstituted powder formula -> 4 hours closed system -> 48 hours

Question 329

lab orders for EN

Answer 329

baseline - CBC - lytes - urea -creatinine - random glucose - calcium, phosphorus, magnesium - albumin daily x 3 days - lytes - urea -creatinine - random glucose - phosphorus, magnesium weekly x 3 - CBC - lytes - urea -creatinine - random glucose - calcium, phosphorus, magnesium - albumin

Question 330

rate of EN administration

Answer 330

standard feed 25mL/h, if tolerate increased to 50mL/h after 8 hours referring syndrome risk 25mL/h for minimum of 24 hours do not increase rate until potassium, phosphorus, and magnesium are in normal levels

Question 331

flushing feeding tubes

Answer 331

flush every 4 hours with 50mLs for continuous feeds flush before and after meds with at least 15mL and flush 30mL after all meds flush pre and post bolus feed flush 50mL BID if feeding tube not in use use tap water for routine flushes, and sterile water in immunocompromised pt and babies less than 3 moths

Question 332

J-tubes

Answer 332

do not twist them -> will become twisted and blocked