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
intradermal parameters
degree: 5-15
inch: 1/4-1/2
gauge: 25, 27
max amount: 0.5mL
no aspiration/massage
subq parameters
degree: 45-90
inch: 3/8-5/8
gauge: 25-30
max volume: 1mL
pinch on people with decrease subq and release before injection
no massage/aspiration
rotate sites
sites: backs of arm, abdomen, fronts of thighs, above butt, scapular region
IM
degree: 90
Inch: 5/8-1 1/2
gauge: 20-25
max volume: 3mL, 1mL in deltoid
sites: deltoid, ventral gluteal, vastus lateralis
Z track: pull skin to side to avoid med uptake
pressure no massage
no aspiration
3 big safety errors
med error
falls
improper use of restraints
QSEN
IOM
TJC
= safety of clinical excellence
sen: quality and safety of education of nurses
IOM: institute meds
TJC: the joint commission
QSEN competencies
patient centered care
teamwork and collaboration
EBP
quality improvement
informatics
safety
3 healthcare failures
failure to recognize, rescue, plan
fire safety
r: resuce
A: activate
C: confine
E: evacuate
3 med errors
omission: missed/didnt do something (most common student)
communication
commission: did something wrong
what increases fall risk
females
>65
history of falls
cognitive impairment
altered gait
meds
incontinice
unsafe environment
sensory deficit
orthostatic hypotension
depression
assistive devices
confusion
new environment
most falls are released to
toilet
restraints recommended use
physical safety and prevent interruption of therapy
exceptions to half time rule
aminoglycosides and chemo
hazards to restraints
impaired circulation
altered skin integrity
altered nutrition/hydration
aspiration
incontience
depression
anxiety
death
do restraints decrease fall risk
no
non violent and violent checks
non voilent: visual, physical comfort, circulation= Q2
violent: visual, physical comfort, circulation= 15 min
ROM/fluid: 2 hours
food: 4 hours
clinical vs critical thinking
critical: mental process of recognizing, analyzing, applying and evaluating information
clinical: critical thinking in clinical setting
ADPIE
assessment
diagnosis
planning
intervention
evaluation
assessments
initial:
- admission: 8 hours of admission, baseline for hospitalization
shift: beginning of shift, baseline for day
focused: one system, not planned return
time lapsed: purposefully come back after certain time to assess
diagnosis
clinical judgment about an individual responses to actual or potential health problems
problem
etiology
defining characteristics
problem RT evidence AEB defining characteristics
problem drives outcome
etiology drives nursing interventions
maslows
physiologic
safety
love
self esteem
self actualization
outcomes
cognitive: increase knowledge (EX: teaching)
psychomotor: new skill (EX: show us what was taught)
affective: change values, beliefs, attitudes (anti vax)
physiologic: physical changes
direct future care
terminate: plan of care when expected outcome is achieved
modify: if difficulties arise
continue: need more time
never events
stage 3-4 injury
falls
trauma
surgical site infection
vascular catheter associated infection
CAUTI
administration of wrong blood
wound types
closed/open
clean: surgical
dirty: pressure
incision
contusion
abrasion
puncture
laceration
incision: edges well approximated, no gapping
contusion: bruise
abrasion: rug burn
puncture: IV
laceration: injury to skin or soft tissue resulting in tearing of tissue
classification
partical thickness: epidermis/dermis
full thickness: subq muscle
acute: heals in expected time
chronic: extended time to heal
intentional: surgery
unintentional: trauma
normal healing requires
circulation
nutrition
hydration
clean environment
ability to heal depends on the extent of the
wound and persons general health
intentions
primary, secondary, tertiary
primary: edges well approximated, clean cut, closed by stapes or stitches
secondary: edges are not approximated, tissue loss, scarring, increase risk of infection since left open, wound builds up from base
tertiary: wounds left open for 3-5 days and then closed with sutures, allows drainage
phases of healing
hemostasis: immediately, clot formation
inflammatory: wound redness, swelling, pain, macrophages enter wound, up to 4 days
proliferation: new capillaries and epithelial cells, 4-21 days
remolding: structure wound remodels, scar forms, collagen remodels
exudate
serous: plasma, clear, yellowish
sanguineous: blood
- bright: fresh bleeding
- dark: older
serosanguineous: pink, blood and plasma
purulent: pus, green, yellow, brown, indicates pathogens (indicate color when charting)
complication of wounds
biofilms: inhibits wound healing, chronic wound inflammation and infection, CAUTI
hemorrhage: bleeding, hemostatisis didn’t occur
dehiscence: rip open to muscle
eviseration: rip through muscle, organs visible
fistula: 2 things connected that aren’t supposed to be
psychological effects: body image
nutrition affecting wind healing
vit a, c, copper, iron, zinc
desiccation
dry skin
maceration
pruning of skin
RYB color code
red= protect
yellow= clean
black=debride
albumin and prealbumin
albumin: protein 6 wks ago
pre albumin: now
lavine method
clean wound first
Z shape on wound
drains
Penrose: passive, not sutured in
JP: active
Hemovac: active
cold vs hot
cold: initial, decreases blood flow, decreased cellular metabolism
hot: few days after, increases blood flow, increase cellular metabolism
3 ways to debride
surgical: cut out
chemical: dakins bleach solution on dressing
mechanical: 4x4 gauze wet to dry
mepliex
waterproof, 7 days, never use for infection, prevents friction and sheer
what is always safe to use in wounds
.9NS
silvadine cream
hydrogel
silvadine cream: antibacterial, burns
hydrogel: water goop, pink granulation
pressure and time for pressure injury
30 mmHg over 2 hours
shear
inner and outer layer separate
risk factors for pressure injury
age
immobility
moisture
nutrition/hydration
previous pressure injury
diseases affecting blood flow
slough
nectroic tissue that is moist, stringy, yellow/grey
eschar
devitalized dermis that has become leathery or thick and black
undermining
area of ulcer beneath the skin that extends under edge of wound
tunneling
narrow extensions into surrounding tissue from slides of ulcer
stage 1 pressure injury
partical thickness
intact skin
non blanch able redness
protect from moisture, pressure, further injury
stage 2 pressure injury
partical thickness
exposed dermis
red/pink
open ruptured blister
stage 3
full thickness
subq visible
epibole
slough and eschar
undermining and tunneling
stage 4
full thickness
exposed bone, ligament, tendon, muscle
slough and eschar
undermining and tunneling
epibole
unstageable
full thickness= 3 and 4
base is predominately covered by eschar/slough
deep tissue
purple maroon
discolored intact skin
blood filled blister
due to damage of underlying soft tissue from pressure/shear
stage is named by what even when healing
highest stage (EX: healing stage 3)
underweight
normal
overweight
BMI
under: <18.5
normal: 18.5-24.9
overweight: >25
alcohol inhibits vit B absorption
decrease B12
diets
NPO: nothing by mouth
clear liquid: yellow, clear at room temp
full liquid: milk
free water: increase water
NG tube
aspiration, swallow fine but need more nutrients, decompress stomach
LIS: low intermittent suction so you don’t damage mucosa
when to not aspirate tube
J tube
feeding
bolus: all at once
gravity: hold up and let gravity do it
continuous
signs pt is not tolerating
cramping, gas, diarrhea, pain, bloating, N/V, increase residual
gold standard for checking patient
gold standard
HOB for feeding
30-45
when to flush
Q4
before, between, after meds
before, after bolus feeding
before after residuals
how to flush, what syringe
> 30mL syringe
30mL warm sterile water
how to unclog a tube
activated pancreatic enzymes to unclog
activate with sodium bicarb
minimum urine production
30mL
fluid intake
2-3L
post void residual
normal is less than 50mL
urinary retention: >150
UA
urine analysis
gross: WBC, RBC, sugar, protein
10mL
urine culture sensitivity
3mL
sterile
CCMS
peri care
start
stop
start=colllect
stop
finish
lab value for urine
BUN
8-23
blood urea nitrogen
creatine
0.6-1.2
GFR
>60
incontinence
stress: weak pelvic floor and or deficient urethral spinchter, loss of urine during increased abdominal pressure (kegal)
urge: involuntary loss of urine that occurs soon after feeling an urgent need to void (bladder training)
overflow: chronic retention of urine (kegal)
functional: inability to reach toilet (bladder training)
reflex: spinal cord injuries emptying with no signal (bladder training)
urinary diversions
ileal conduit: urter illium bag
uretostomy: urter to surface
neobladder: small intestine to make fake bladder
UTI
dysuria, frequency, cloudy urine with foul odor, back pain
urine analysis/urine culture
increase temp
increase WBC
change in LOC
increase risk of UTI
females
age
indwelling caths
diabetics
urinary retention meds
anticholinergics, tricyclic antidepresants, calcium channel blockers, narcotics, anesthetics
catheters
straight: intermitten
indwelling: stays in
suprapubic
foley care
clean clean to dirty
6 inch down tube
keep off floor
secure to thigh
green clip on bed
no dependent loops
never higher than bladder
pure wick change and suction
8hr
low suction
parts of catheter
drain, ballon, bifurcation, ballon port, seal, specimen port, clamp,
fiber amount
25-30
stool culture and sensitivity
1 inch/15-30mL
occult blood/guaiac
blood that cannot be seen
no red meat diet before
what do we want to give after barium and contrast
fluids and laxatives bc it hardens
impaction
hard and immovable
upper GI: fluid/water as a bowel movement
can cause urinary incontinence
can be in all parts of bowel
laxative
irritates bowel lining to get peristalsis
treatment for impaction
disimpaction: rectum only, double glove, lubrication
enema: left side lying, room temp. lubricate tube, assess for perforation
enema
tap, NS, soap suds, lactulose, kaexelate, oil retention
signs and symptoms of perforation
abdominal pain, rectal pain and bleeding, back pain, fever,
bowel diversion
sigmoid: formed
descending: formed
transverse: pastey
ascending: liquid
ileostomy: total liquid
colorectal cancer
ribbon like stool
changes in habits
blood in stool
constant need to evaluate bowels
weakness and fatigue
cramping/adbmoinal pain
weight loss
3 phases of periop
pre
intra
post
urgency, risk and purpose of bowel
elective: scheduled
urgent: perform soon
emergency: stat
increase risk the longer the surgery is
diagnostic: not curative, find out what’s wrong
ablative: organ removal
palliative: reduce intensity
reconstructive: restore function
transplantation: organ
ambulatory surgery
stay at home night before
elderly woundnt be good candidate
preop
screening and teaching
intraop
safety monitoring
anesthesia
general: LOC, analegsia, relaxation, loss of reflexes, amnesia
greatest risk
regional: analgesia, relaxation, loss of reflexes, below site of injection
conscious: analgesic, relaxation, loss of reflexes, amnesia
topical: analgesia
malignant hyperthermia
autosomal dominant
dantrolene
post op
assessment and prevention
vitals post op
Q15x4
Q30x4
Q1x4
Q4x4
sickle cell
fluids, oxygen, pain meds
process of pain
transduction: activation of pain receptors
- nociceptors: peripheral pain receptors
transmission: impuse travling up spinal cord to higher center
perception: awareness of characteristics of pain
modulation: inhibition or modification of pain
threshold vs tolerance
threshold: lowest intensity of stimulus that causes you to recognize pain
- same in everyone
tolerance: greatest level of pain that a subject is able to endure
- different
gate control
relationship between pain and meds
determines impulse that reach the brain
blocks pain receptors from reaching brain
acute vs chronic pain
acute: heals with the cause
chronic: pain lasts beyond normal healing
responses to pain
physiologic: pulse BP, HR
behavioral: voluntary, protecting, grimacing
affective: psychological, pain causes… fear, anger, depression
when assessing pain also assess
sedation
somatic feeling
aching, deep, dull, gnawing, throbbing, sharp, stabbing
visceral feeling
cramping, squeezing, pressure, referred
neuropathic
burning, numbness, radiation, shooting, tingling, touch
referred pain
pain perceived at another location other than site of painful stimulus
atractable sigh
severe constant, relentless, debilitating, incurable, early death
3 step ladder
- nonopoiid and adjuvant
- opioid, nonopoid and adjuvant
- increase dose and frequency
goal: freedom from pain
opoids:
morphine: gold standard, N/V, itch, decrease reps
codeine: stomach issues
hydromorphone: delauded
methadone: dolphins
fentnyal: 12 hours to activate, 8-10x stronger than morphine
breakthrough pain
flare up of moderate-severe pain that occurs in-between around the clock meds
physical dependence
body physiologically adapts to presence and suffers withdraws
psycholigcla dependence
addiction
craving
need for effects other than pain
tolerance
need larger dose to reach and maintain analgesic levek
sleep vs rest
rest: decrease state of decreased activity and result is feeling refreshed
sleep: altered LOC state of rest and relative inactivity
NREM
non rapid eye movement
1. transition stage between wakefulness and sleep, very light sleep
2. light sleep, easily aroused 50%, go in and out of REM through this stage
3. deep sleep
4 deep sleep (delta sleep)
REM
dreaming
5-45 mins
20-25% of nightly sleep
increase pulse, blood pressure, metabolic rate, body temp
decrease skeletal muscle tone, deep tendon reflexes
deep sleep
growth, physical renewal, hormonal regulation
REM
storing memories, learning mood
illness affecting sleep
GERD: increase gastric secretions in REM
coronary artery disease: increase angina in REM
epilepsy: increase seizers in NREM
liver failure: total disruption
end stage renal: day time sleep
insomnia
difficulty falling asleep, intermitten sleep early wakefulness, >60yo, post menopause, depression, meds (antihypertensive, ADD, cold and allergy)
narcolepsy
cataplexy
sudden loss of muscle tone
what is an example of direct transmission
contact and droplet
what is an example of indirect transmission
airborne
vehicle bound (fomites)
PPE donning and doffing order
hand hygiene, gown, mask/respirator, goggles, gloves
gloves, goggles, gown, mask respirator, hand hygiene
research practice gap
we have the evidence but is not implemented into practice
goals of EBP
Reduce variations in care
Achieve clinical excellence
Promote effective interventions
Provide nurses with the best EBP
Assist with clinical decision making
informed consent
Right not to be harmed
Right to full disclosure
Right to self determination
Right to privacy
EBP is surrounded by
Evidence
Clinical expertise
Patient/family preferences and values
sentinle event
Suicide in a staffed setting or in 72 hours of discharge
Unanticipated death of a full-term infant
Discharge of an infant to the wrong family
Abduction of any patient receiving care, treatment, or services
how to promote safe culture
Leadership - everyone should feel safe to speak up
Human factors - teamwork & communication
Reliability - policies & procedures
ISBAR
Introduction - of yourself
Situation - 5-10 seconds
Background - how did we get here
Assessment - what do you think the problem is
recommendations - what you think needs to be done
pre albumin
15-35
albumin
<3.5
