Final Exam Flashcards
Infiltration
=leakage of non-vesicant solution into surrounding tissues
-stop infusion, remove site, elevate extremity, cold/warm compress
Extravasation
=leaking of vesicant solution
-stop infusion, surgical intervention may be necessary
Phlebitis
=inflammation of the vein
-remove site, heat, and elevate extremity
Site Infection
=infection at the insertion point, port pocket, or subq tunnel
-clean site, remove cath, send for culture, cover with a dry sterile dressing
PICC vs. PIV- techniques for use and care
PICC=10mL barrel syringes only, contrast injection-power PICC only
PIV=3mL-10mL flush
-avoid joint flexion, choose most distal site, avoid the dominant side, do NOT use the side of mastectomy, AV fistula, lymph nose dissection or paralysis, limit unsuccessful attempts to 2 per clinician
Fluid Imbalances- care of a patient with fluid overload
- Airways, breathing, circulation, stop fluid infusions -
Ensure patient safety, restore normal fluid balance, Provide supportive care,
Prevent future fluid overload
Hypokalemia
-weak thready pulse
-Ortho hypo
-shallow resp
-anxiety, lethargy, confusion, coma
-paresthesias
-hyporeflexia
-hypoactive bowel sounds
Hyperkalemia
-tight and contracted
-muscle cramping and weakness
-urine abnormalities
-resp depression
-decreased cardiac contractility (low HR, BP)
-increased DTR
Hypernatremia
-big and bloated
-flushed skin
-restlessness, anxiety, confusion, irritable
-increased BP and fluid retention
-edema (pitting)
-decreased urine output
-skin flushed and dry
-agitation
-low-grade fever
-thirst
Hypocalcemia
-Convulsions
-arrhythmias
-tetany
-spasms and stridor
-Positive trousseau’s and chvostek’s
Fluid and Electrolyte Imbalances- Laboratory Values Associated with Dehydration
-high H&H
-high BUN
-high urine specific gravity
-high sodium
-high glucose
-high protein
ABG Interpretation – Respiratory Insufficiency
pH <7.35 PaCO2 > 45mmHg
-Respiratory acidosis: increasingly difficult breathing, dyspnea, weakness, dizziness, sleepiness, change in alertness
ABG – Indication of Metabolic Acidosis
-pH < 7.35 HCO3 < 21mEq/L
-weakness, lethargy, confusion, headache, stupor/unconsciousness, coma or death
Right-sided Heart Failure- Assessment Findings
- peripheral edema, distended jugular veins, distended abdomen, enlarged liver and spleen (hepatomegaly), polyuria at night
Left-sided Heart Failure- Assessment Findings
-SOB, pulmonary edema, pink frothy sputum, crackles or wheezing, fluid in lungs, S3/S4 summation gallop, tachypnea, confusion/dizziness, oliguria during day
Heart Failure- Loop Diuretics and Adverse Effects
Hypokalemia
Heart Failure- Digoxin and Adverse Effects
-Digoxin= lowers BPand heart rate
-Adverse effects= fatigue, bradycardia, anorexia, N/V, dysrhythmias, digoxin toxicity (>2ng/mL), GI distress, CNS effects
Right-sided Heart Failure- Nursing Actions
-daily weight @ same time each day
Heart Failure- Patient Education
-low sodium diet, low fat, take medications as prescribed, take breaks when exercising, be able to hold a conversation while exercising
Left-sided Heart Failure: Manifestations and Risk Factors
Manifestations
-dyspnea (exertional dyspnea, paroxysmal nocturnal dyspnea)
-fatigue
-weakness
-arm heaviness
-chest pain or palpations, skipped beats, fast rate
Risk Factors
-hypertension
-coronary artery disease
-valvular disease
MI- Interventions (consider medication management)
-M-morphine
-O-oxygen
-N-nitroglycerin
-A-aspirin
Angina- Teaching about Sublingual Nitroglycerin
-3 tabs max every 5 minutes until chest pain is absent
MI- Diagnostic Testing
-EKG
-troponin t and I value (normal 0-0.04ng.mL >0.04 for MI)
Coronary Artery Bypass Graft Surgery- Psychosocial Integrity- Relieving Patient’s Anxiety
-statement patient makes ab being anxious, have to pick response
Angina and MI- Purpose of Cardiac Enzyme Studies
-to help healthcare providers know if symptoms are due to a heart attack, angina, heart failure, or another problem
Patient and Family teaching about Heparin
-s/s of bleeding should be reported immediately
PAD vs PVD- plan of care
PAD
-promote vasodilation (maintain warm environment, wear socks and avoid cold when possible, avoid caffeine and nicotine-cause vasoconstriction)
-encourage appropriate positioning (do NOT cross legs, refrain from wearing restrictive garments, cautiously elevate extremities
-dangle legs
PVD
-encourage ambulation after anticoagulation therapy is initiated, warm moist compress, do NOT massage affected limb
-elevate legs
-avoid crossing legs
-elevate legs for 20min, 4-5/day
-elevate legs above heart when in bed
Hypertension- Medications used for Drug Therapy, consider the effectiveness of drug therapy
-Diuretics
-Calcium Channel Blockers
-ACE inhibitors
-Angiotensin II receptor blockers (ARBs)
-Beta-adrenergic blockers
Deep Vein Thrombosis (DVT)
Drug Therapy, Heparin, and Coumadin
Diabetes- Criteria for Diagnosis
A1C
Hypoglycemia vs Hyperglycemia- Clinical Manifestations
Hypoglycemia
-Skin: Cool, Clammy, sweaty
-Dehydration: absent
-Respirations: No particular or consistent change
-Mental status: anxious, nervous, irritable, mental confusion, seizure, coma
-Symptoms: weakness, double vision, blurred vision, hunger, tachycardia, palpitations
Hyperglycemia
-extreme thirst (polydipsia)
-frequent urination (polyuria)
-hunger (polyphagia)
-dry skin
-blurred vision
-drowsiness
-decreased healing
Insulin Administration- Technique for Administering
-clean with alcohol, scrub the hub, Administer SQ, 2 inches for the umbilicus, rotate injection site
Insulin Administration- Sliding Scale
-know how to use
-match the glucose # to number on the sliding scale to know the amount of insulin to administer
Preventing Complications – Labs (peri-op)
-WBC
-H & H low (indicates bleeding)
-Ptt
-INR
-platelet
Surgical Classifications – Elective, Urgent, Emergent
Elective =planned for correction of a nonacute problem (ex. cataract removal, hernia repair)
Urgent= requires prompt intervention, potentially life-threatening if delayed more than 24-48 hours (ex intestinal obstruction, bone fracture)
Emergent= requires immediate intervention, life-threatening consequences (ex gunshot/ stab, severe bleeding, appendectomy)
Informed Consent
-review consent
-verify and clarifies facts
-confirms consent is signed, dated, and times
-may serve as a witness
Stage 1 Pressure Injury- Assessment Findings
-intact skin with localized area of non-blanchable erythema
-may be precede by changes in sensation, temp, or firmness
-color changes are not purple or maroon
Stage 2 Pressure Injury- Assessment Findings
-partial-thickness loss of skin with exposed dermis
-wound bed is visible, pink, or red and moist
-may look like intact or ruptured serum-filled blister
Risk for a Pressure Injury- Nursing Actions
-Determine Risk Level (Braden score)
-Reduce pressure
-Improve pressure tolerance
Pressure Injury- Description for Stages 1-4, Unstageable, DTI
stage 1: intact skin with localized area of non-blanchable erythema
stage 2: partial thickness loss of skin with the exposed dermis, wound bed pink/red/ moist
stage 3: full thickness skin loss with adipose visible in the ulcer, slough, or eschar may be present, undermining and tunneling may be present
stage 4: full-thickness skin loss with exposed or palpable fascia, muscle, tendon, ligaments, cartilage, or bone, may have slough, eschar, undermining, tunneling
unstageable: full thickness covered by eschar or necrotic tissue
DTI: unstageable with suspected deep tissue injury
Non Healing Pressure Injury- Nursing Action
-adjuvant therapies
-electrical stimulation
-therapeutic ultrasound
-negative-pressure wound therapy (NPWT)
-hyperbaric oxygen
Pressure Injury- Patient with Greatest Risk
-low braden score
-older adults
-incontinect patients, excessive moisture
-not being turned
Pressure Injury- Lab Assessment
-elevated WBC (4000-11000)
-positive blood cultures
COPD- Plan of Care- Hydration
drug therapy, airway maintenance, monitoring, breathing techniques, positioning, effective coughing, oxygen therapy, exercise condition, suctioning, and hydration
Pulmonary Embolism- Medication Management
-Heparin: anticoagulant
Pulmonary Embolism – Interventions
Manage hypoxemia
-apply oxygen, elevate HOP, and reassure the patient
-oxygen therapy
-monitor the patient for changes in status
-administer anticoagulation or fibrinolytic therapy
Managing hypotension
-IV fluid therapy used (using crystalloid solutions) to restore plasma volume and prevent shock
-drug therapy with vasopressors (norepinephrine, epinephrine, or dopamine) used if fluid therapy does not help
Controlling bleeding
-assess for evidence of bleeding, ensure correct dosing and timing of medication, monitor lab values
Minimizing anxiety
-patient with PE struggles with anxiety, fear and pain
-maintain proper communication with your patients
-anti-anxiety medication
-pain management
Asthma Attack- Medication Therapy
-Albuterol inhaler
Pneumonia- Assessment Criteria
-General appearance- assess for flushed cheeks, anxious look, chest pain/discomfort, myalgia, headache, chills, fever, cough, tachycardia, dyspnea, hemoptysis (bloody sputum), sputum production
-Respiratory assessment- breathing pattern, use of accessory muscles, positioning, cough, sputum assessment, lung sounds (such as crackers)
-Vital signs- increased resp rate, hypotension, tachycardia
-Dysrhythmias
Oxygen Therapy- Tasks to Delegate to a PCA related to oxygen therapy
-measure pt pulse ox
-positioning (elevate HOB)
-keeping nairs moist
Chronic Kidney Disease- Interpreting Lab Values
-reduced GFR <60
-BUN increases >20, urine output decreases
Acute Kidney Injury- Interpreting Lab Values
-increase in serum creatinine by 0.3mg/dL or more within 48 hours
-increase serum creatinine to 1.5 times or more occurring in the previous 7 days
Chronic Kidney Disease- Assessing fluid volume increase
-daily weight
-fluid restriction
-fluid overload due to the inability of disease kidneys to maintain body fluid balance
Know the difference between Types of Incontinence
Stress= when urine leaks out at times when your bladder is under pressure (cough of laugh)
Urge= when urine leaks as you feel a sudden, intense urge to pee, or soon afterward
Mixed=stress and urge incontinence
Overflow (reflex)= when you’re unable to fully empty your bladder, which causes frequent leaking
Functional= leakage of urine caused by factors other than disease of the lower urinary tract
Urinary Incontinence- Interventions for Preventing Skin Breakdown
-chech regulary, keep skin dry
-barrier cream
-changing and cleaning after an incontinet episode
-checking for skin breakdown
Urolithiasis- Interventions
-high fluid intake (3L/day or more)
-accurate measurement of I/O’s
-drug therapy
-nutrition therapy/ diet modification
Cystitis- Interventions
Nonsurgical
-drug therapy
-fluid intake
-comfort measures such as pain relief
-no cranberry juice, no spices, soy, tomato, caffeinated drinks, alcohol
Bladder Cancer- Risk Factors
-GREATEST RISK FACTOR Tobacco use
-exposure to toxins such as gasoline and diesel fuel, chemicals used in hair dyes and in rubber paint, electric cable, and textile industries
-family history, Schistosoma haematobium (a parasite) infection, excessive use of drugs containing phenacetin, and long-term use of cyclophosphamide
Peptic Ulcer Disease- Complications
-Hematemesis
Hemorrhage
-occurs more often in patients with gastric ulcers and in older adults
-patients have a second episode of bleeding if underlying infection with H. Pylori remains untreated or if therapy does not include H2 antagonist
-massive bleeding = vomiting bright red or coffee-ground blood
-minimal bleeding from ulcers = minimal occult bleeding in a dark “tarry” stool, melena may occur with gastric ulcers, more common with duodenal ulcers
Perforation
-occurs when the ulcer becomes so deep that the entire thickness of the stomach or duodenum is worn away
-the stomach or duodenal contents can then leak into the peritoneal cavity
-patients can experience sudden, and sharp pain, peritonitis infection, severe illness within hours, bacterial septicemia and hypovolemic shock, paralytic ileus
Pyloric obstruction
-vomiting caused by stasis and gastric dilation
-symptoms of obstruction include abdominal bloating, nausea, and vomiting
Intractable disease
-ulcers, excessive stressors in the pt life, or an inability to adhere to long-term therapy
Gastrointestinal Perforation- Assessment Findings
-board-like/rigid abdomen
-abdomen pain
Ulcerative Colitis- Assessment findings and Interventions for Acute Exacerbation
-manage diarrhea
-consider nutritional therapy and rest
-drug therapy (aminosalicylates, glucocorticoids, antidiarrheal drugs, and immunomodulatory)
-complementary and integrative health (herbs (flaxseed), selenium, and vitamin C)
Inflammatory Bowel Disease- Manifestations of Ulcerative Colitis
-low grade fever
-abd distention along the colon
-assess for signs and symptoms associated with extraintestinal complications, such as inflamed joints and lesions inside mouth
-usually findings are nonspecific
Ulcerative Colitis- Managing Skin Integrity
-barrier cream
Crohn’s Disease- Recommended Diet
-bowel rest and nutrition support with TPN, nutritional supplements, avoid caffeine and alcohol
-bland food: toast, banana
Acute Gastritis- Patient Teaching
-avoid caffeine, highly acidic foods, spicy foods
Cirrhosis- Client Teaching for Lactulose
-will be pooping 2-3 times a day
-used to reduce the amount of ammonia in the blood of patients with liver disease
Cirrhosis and Ascites- Plan of Care
-Go on a low-sodium diet
Chronic Cholecystitis- Dietary Teaching
-high-fat diet puts pt at risk
-avoid fatty foods, withhold food and fluid if nausea and vomiting occur
Chronic Cholecystitis- Assessment Findings
-persistent recurrent RUQ pain
-afebrile; may have localized tenderness over a palpable gallbladder
Acute Pancreatitis- Lab Findings
-serum amylase elevated
-Lipase elevates
serum bilirubin and alkaline phosphatase elevated
-ALT
-WBC
-ERS
Pancreatitis- Appropriate Diet
-bland diet= chicken, rice, pasta
-foods high in carb and protein assist in the healing process, avoid foods high in fat because it causes or increases diarrhea
-avoid caffeine and alcohol
Colostomy- Assessment Findings, Normal and Abnormal
-healthy: red, beefy, moist, shouldn’t be painful
-unhealthy: purple/ pale blue, dry
-avoid lifting heavy objects, or straining on defecation to prevent tension on the anastomosis site
-avoid drinking and extreme physical activity for 4-6 weeks while the incision heals
Osteomyelitis – Interventions and Treatment (include considerations of medication)
Nonsurgical
-4-6 weeks of antimicrobial therapy
-contact precautions with wound drainage
-treatment for MRSA infection- IV vancomycin, linezoid
-irrigate wound with antimicrobial solution
-drug therapy for acute and chronic pain (opioid)
-administer hyperbaric oxygen (HBO) therapy=wound healing
Surgical
-surgical techniques include incision and drainage of skin and subcutaneous infection, wound debridement, and bone excision
-sequestrectomy- removes the necrotic bone and allows revascularization of tissue
-bone grafts to repair bone defects
-microvascular bone transfers or bone graft from donor bone
Amputation – Pain Management
-IV infusions of calcitonin during the week after amputation can reduce phantom leg pain
-other pain management modalities may be used for pain management
Fractures - Traction and purpose of traction
-Buck’s traction=for hip fracture
-the application of a pulling force to part of the body to provide bone reduction or as a last resort to decrease muscle spasm (thus REDUCING PAIN)
Osteoarthritis – Interventions and Treatment
-Tylenol primary drug of choice
-topical for temporary relief of mild pian
-do not take more than 4000mg a day (weight over 150lbs)
-ketorolac, ibuprofen, Celebres
-tramadol
Rheumatoid Arthritis – Diagnosis (Consider Lab Values)
-RF(rheumatoid factor=measures unusual antibodies)
-Anti-CCP (detects early RF)
-ANA (determines the cause of tissue death)
-ESR
-hsCRP
