FINAL EXAM Flashcards
elder speak
infantilizing
message that the receiver is incompetent and dominance of the speaker
results in resistance to care
when to assess VS
admission
order
change in condition
before procedures (so we know baseline before and able to compare after)
medications (meds change vs and we don’t want to push out of normal)
before/after activity
vs are part of what ADPIE
assessment
normal VS
35.8-37.5
60-100
12-20
<120/80
>95%
how to calculate temp
heat produced-heat lost
things that affect temp
circadian rhythm
age
gender
physical activity
environmental temp
primary source of heat production
metabolism
heat loss
skin
sites for temp
rectal, tympanic, temporal, bladder, oral, axillary
who not to take rectal in
heart problems
kids
low WBC
low platelets
probe colors
red-rectal
blue-oral and axillary
interventions for fever
maximize heat loss
minimize heat production
convection
wind/fan blowing
conduction
hot transferred to cold
what to report with pulse
rate/rhytum
amplitude
pulse deficit
difference between apical and peripheral
orthopnea
difficulty breathing laying flat
korokoff sounds
systolic 1
diastolic 5
blood pressure parameters
elevated 120-129/80-89
stage 1 130-139 OR 80-89
stage 2 >140 OR >90
crisis 180 AND/OR 120
factors affecting BP
age
race
circadian rhythum
food intake
exercise
weight
emotional state
body position
drugs
disease process
cig smoking
2 step is for
auscultory gap
where not to take BP
lymphedema, fistula, mastectomy, IV
hypotension
90/60 with symptoms
orthostatic hypotension
20 systolic
10 diastolic
MAP
mean arterial pressure
>60 to perfuse organs
SpO2
amount of hemoglobin saturated with oxygen in arterial blood
abnormal SpO2 in everyone
<85%
FiO2
fraction of inspired oxygen
factors affecting pulse ox for false low
outside light
carbon monoxide
patient motion
jaundice
factors affecting pulse ox high
dark skin
HAI
healthcare associated infections, develop during course of treatment
- CAUTI
- surgical site infection
- vascular catheter infection
- blood stream infection
- pneumonia
nosocomial and predisposing factors
something that originated or occurred inside a hospital setting
- invasive medical devices
- antibiotic resistant organisms
- poor hand hygiene
iatrogenic
something that wasn’t supposed to happen that happened under our care that resulted in infection
infection cycle and how to break
infectious agent
reservoir
portal of exit
means of transmission
portal entry
susceptible host
hand hygiene
what makes someone a susceptible host
intact skin
WBC
splenectomy
age
immunization
nutritional status
drugs
stress
indwelling medical devices
stages of infection
incubation: growing/multiplying
prodromal: most infectious, vague nonspecific signs
full stage: specific signs
convalescent: recovery
types of infection and apperence
local: swelling, heat, redness, loss of function
systematic: increase temp, HR, RR, enlarged lympnodes, confusion in elderly
labs for infection
WBC >10,000
- neutrophils (bands=immature) acute bacterial infection
- bands = >10%
lymphocytes: chronic bacterial, and viral
Eosinophil: parastitic, fungus, allergic
C reactive protein: nonspecific, indicates inflammation
blood borne pathogens/standard precautions/ tier 1
hep b, hep c, HIV
- hand hygiene
- PPE
- safe work practice (never recap dirty needles, cough ettiqute, needless system)
PPE
not sterile
- gloves
- gown
- mask
- goggle
Masks
N95: inhaled air
PPE: exhaled air
never recap what
dirty needles
transmission/tier 2
used in addition to standard
contact: C.diff, MRSA
- indirect and direct
droplet: influenza, pertussis
airborne: COVID, TB, measles, chicken pox
neutropenic
medical asepsis vs surgical asepsis
clean technique: hand hygiene, PPE
surgical: sterile
sterile/surgical asepsis
waist to shoulder
do not turn back on sterile field
allow only other sterile objects to touch eachother
avoid talking, coughing, reaching over sterile field, solutions expire in 24 hours
pour fluids with label in palm of hand
w/o sterile gloves handle outer 1 inch
cleanliness and grooming promotes what and enhances what process
physical, psychological
healing
what does the skin need
nutrition, hydration, circulation
braden scale
sensory perception
moisture
activity
mobility
nutrition
friction and shear
elderly
thinning of subq and dermal layer
decrease activity of glands
longer time window for cell renewal
decrease in collagen fiber
nail changes
first thing to ask patient for AM care
bathroom
goldstandard oral care and unconscious patient and who to do it more in
brushing teeth
put on side with suction
supplemental oxygen, NG tube, meds, infection, mechanical ventilation
types of baths
CHG: reduces pathogens on skin, cumulative affect, bathe first and then CHG
do not use on face and perineal
warming helps activate
bag bath: no rinse, not soap, good for elderly
wipe warmer
yellow: not ready
solid green: ready
blinking green: going to expire
red: expired
purewick
low suction
change Q8
do not use barrier cream (impedes suction)
don’t clean vaginal area with soap, use non rinse cleanser
condom cath
change q24
clean least (head) to most (scrotum) dirty
retract foreskin to clean and then replace
leave 1 inch from penis to end of cath
foley care
good peri care
cleaning 6 inch down tubing
tube must be secured to thigh
green clamp on bed sheets
tubing is off floor
no dependent loops
tubing off floor
bag on non moveable part of bed
when to get mepiplex
<18 braden, red sacrum, history of sacral ulcer, cannot reposition, ICU, older than 65, mechanical ventilation, surgery longer than 4 hours
diabetic foot care
wash in lukewarm water
apply lotion but not in-between toes
file nails straight across
cotton socs
body mechanics
work close
broad base of support
flex knees and straight back
strong core
low center of gravity
use legs
weight limit
35lbs
no manual lift laws
have lift machines in each hospital
movement exclusion
physiologically unstable: hypotension, uncontrolled blood sugar, Brady/tachy cardiac
ekg changes/ cardiac enzymes
INR and PTT
doesn’t respond to verbal stimuli
spinal trauma
positioning
fowlers: 45-60
semi fowlers: 30
low fowlers: 15
high fowlers: 90
orthopedic: 90 and laying on table
prone: COVID perfusion
lateral side lying: protect bony prominences
sims: laying flat/side
lithotomy: legs in stirups
protection
hand rolls: protect from contractures
trochanter rolls: protect from external rotation
log rolling: keep spine, neck, align
boots: protect from plantar flexion and pressure
when moving ask patient to
cross arms and put knees up and push
one nurse assist
stand on weak side
cane
hold on strong side
advance cane
advance weak leg
advance strong leg
oxygenation and ventilation
oxygenation: ability to transport gases
ventilation: ability to transport air
meds and lifestyle that affect pulmonary
opioids: depress
obesity: hypoventilator
smoking: vasoontrictor
smoking
pack year
adventitious sounds
wheeze: narrow airway, high pitch, asthma and obstruction, TX: bronchodilator and removal
crackle: discontinuous, TX: diuretics, chest perfusion, fluid in alveoli, collapsed alveoli
rhonci: course continuous, increase secretions in larger airways, TX: suction or 3 small cough and 1 big cough
noninvasive ways to assess pulmonary
pulse ox:
oxygenation, arterial hemoglobin saturation, continuous <90%
CXR
PFT
invasive pulmonary assessment
arterial blood gas analysis: used in code, assess oxygenation and ventilation
bronchoscopy
PaO2 and SpO2 numbers
PaO2 SpO2
40%. 70%
50%. 80%
60%. 90%
80%. 95%
nursing interventions for pulmonary
position: up
pursed lip breathing: exhalation longer than inhalation
fluids losen secretions
humidify over 3L
SMILLE
who to do pulmonary toilet and who to not
don’t: osteoporosis, broken rib, surgical scars
do: atelectasis, pneumonia, cystic fibrosis
meds
suppressants: non productive
expectorant: productive
bronchodilator: tachycardia
corticosteroids: reduce inflamation
3 develiver
nebulizer: fine particles, med gets into deeper passages
MID: controlled dose, spacer, inhale when releasing, rinse after steroid could cause thrush
dry powder: activated by pateint inspiration
nasal canula percent in L and FiO2
RA: 21%
1L: 24%
2L: 28%
3L: 32%
4L: 36%
5L: 40%
6L: 44%
high flow NC percents
10L: 60%
15L: 80%
20L 90%
30L: 98%
venturi mask percent
24-40%
nonrebreather percent
80-100%
set on full flow, % depends on patient depth and rate
oxygen and air color
oxygen=green
air= yellow
drug kidney and liver
liver is metabolized
kidney is excreted
adverse effect vs allegric effect
adverse is a side effect (ex: opioid causes consitipation, normally causes it in a lot of people)
allergic reaction
- mild
- anaphylactic
individual for the patient
idiosyncratic
opposite effect of anticipated affect
drug ranges
therapeutic range: concentration in blood that produces the desired effect
peak: point when drug is at highest (60 min after given)
trough: point when drug is lowest concentration, indicates the rate of elimination (60 min before next dose)
half life: amount of time it takes for 50% of blood concentration of a drug to be eliminated from body
aging adult with meds
decreased gastric motility: meds stay in gastric region longer, increased N/V and aspiration
decreased total water and lipid content: absorption, exaggerated reation
kidney/liver: wont be metabolized excreted, can result in cumulative affect
altered peripheral vascular tone: extemely reactive to anti hypertensive= orthostatic hypotension
5 rights
pt, drug, time, route, med
orders
verbal: mandatory write down and read back
standing: written in chart, stand until discontinoued
PRN: as needed
STAT: immediately
one: one dose only
2 pt identifiers
name
birthday
medical record number
late meds
more frequently Q6/rapid short acting insulin: 30 mins within time
Q6 or less: 60 mins
daily/weekly/monthly: 2 hours
half time
late dose can be giver up to half way to next scheduled dose and continue with the schedule
given later than halfway between doses give the med, skip next dose and resume schedule
what not to cut/ crush
SR: sustained release
XL: extended released
CR: controlled release
Enteric coated: special coating to decrease gastric irritation, med released in small intestine
eye drops
aim for conjunctival sac
tell pt to look up
put tissue pressure over inner corner to prevent med from leaking down
direct and indirect syringe contaimination
direct: use of same syringe for more than 1 patient
indirect: accessing vials with used syringe followed by reuse of the vial
