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Semester 2 > Final Exam > Flashcards

Final Exam Flashcards

1
Q

CN I

A

Olfactory - smell

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2
Q

CN III

A

Oculomotor - upper eyelid movement (upper movement, down and out angle, and inward)

Test: EOM

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3
Q

CN IV

A

Trochlear - eye movement downward angle to nose

Test: EOM

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4
Q

CN V

A

Trigeminal - sensation of face and motor

Test: have pt clench their jaw and assess for strength, tenderness, and superficial pain sensation

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5
Q

CN VI

A

Abducens - move eyes laterally towards ear

Test: EOM

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6
Q

CN VII

A

Facial - facial expression, lacrimation, taste of anterior 2.3 of tongue

Test: smile, wrinkle forehead, puff out cheeks

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7
Q

CN VIII

A

Vestibulocochlear aka acoustic - transmits sounds to brain and responsible for balance/equilibrium

Test: whisper in one ear and have pt repeat (auditory) and rhombergs test (balance)

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8
Q

CN IX

A

Glossopharyngeal - posterior 1/3 taste

Test: gag reflex

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9
Q

CN X

A

Vagal - muscles of larynx and pharynx, taste from tongue to epiglottis

Test: gag reflex

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10
Q

CN XI

A

Accessory - torticollis (twisting neck)

Test: shrug shoulders and turn head side-to-side

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11
Q

CN XII

A

Hypoglossal - tongue movement side-to-side

Test: stick tongue out and move side-to-side

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12
Q

Pupil accommodation (what nerves are involved and how do you test it?)

A

CN II & III - start with light by nose and pull it away
Distance = dilate
Close = constrict

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13
Q

Corneal reflex (what nerves are involved and how do you test it?)

A

CN V & VII - test blink reflex by stimulating the eye

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14
Q

How should the ears be aligned?

A

Top of ear should be at or above the outer canthus of the eye (if lower, consider fxn of kidneys b/c of time of development)

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15
Q

What should the tympanic membrane look like?

A

Shiny, grey, translucent

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16
Q

How should light reflect on the tympanic membrane?

A

@ 5 o’clock on the right

@ 7 o’clock on the left

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17
Q

What are the CNs of the ear?

A

VIII - acoustic

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18
Q

What does the Rhombergs test assess for?

A

Test equilibrium and assess for any ataxia (or loss of motor coordination)

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19
Q

Ptosis

A

Drooping of the upper eyelid

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20
Q

Exopthalomus

A

Bulging of the eyes r/t hyperthyroidism

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21
Q

Xanthelasma

A

Yellow pre-orbital lesions r/t lipid disorder (hypercholesteremia)
Most common in F >50

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22
Q

EOM (nerves responsible, cardinal movements, concerns, and balance)

A

CN III, IV, VI
6 cardinal movements - up and out, up and in, abduction, adduction, down and out, down and in
Strabismus
Test balance with corneal light reflex (light should reflect symmetrically)

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23
Q

CN of the Eye

A

CN II, III, IV, VI

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24
Q

CN II

A

Optic - near and distant vision

Test: Snellen chart @ 20’ and Rosenbaum chart @ 14”
E chart used for language barriers
Confrontation test for peripheral vision

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25
Q

Presbyopia

A

loss of near vision r/t age >40

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26
Q

What CN is involved in a confrontation test and what population is it most important for?

A

CN II - glaucoma and MS (people who tend to lose their peripheral vision first)

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27
Q

PERRLA

A

Pupils equal, round, reactive to light, and accommodating

Look for consensual reaction

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28
Q

Anisorcia

A

Unequal pupil sizes

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29
Q

Mitosis

A

Pupils <2 mm (think: opioids)

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30
Q

Mydriasis

A

Pupils >6 mm (think: cocaine or THC)

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31
Q

Glaucoma

A

Loss of peripheral vision that progresses to loss of central vision due to nerve damage from fluid buildup that has increased pressure behind the eye (incurable)

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32
Q

Cataracts (what is it and what are the types?)

A

Progressive clouding of the lens

  1. Senile - most common, age >50
  2. Trauma - injury or radiation
  3. Medication - steroids
  4. Disease - diabetes

Surgery to replace lens

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33
Q

Retinal Detachment

A

Painless vision loss when retina separates from back of eye due to fluid buildup underneath it
Surgery to insert gas bubble

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34
Q

Strabismus

A

Cross-eyes (can lead to a lazy eye)
Weakness of CN III, IV, or VI

Test: corneal light test

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35
Q

Macular Degeneration

A

loss of central vision

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36
Q

Lymph Nodes (purpose and types)

A

Part of immune system; detect and eliminate foreign substances (drain into cervical chain)

  1. Pre-auricular
  2. Occipital
  3. Post-auricular
  4. Parotid and tonsillar
  5. Submandibular
  6. Submental
  7. Anterior cervical
  8. Posterior cervical
  9. Supraclavicular
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37
Q

What do normal lymph nodes feel like?

A

moveable, discrete, non-tender

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38
Q

What do acutely infected lymph nodes feel like?

A

bilaterally warm, tender, non-firm, moveable

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39
Q

What do malignant lymph nodes feel like?

A

hard, >3 cm unilaterally, non-tender, matted, fixed

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40
Q

CNs of the Face

A

CN V & VII

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41
Q

CNs of the Neck

A

CN IX, X, XI, XII

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42
Q

How to Assess Movement of the Neck

A

Chin to chest, side to side, extension, ear to should (note any limitations)

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43
Q

What are the AV valves?

A

Tricuspid and mitral

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44
Q

What are the SL valves?

A

Aortic and pulmonic

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45
Q

Are valves of the heart uni or bidirectional? Do they work through passive or active movement?

A

Valves are unidirectional and work through passive movement with pressure increases

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46
Q

Where can you assess the aortic valve and what should you hear?

A

2 ICS, RSB, S2>S1

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47
Q

Where can you assess the pulmonic valve and what should you hear?

A

2 ICS, LSB, S2>S1

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48
Q

Where can you assess erb’s point and what should you hear?

A

3 ICS, LSB, S1=S2

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49
Q

Where can you assess the tricuspid valve and what should you hear?

A

4 ICS, LSB, S1>S2

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50
Q

Where can you assess the mitral valve and what should you hear?

A

5 ICS, MCL, S1>S2

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51
Q

What is the S1 sound and where is it loudest?

A

Closure of AV valve, beginning of systole

Loudest at apex

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52
Q

What is the S2 sound and where is it loudest?

A

Closure of the SL valve, end of systole and beginning of diastole
Shorter and high pitch than S1
Loudest at base

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53
Q

What is the S3 sound, where is it heard, and who is this most common in?

A

Extra sound; caused by turbulent blood flow
Can result in fluid backing up b/c of rapid ventricular filling&raquo_space;> cardiac failure
Hear “slushing” at apex @ end of 1st 3rd of diastole
Most common in pregnant women and children b/c of increased CO

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54
Q

What is the S4 sound, where is it heard, and who is this most common in?

A

Extra sound; sound of non-compliant ventricles due to “stiff wall”
Heard over tricuspid and mitral valves
Most common in HTN, elderly, and those with history of MI

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55
Q

What is the carotid artery, how do you inspect/palpate/auscultate it, and what are normal/abnormal findings?

A

Purpose: supplies neck and brain with blood

Assess: never palpate bilaterally (can occlude blood flow); auscultate while pt holds breath (only perform on older adults or those with s/s CVD)

Normal findings: local, brisk pulse that is not interrupted by sitting or talking; soft blowing, loud grunting, beat of HR, or no sound at all

Abnormal findings: bruits

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56
Q

What is the jugular vein, how do you assess it, and what are normal findings?

A

Purpose: returns blood to heart via SVC- determines hemodynamic function of right side
Assess: sit pt at 45 degrees and have them turn head away from you
Normal findings: no distention

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57
Q

Heaves (what are they and what do they indicate?)

A

abnormal visible pulsations of the the heart due to hypertrophy and increased workload

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58
Q

Bruits (what are they and what do they indicate?)

A

blowing sound of turbulent blood flow from atherosclerotic plaque
increased risk for TIA/stroke

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59
Q

What 3 positions can you auscultate the heart in? When are murmurs and friction rub best heard?

A

Sitting up, left side-lying, HOB slightly raised to 30-45 degrees
Murmurs and friction rub best heard when sitting and leaned forward

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60
Q

What is the main sign of a valve problem and which valves are most often affected?

A

Murmur

Mitral and aortic

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61
Q

What are the two causes of valvular heart disease and explain them?

A
  1. Stenotic/stiff- valve-opening problem; narrowing and decreasing blood flow
  2. Insufficiency- valve-closing problem; incomplete closing results in backflow
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62
Q

List different arteries

A 
Temporal- head
Carotid- neck
Brachial- upper arm
Ulnar- forearm
Radial- wrist
Femoral- groin
Popliteal- knee
Posterior tibialis- lower leg
Dorsal pedis- foot
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63
Q

During systole, are the muscle fibers contracting or dilating? What about in diastole?

A 
Systole = recoil/contract
Diastole = stretch/dilation
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64
Q

What is ischemia?

A

Decreased O2 delivery to tissues

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65
Q

Does peripheral artery disease affect arteries of the heart?

A

No, only the periphery

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66
Q

List and explain the 3 causes of pitting edema

A
  1. Cellulitis/DVT - acute swelling <72 h
  2. Acute compartment syndrome - from trauma, fracture, or CCB rx
  3. Chronic - renal/liver disease
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67
Q

Stages of Pitting Edema (+1-4)

A

+1 mild pitting, slight indentation, no perceptible swelling
+2 moderate, indent subsides quickly
+3 deep pitting, short-lasting indent, looks swollen
+4 very deep, long-lasting indent, grossly swollen/distorted

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68
Q

What population are murmurs normal in?

A

Children

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69
Q

Grades of Murmurs (I-VI)

A 
I. Barely audible with stethoscope
II. Quiet but audible
III. Moderately loud (like S1/S2)
IV. Loud w/ thrill
V. Very loud, palpable thrill
VI. Audible w/o stethoscope and palpable/visible thrill
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70
Q

PAD vs. PVD (think: causes, skin, temp, circulation, hair, swelling, necrosis, pain, and healing)

A

PAD: caused by athero. plaque; skin is shiny and pale with dependent rubor; temp cool; >3 sec cap refill and weak thready pulse; no hair on area; no edema; necrosis likely; sharp stabbing pain and claudication; non-healing wounds

PVD: caused by valvular insufficiency or stenosis; skin is brown and pruritus; temp is warm; cap refill <3 sec and strong pulse; hair present; edema present; no necrosis; achy cramping pain (1st sign!)

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71
Q

Claudication

A

Achy pain during activity fro increased O2 demands

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72
Q

12 Lead ECG (purpose, electrodes, skin prep, pt position)

A

Measures electrical activity of the heart (timing and strength)
10 electrodes (6 on chest, 4 on limbs)
Skin is warm, dry, clean
Patient is supine with HOB slightly raised

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73
Q

What assessment is most important to determine sign of declining?

A

LOC and mentation

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74
Q

Levels of Consciousness (and definitions)

A

(think: CLOSE)
1. Full conscious- alert, attentive, responds promptly and obeys direction
2. Lethargic- drowsy but awaken to stimulation, follows commands but slow and inattentive
3. Obtunded- difficult to arouse, responds with few words, needs constant stimulation to follow commands or will fall back asleep
4. Stuporous- arouses to constant and vigorous stimulation (typically painful), may respond with moan or attempt to withdraw from stimulus, does not follow commands
5. Comatose- no verbal or motor responses (possible reflexes)

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75
Q

Mentation (what is is it and how do you assess it?)

A 
Someone's awareness
Ask general questions that are not yes/no
What is your name?
Where are you?
What year is it?
Why are you here?
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76
Q

LOC tools for special populations (stroke, dementia, head injury, unresponsive)

A

stroke - NIHSS
dementia- MMSE
head injury- Glasgow (GCS)
unresponsive- FOUR (brainstem reflexes)

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77
Q

What are the 3 aspects of the GCS and what score indicates coma?

A
  1. Eye opening
  2. Motor response
  3. Verbal response

Score 8-11, <8 = coma

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78
Q

How many questions are part of the MMSE, what does it test, and what score indicates severe dementia?

A

30 Qs
Cognitive skills only
<9 = severe

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79
Q

How do you test and score (1-5) muscle strength?

A

Squeeze fingers, flex and extend hand/feet against nurses hand, lift leg against nurses hand, lift leg against gravity

5/5 = full strength
4/5 = weakness w/ resistance
3/5 = overcomes gravity only 
2/5 = moves limb w/o gravity 
1/5 = no activation of muscle
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80
Q

What two tests assess for motor dysfunction?

A
  1. Strength

2. Cerebellar fxn

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81
Q

What does a cerebella function test assess for and how? Who can be tested?

A

Assesses for coordination, fine motor movement, and balance
Must be alert and responsive to verbal stimuli

Balance- assess gait with initial interaction, heel-toe walk (tandem gait), and rhombergs test
Coordination- rapid alternating movements, finger to nose, heel down shin

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82
Q

Spastic hemiparesis (hemiplegic) gait

A

drags one side of body

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83
Q

Spastic diplegia (scissoring or diplegic) gait

A

abnormally narrow base dragging legs (ex. cerebral palsy)

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84
Q

Cerebellar ataxia gait

A

similar to alcoholics walk, wide base, swaggering

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85
Q

Steppage gait (neuropathic)

A

pts with foot drop take abnormally high steps to avoid dragging foot

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86
Q

Dystrophic (waddling) gait

A

weakness of pelvis (+Trendelburg) causes drop in hip to appear like waddling (ex. muscular dystrophy)

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87
Q

Sensory ataxia gait

A

pt slams foot to ground to receive proprioception (stomping)

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88
Q

Parkinsonian gait

A

slow, little steps with stooped head

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89
Q

What are the two deep tendon reflexes we might assess and how would you grade them (0-4+)?

A

Patellar and bicep

0 = absent (diminished)
2+ = normal 
4+ = CLONUS, dorsiflex foot back and observe for tap tap tap
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90
Q

What are the 3 steps to assess for sensation?

A
  1. Assess for sensation with light touch from foot to face (distal to proximal)
  2. Test superficial pain with safety pin (can they tell the difference between sharp and dull?)
  3. Test proprioception by moving fingers up or down (can they tell you the position?)
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91
Q

Steneognosis

A

Pt can recognize an object with their eyes closed

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92
Q

Graphesthesia

A

recognize letters or # drawn on palm

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93
Q

How do you assess superficial reflexes? What is normal and abnormal?

A

Stroke lateral aspect of sole of foot
Normal = plantar flexion
Abnormal = bubinski; toes fan out (upper motor neuron disorder)

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94
Q

What are the 2 meningeal signs?

A

Kernigs- knee and hip flexed to 90 degrees and then pain in knee when knee is extended
Brudzinski- lie supine and flex neck, pain in neck and/or knees and hips flex

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95
Q

What is posturing and describe the 2 types (think feet, hips, elbows, arms, wrists)?

A

Withdrawal response from painful stimuli while in a coma

  1. Decorticate- plantar flexion, hips internally rotated, elbows flexed, wrists flexed, arms adducted
  2. Decerebrate- plantar flexion, arms adducted, elbows extended, wrists flexed, forearm pronated
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96
Q

What are the purposes of an IV?

A 
Fluids/e-
Parental nutrition
Medications 
Blood products
Contrast dyes
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97
Q

Name the 3 types of IV solutions, examples for each, and what they do

A

Isotonic: NS 0.9% expands volume, dilutes meds, keeps vein open; LR fluid resuscitation

Hypotonic: D5W metabolizes glucose and hydrates cells

Hypertonic: D5 1/2 NS Na/volume replacement, dehydrate cells

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98
Q

Who should never receive D5W?

A

Infants and those with head injury

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99
Q

How should you administer a hypertonic solution?

A

SLOWWWWLY

monitor BP, HR, lung sounds, serum Na, and urine

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100
Q

Considerations for IV placement

A

Timing
General health (consider substance abuse)
Solution/meds px
What poses the least risk

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101
Q

What are the aspects of an IV order and what are things to consider before admin?

A

Date/time and signature of HCP
Type of solution
Amount prescribed (infusion rate may not be given)

Consider if the order is the most recent, pts e- values, compatibility, and safe rate of infusion

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102
Q

Peripheral IVs (who inserts them, where are they placed, what can be given via PIV, considerations, contraindications)

A

Most common IV
RN can insert them
Places in hand or forearm
Used for fluids, meds, blood
More comfortable because of auto-retracting needle
Not appropriate for TPN, pH <5 or >9, osmolality >600

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103
Q

What needle color corresponds to what gauge and what are they most commonly used for?

A

Magma- 14g trauma
Grey- 16g major surgery, lg volume infus, unstable
Green- 18g lg volume infus, multiple/rapid trans
Pink-20g meds, fluids, trans
Blue- 22g small veins, chemo, NO trans
Yellow- 24g fragile, small veins

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104
Q

What are considerations for primary lines? (what are the variations?)

A

Vented or nonvented
How many lumens (1, 2, or 3)
Macro or micro drip (diameter of drop chamber) Continuous or bolus

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105
Q

Which types of lines need to be flushed and what method is used?

A

Intermittent (non-continuous)
2-3 ml saline q8h or each use
Push pause method (pos pressure)

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106
Q

What position should someone be in for a venipuncture and why?

A

supine with head slightly elevated and arm supported

prevent vasovagal rxn

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107
Q

What areas should be avoided during a venipuncture?

A

Areas below phlebitis or sclerosed veins
Same limb as an infiltration, mastectomy, edema, clot, shunt, or fistula
Inflammation, bruising, or skin breakdown

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108
Q

How to perform venipucture

A 
Use non-dominant hand if possible
Have patient supine with head slightly elevated 
Turnicut 5-6" above puncture site 
Dilate vein 
Cleanse with chlorahexadine and dry 
Pull skin taught and stabilize vein 
Bevel up 
Insert 10-30 degrees
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109
Q

How do you dilate a vein and which population may need this most often?

A

Stroke down distally
Light tap
Warm, moist heat
Pump fist lower than heart

Elderly and dehydrated

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110
Q

What are things to monitor after IV placement?

A

Tolerance and complications of IV
Dressing and skin integrity around IV
IOs

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111
Q

How do you prevent infection during and after IV placement?

A 
Hand hygiene before and after 
Change site q3-4d
Aseptic technique
Change primary tubing q4d
Change secondary tubing q1d
Change fluids q1d
Change dressing q1d
Discontinue ASAP
Avoid writing directly on bag 
Wipe all ports with aseptic wipe before use
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112
Q

What are the 3 local complications of an IV?

A

Infiltration
Phlebitis
Extravasation

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113
Q

What is infiltration?

A

Leaking of IV fluid into surrounding tissue

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114
Q

Describe the stages of infiltration (0-4)

A 
0 = no s/s
1 = edema <1", cool, pale
2 = edema 1-6", cool, pale
3 = gross edema >6", cool, pale, pain, numbing
4 = gross edema >6", pitting, skin tight, leaking, bruising, mod/sev pain
115
Q

How do you treat infiltration?

A 
Warm compress for normal/alkaline; cool for acidic
Elevate extremity
Check pulse and cap refill
Remove catheter and restart elsewhere
Continue to recheck site
Document
116
Q

What is phlebitis and what are possible causes?

A

Inflammation of vein from bacteria, physical, or chemical irritant
Possible causes: wrong catheter size, increased osmolarity, alkaline/acidic solution, prolonged use

117
Q

Describe the stages of phlebitis (0-4)

A 
0 = no symptoms
1 = erythema, possible pain
2 = erythema, edema, pain 
3 = "", streaks formation, palpable venous cord
4 = "". venous cord > 1", purulent drainage
118
Q

How do you treat phlebitis?

A

Remove catheter at 1st s/s and restart on other arm
Warm compress
Document and treat

119
Q

What is extravasation?

A

leaking of vesicant fluid into surrounding tissue

120
Q

What is vesicant fluid?

A

Medication that can cause blistering or necrosis of tissue

121
Q

How do you treat extravasation?

A 
Immediately stop infusion
Aspirate meds from port 
Elevate
Notify MD ASAP
Call pharmacy for antedote 
Apply ice for 15-20 min (warm for vinka alkaloid)
Document in med record and safety report
122
Q

Where do you document that extravasation has occured?

A

Med record and safety report

123
Q

What are the 4 systemic complications of an IV?

A

Fluid overload
Speed shock
Sepsis
Air embolism

124
Q

What are symptoms of fluid overload?

A

dyspnea, increased BP/HR/RR, crackles, JVD, edema

125
Q

What are symptoms of speed shock?

A

dizzy, chest tightness, flushed, pounding HA, chills

126
Q

What are symptoms of sepsis?

A

red, tender IV site, fever, malaise, VS changes

127
Q

What are signs of an air embolism?

A

RD, decreased HR, increased BP, cyanosis, decreased LOC

128
Q

What is a central venous access device (CVAD), how are they placed, and what are the types?

A

IV insertion with terminal end in SVC
Placement confirmed by radiology
Short term- non-tunneled, PICC
Long term- tunneled, implantable

129
Q

What are the uses for a CVAD?

A 
long term therapy 
poor peripheral access
hypertonic, vesicant, or extreme pH
TPN (need isolated line)
chemo
130
Q

Describe a non-tunneled percutaneous catheter CVAD (where are they inserted and by who, length of time, lumens, how do they stay in place, and considerations?)

A 
Inserted most often in subclavian but also jugular or femoral
Inserted by MD
3-10d
1-3 lumens
Sutured in place 
High risk for CLABSI or pneumothorax
Patient in Trendelenburg doing Valsalva
131
Q

Describe a PICC CVAD (where are they inserted and by who, length of time, how do they stay in place, and considerations?)

A 
Insert in AC fossa of upper arm
Insert by certified nurse
Weeks to months (possibly year) 
Secured by wound closure strip 
Good for all ages, may need frequent flushing, decreased risk for complications
132
Q

Describe a tunneled CVAD (where are they inserted, length of time, how do they stay in place, and considerations?)

A

Inserted 3-6” into SQ of subclavian or jugular
Long term
Dacron cuff seals internal cath to keep in place and prevent infx
Easily maintained at home, less visible, more moveable

133
Q

Describe an implanted port CVAD (where are they inserted, lumens, length of time, and considerations?)

A

Implanted into SQ in upper chest from chest, abd, or forearm
Multiple lumens
Long term (access with noncore needle can remain 7d)
Reservoir under skin
Great for young kids and adults that swim
Minimal daily care

134
Q

How to flush a CVAD

A

> 10ml syringe
3-5 ml saline
3 ml heparin
q7d if not in use
After placement, before/after use at same ROF
Push pause method
Use 2x more solution than capacity of cath

135
Q

CVAD dressing changes (PPE, types of dressings, other considerations)

A

PPE: mask, gown, gloves, and pt in mask

Occlusive gauze/tape if site oozing or wet and change q8h or semi-permeable membrane if dry to allow for visualization and replace q7d or if damaged

Anticrobial scrub 30 sec, 2” radius, and allow to dry
Change caps
Change tubing (TPN q1d)

136
Q

Complications of CVAD

A 
CLABSI
Pneumo/hemothorax
Air embolism 
thrombosis
Catheter migration
137
Q

How do you treat a pneumo/hemothorax from a CVAD?

A 
O2
VS monitoring
Pressure over entry site 
Remove catheter
Possible chest tube
138
Q

How do you treat a thrombosis from a CVAD?

A

Move IV and apply warm compress

Do NOT massage

139
Q

Name and describe the 3 types of med incompatibilities

A
  1. Physical- drugs mix and become unsafe (form precipitate)
  2. Chemical- drugs mix and integrity or potency is changes
  3. Therapeutic- drugs mix and result in undesirable response
140
Q

5 Rights to Med Admin

A
  1. Patient
  2. Med
  3. Time
  4. Dose
  5. Route
141
Q

How to add a piggyback

A 
Mix 50-100 ml bag
Connect to port most proximal to primary bag 
Back prime 
Lower primary bag 
Set rate on primary bag
142
Q

How to administer an IV push

A

Clamp tubing above distal port to prevent backflow
Aspirate for blood
Flush with saline
Administer med slowly at appropriate rate of infusion
Observe pt for response to med
Flush again with saline at same rate of infusion for med to prevent bolus

143
Q

What are the verifications you need to check with new blood sent for a transfusion?

A 
Document along with another nurse
Right patient
Right label
ABO compatibility 
Expiration
144
Q

What equipment is needed for a blood transfusion and why?

A

Y-set filter (primary bag for NS and another lumen for blood)

145
Q

How do you infuse blood? When might you discontinue it?

A

Turn saline off when blood is hung
Consider pump or gravity drip
Infuse at 2-5ml/min and take VS for 1st 15 min
Discontinue at first signs of problem

146
Q

How long do you have to hang blood after receiving it from the bank? In what time frame do you have to use it?

A

Blood must be hung w/in 30 min of receiving it

Blood must be used w/in 4h

147
Q

What are the 3 types of infusion rxns?

A

Allergic
Febrile
Hemolytic

148
Q

What is an allergic transfusion rxn? When might you see it?

A

Seen usually within first 15 min

Allergy symptoms from runny nose and wheezing to shock, cardiac distress, hives

149
Q

How do you treat an allergic transfusion rxn?

A

Pause infusion and run NS
Admin CPR if needed
Anticipate steroid and antihistamine use
Maintain BP

150
Q

What is a febrile transfusion rxn? What are s/s associated with it? When might you see this?

A 
Response to leukocytes or platelets (possibly prevent with leukocyte reduced blood) 
Fever (rise of 1 degree) 
Chills
HA
Tach
Nonproductive cough

Seen immediately or w/in 1-2h

151
Q

How do you treat a febrile transfusion rxn?

A

Discontinue transfusion and run NS
Notify HCP
Monitor VS
Admin antipyretic

152
Q

What is a hemolytic transfusion rxn? What are the s/s?

A 
The transfusion activates the coagulation response resulting in vasomotor instability, CV collapse, or DIC
Hemoglobinuria
Bleeding
Apprehension
Lumbar, flank, or chest pain 
Fever (w or w/o chills) 
Tach
Decreased BP
153
Q

What is the most serious transfusion rxn?

A

Hemolytic

154
Q

How do you treat a hemolytic transfusion rxn?

A

Stop transfusion and disconnect tubing
Admin NS only
Get help
Monitor for shock and dialysis

155
Q

Factors affecting skin integrity

A

Moisture
Dryness
Circulation
Nutrition

156
Q

What are the 4 wound variations?

A
  1. Intentional or unintentional
  2. Acute or chronic
  3. Partial thickness or full thickness
  4. Open or closed
157
Q

Unintentional wounds vs. intentional wounds

A

Unintentional- not done under control (highest risk for infx) - ex. gunshot
Intentional- done under control and aseptic - ex. surgery

158
Q

Open vs closed wounds

A

Open- exposed tissue at base of wound

Closed- damage to tissue w/o exposure (i.e. bruise)

159
Q

Acute vs chronic wounds

A

Acute- close efficiently

Chronic- not efficient at healing (weeks to months to yrs)

160
Q

Partial vs full thickness wounds

A

Partial- depth to dermis/epidermis

Full- depth beyond dermal layers

161
Q

List the 4 types of acute wounds and which one is most prone to infx

A

Avulsions
Abrasions
Lacerations
Punctures

162
Q

How can you prevent skin tears?

A 
Adequate nutrition and hydration 
Moisturize at least 2x/day 
Minimize bathing 
Use neutral pH cleanser
Proper safety and transfering to minimize friction 
Falls precautions
163
Q

List and describe the 2 ways that wounds heal

A

Regeneration- shallow wounds are replaced by healthy tissue (recover 100% of fxn and 80% of tensile strength)

Scar formation- deep wound cannot regenerate so fibrous scare tissue forms (loss of fxn)

164
Q

Venous stasis ulcers vs. decubitus ulcers (think: other names, causes, and prevention)

A

VSU- aka leg egg ulcer; caused by venous insufficiency and blood pools in legs; pressure results in ulcer

DU- aka bed sores; caused by pressure over bony prominence; prevented by postural changes

165
Q

What are the 4 phases of wound healing?

A
  1. Hemostasis (bleeding stops)
  2. Inflammatory (WBCs neutrophils&raquo_space; macrophages)
  3. Proliferation (connective tissue, angiogenesis, and scarring)
  4. Maturation (collagen remodeling, scarring, and strengthening)
166
Q

Name and describe the 2 types of necrosis

A

Slough- yellow, moist, stringy, loose

Eschar- black, leathery, dry, thick

167
Q

Principles of Surgical Asepsis

A

Keep sterile items above waist
Never turn your back to sterile field
Avoid drips/moisture on field
Outer 1” of sterile field is considered contaminated
Lip bottles of solution (2 ml)
Avoid laughing, talking, sneezing over field
Consider that fluids flow towards gravity

168
Q

Systemic factors that affect healing

A 
Age
Nutrition 
Circulation 
Health status 
Immunosuppression 
Medications
Adherence to tx
169
Q

Primary vs. Secondary vs. Tertiary Wound Healing (which is the most common?)

A

Primary- intentional w/ sutures, staples, glue, or strips
approximated edges, little tissue lost, fastest

Secondary- most common; extensive tissue loss, non-approximated edges, heals inside to out, increased risk for infx

Tertiary- delayed healing and scar formation

170
Q

How do you remove sutures?

A

NEVER pull outside of suture through underlying tissue
First and last suture are last to be removed
Begin by pulling out every other and replacing with steristrip

171
Q

What is the purpose of applying heat to a wound?
What types of heat applications are there?
How long can you apply heat?

A

Vasodilation, increased O2/blood/nutrients, increased waste removal and drainage, decreased pain/aching/inflammation

Moist heat = more penetrating b/c better conductor
Dry heat = stays at temp longer but needs higher temps

Limit time to 20-30 minutes or rebound could occur

172
Q

What is the purpose of applying cold to a wound?

How long can you apply cold?

A

Vasoconstriction, decreased pain by numbing, prevent swelling, stop bleeding, cool fever

Limit to 20 min or rebound

173
Q

How to relieve edema

A 
elevate above heart
sodium restrictions
ambulation/activity 
compression 
massage
174
Q

How do you record drainage characteristics?

A

Scant, moderate, or heavy

Serous- normal, clear, watery
Serosangenous- normal, pink, serum and blood
Sangenous- abnormal, red, blood
Purulent- abnormal, infection, yellow/green, odor

175
Q

What are 4 wound bed terms? Can you match colors associated with each term?

A

Necrotic- black
Sloughy- yellow, grey
Eschar- black
Granulation- red, pink

176
Q

What does the Braden Scale assess for and how is it scaled?

A

Risk for pressure ulcers

Scored 6-23 (lower the score, higher the risk)

177
Q

What are 5 wound complications?

A 
Infection
Hemorrhage
Dehiscence (can lead to evisceration)
Evisceration
Fistula
178
Q

How can you promote wound healing?

A 
Remove exudate/clean w/ drains, vac, irrigation
Debridement to remove dead tissue 
Pack wound loosely 
Nutrition (high PRO and fluids)
Keep wound moist and peri-wound dry
179
Q

4 Principle of Choosing Dressings

A
  1. Dry or desiccant
  2. Need for absorption
  3. Necrotic
  4. Infection
180
Q

Dry Gauze Properties

A

Absorptive
Can be impregnated
Good for low exudate
Can stick to heavy exudate

181
Q

Transparent Dressing Properties

A

Allows O2 exchange w/o bacterial contamination
Moist healing&raquo_space; can lead to maceration
Autolytic debridement
No absorption
Used for necrotic tissue or superficial tears

182
Q

Hydrogel Dressing Properties

A

High water content promotes epithelialization
Autolytic debridement
Do NOT use for dry, gangrene, or ischemic wounds

183
Q

Antimicrobial Dressing Properties

A

Prevent infx

184
Q

Hydrocolloid Dressing Properties

A 
Gel w/ some absorption 
Moist environment
Autolytic debridement
Protects against contamination
Change q7d
Cushioned- good for bony prominences
185
Q

Alginate Dressing Properties

A

Absorb LARGE amounts of exudate
Maintains moisture
Establishes hemostasis
Does not adhere to wound - contact with wound activates gel

186
Q

Foam Dressing Properties

A

VERY absorptive
Moist environment
Self-adherent
Cushioned- good for bony prominences

187
Q

How to clean a wound

A 
Only clean when indicated (infx, necrosis, contamin)
Use new gauze with each wipe
Wipe inside to outside, top to bottom (clean to dirty) 
Use clean pad to collect drainage 
NS used to irrigate 
Dry peri-area
Report drainage or necrosis
Assess and treat for pain before/after
188
Q

What are the 2 types of saline moistened dressings?

A

wet to dry (nonselective debridement)

wet to moist- done aseptically

189
Q

How to obtain a wound culture and what is the goal?

A

Clean wound
Roll swab in wound for maximal contact
Different swab for different areas

Goal: identify if there is infx

190
Q

What is the purpose of irrigating a wound?
When do you irrigate a wound?
What solutions or equipment do you need?
PPE?

A

Most effective method of cleaning wound
Do at initial assessment and with every dressing change
Use NS and 35ml syringe w/ 19g to deliver 8psi (4-18psi)
PPE: gown, gloves, mask, goggles
Do until solution runs clear

191
Q

List the 4 wound drainage instruments

A
  1. Penrose
  2. Jackson Pratt (JP drain)
  3. Hemovac
  4. Vacuum assisted closure (VAC)
192
Q

Describe a penrose drain

A 
Open drain- aseptic
No secured- safety pin on end 
Passive drainage 
Pin is pulled out a little each day as drainage minimizes
Clean in circular motion
193
Q

Describe a jackson pratt drain

A

Implanted surgically and sutured in place
Squeeze tube for negative pressure
Empty drain when 1/2 full
Holds 50-100ml (most effective at measuring)
Located along side wound

194
Q

Describe hemovac drain

A 
Similar to JP
Surgically placed and sutured
Negative pressure system
Empty when 1/2 full
Holds 400-800ml
195
Q

Describe the vacuum assisted closure drain (VAC)

A

Secondary intention
Negative pressure system
Reduced risk for infx
Suction decreases edema and improves circulation and angiogenesis
Fenestrated tube imbedded in foam for even pressure
Occlusive dressing prevents air from entering
$$$

196
Q

List the 5 types of debridement

A
  1. Mechanical
  2. Autolytic
  3. Enzymatic
  4. Surgical
  5. Biological
197
Q

Describe the pros and cons of mechanical debridement

A

PROS: simple, $, promotes healing
CONS: non-selective, risk of infx, painful

198
Q

Describe the pros and cons of autolytic debridement

A

PROS: selective (body’s own response), for stage 2/3, not painful
CONS: not for stage 4, takes days to weeks, constant monitoring, and possibility of anaerobic growth

Need semi or occlusive dressing

199
Q

Describe the pros and cons of enzymatic debridement

A

PROS: selective, useful for necrosis or eschar, faster than autolytic
CONS: can burn, need rx

200
Q

Describe the pros and cons of surgical debridement

A

PROS: selective, good for large wounds with lots of necrosis, good control/fast, speeds healing process
CONS: painful, $$$

201
Q

Describe the pros and cons of biological debridement

A

PROS: selective
CONS: can be gross and painful

202
Q

Who should or shouldnt use pneumatic compression devices?

A

Those who are immobile who need to decreased risk for edema, blood pooling, and DVT should use PCD

Someone with a current DVT should not

203
Q

What is the most common HCAI?

A

CAUTIs

204
Q

How to prevent CAUTIs

A 
Hand hygiene
Shortest needed time
Assess cath 2x/day and remove ASAP
Prevent obstruction/kinds
Empty collections frequently and attach new bag
Dont use when not indicated
Educate staff
205
Q

What is the purpose of a bladder scan? How do you read the results?

A

Calculates amount of urine in bladder to prevent necessary catheterization by calculating post-void residual >100ml
Non-invasive, painless

Average results from 3 scans

206
Q

When can you use a catheter?

A

Urinary retention or obstruction
Accurate measurements for critically ill
Perioperative
Assistance for wound healing with stage 3/4 perianal or sacral wound
Hospice/palliative care
Require immobilization from trauma/surgery

207
Q

What are the 4 types of catheters?

A
  1. Suprapubic
  2. Indwelling
  3. Intermittent/straight cath
  4. Purewick or condom cath
208
Q

Is clean or aseptic technique used with a straight cath?

A

@ home - clean

@ hospital - aspetic

209
Q

Causes of urinary retention

A

Urethral obstruction
Nerve problems
Meds
Weak bladder

210
Q

What are the differences between single, double, and triple lumen caths?

A

single lumen = straight cath, urine only
double lumen = urine and saline (cuff)
triple lumen = urine, saline (cuff), meds

211
Q

What kind of catheter may be used for someone with an obstruction like BPH?

A

Coude-tipped

212
Q

How do you prepare your patient for catheterization?

A 
Ask about allergies- iodine or latex
Female - dorsal recumbant or side lying
Men - supine 
Provide privacy
Choose appropriate size (14-16Fr with 5-10 ml balloon)
213
Q

What are the 3 types of urine drainage bags and why are they used?

A
  1. Standard bag- large capacity, empty q8h
  2. Urine meter- strict IO
  3. Leg bag- discreet but small capacity
214
Q

How do you insert a catheter in a female?

A

Position dorsal recumbant or side lying
Clean labia down each side and then down middle meatus&raquo_space; keep labia separated
Insert catheter until urine return and then continue in another 2-3”

215
Q

How do you insert a catheter in a male?

A

Position in supine
Clean from tip of penis down the head&raquo_space; keep foreskin retracted
Insert catheter until urine returns and then insert all the way up to Y

216
Q

What are the two ways you can take a urine sample?

A

Clean catch and cath system (NEVER from bag, clamp tubing and take from port)

217
Q

What is the purpose of irrigating a closed catheter system?

A

To observe for any blockages

218
Q

How do you irrigate a closed system?

A

Kink tube to irrigate bladder
Instill 30-60ml or room temp solution slowly
Subtract irrigant from IO

219
Q

What is the purpose of continuous irrigation for a catheter?

A

Flush clots and debris from catheter and bladder
Instill meds into bladder
Restore patency of cath

220
Q

What is a stoma?

A

The visible, communicating end of the bowl after resectioning

221
Q

List the 3 types of ostomies

A
  1. Colostomy
  2. Ileostomy
  3. Urinostomy
222
Q

What is a colostomy?
What is the difference between an end, a loop, and a double barrel colostomy?
Where can a colostomy be placed and what does the drainage look like for each?

A

Part of LI is removed or bypassed (temporary or permanent)
End = damaged section removed, permanent
Loop = remove obstruction, two openings in one stoma, temporary
Double barrel = two separate stomas, temporary

Ascending = liquid
Transverse = liquid, semi-formed
Descending = semi-formed
Sigmoid = formed
223
Q

What is an ileostomy and what are teachings associated with having one?

A

Permanent bypass of the LI
Smaller in diameter than colostomy
Thin, watery&raquo_space;> thick, yellow/brown (very acidic)

Educate on increased fluid intake
Empty pouch when 1/3-1/2 full
Skin care
Low residue diet

224
Q

How do you know you have a ileostomy obstruction and what do you do?

A 
No output for >6h
Drink tea
Knees to chest 
Warm towel on abdomen 
If swollen, use pouch with smaller hole
225
Q

What are 4 types of incontinent urinary diversions?

A
  1. Urostomy
  2. Ileal conduit- most common
  3. Transureterostomy- most prone to complications
  4. Ureterostomy
226
Q

What should a stoma look like?

A

Shiny, red, and wet

227
Q

How do you change an ostomy bag?

A

Push on skin rather than pull on adhesion to remove
Measure stoma with guide and trace on back of stoma pouch
Cut opening 1/8” wider to prevent constriction

228
Q

What is the purpose of an NG tube?

A 
Enteral nutrition
Lavage
Decompression
Compression 
Diagnose problems with GI motility
Aspirate contents for analysis
Admin radiographic contract media
229
Q

What does it mean to lavage the stomach?

A

irrigate the stomach to remove toxins or treat hyper/hypothermia
Contraindicated for poison&raquo_space; activated charcoal

230
Q

What does it mean to decompress the stomach?

A

removes gas/fluid for those that are NPO, have a bowel obstruction, or paralytic ileus&raquo_space;> continue until peristalsis resumes

231
Q

What should you do if PO meds are needed but you have decompression going through their NG tube?

A

Stop the suction and resume once meds are absorbed

232
Q

What is the purpose of compression?

A

Stop GI bleeding when endoscopy is not available

233
Q

What size NG tube is used for adults? Neonates? Peds?

A

Neonates 4-8F
Peds 6-14F
Adults 12-18F

234
Q

What are the 4 types of NG tubes?

A

Single lumen
Double lumen (Salem sump)- most common
Dobhoff
Sengstaken/Blakemore

235
Q

What is a single lumen NG tube? What is it used for?

A

NG tube with small drainage holes at end
Small holes can get blocked
Can only use suction on low, intermittent to prevent erosion of gastric mucosa

236
Q

What is a salem-sump NG tube? What is it used for?

A

The most common NG tube
Can do continuous suction because of pigtail vent
Used for irrigation and tube feeding

237
Q

What is the purpose of the pig tail?

A

Creates a vent that prevents adherence to gastric mucosa and prevent reflux

238
Q

What are things you should know about a pig tail?

A

Always keep it above waist and NEVER clamp is

239
Q

What NG tube is most often used for tube feeding and why?

A

Dobhoff tube- has one big hole at end instead of tiny holes

Inserted into jejunum or duodenum

240
Q

What NG tubes are most common for treating GI bleeds? How is it inserted?

A

Blakemore- triple lumen, one reserved for GI suction
Recommend endotrach intubation to promote airway
Distall balloon in stomach
Proximal balloon in esophagus

241
Q

What NG tubes can be used for intermittent suctioning? Continuous suctioning?

A

Intermittent- single lumen or salem-sump

Continuous- salem sump ONLY

242
Q

What should you assess prior to inserting an NG tube?

A

Nares patency and see which one is more open
Must have gag reflex present
Suction must be working and ready

243
Q

What position should a patient be in when being suctioned?

A

high fowlers

244
Q

What PPE is needed for suctioning?

A

Gloves

245
Q

How do you measure an NG tube?

A

tip of nose to earlobe to xyphoid

246
Q

How do you insert an NG tube?

A

Have the patient deep breath

Have patient tilt chin to chest and slowly drink water

247
Q

How do you assess placement of NG tube?

A

CXR for first use

Then…aspirate GI content or test pH 0-5

248
Q

How do you irrigate an NG tube?

A

q4h
verify placement and markings
use 60ml syringe
disconnect distal tube from suction
irrigate with 20-30 ml of tap, saline, or sterile saline
irrigate pig tail with 20 ml of air to reestablish buffer
document amount to subtract from IO

249
Q

How do you remove an NG tube?

A

verify order
intermittently clamp to assess for N/V or distention
PPE: gloves
inject 10ml fluid/air
remove tape from nose and unpin from johnnie
place towel across lap and emesis bin redy
take deep breath and hold
withdraw slowly until at esophagus

250
Q

When are artificial airways used?

A

Loss of consciousness or obstruction (or risk of)

251
Q

Is clean or sterile technique used to insert an artificial airway?

A 
Clean = oral airway
Sterile = everything else
252
Q

What are the 5 types of artificial airways?

A 
Oralpharyngeal 
Nasopharyngeal 
Endotracheal 
Laryngeal mask 
Tracheostomy
253
Q

Who can get an oropharyngeal airway and how do you measure it?

A

Someone with low LOC because this airway stimulates the gag reflex
Prevents obstruction or secretions from blocking the airway
Measure corner of mouth to angle of jaw under ear

254
Q

Who can get a nasopharyngeal airway and how do you measure it?

A

Someone with an obstruction or secretions that block airway (or risk of)
Measure nose to angle of jaw under ear

255
Q

How is an endotrach airway inserted (from where to where) and how long can it stay in?

A

Inserted by a laryngoscope in mouth or nose and ends where the trachea bifurcates to lungs
Short term <14 days (unless weaning)

256
Q

Who can insert a laryngeal mask and why is it benefiticial?

A

EMTs can insert it and its good for those that are not skilled in airways and decreases distention and risk for aspiration

257
Q

What is a tracheostomy used for? How long is it used? What are the 3 different variations?

A

Used for mechanical ventilation, secretions, or obstruction of airway
Used long term >14 days

Cuffed or uncuffed
Fenestrated or nonfenestrated
Single or double lumen

258
Q

What are the differences between a cuffed trach and an uncuffed trach?

A

Cuffed- airtight seal, direct air flow (especially needed for mechanical vent), prevents aspiration, increased risk for necrosis

Uncuffed- can still speak, for adults and ped with no aspiration risk or risk for mechanical vent

259
Q

How do you deflate a cuffed trach and when might you deflate the cuff?

A

Suction 1st
Deflate slowly during peak inspiration
Deflate before meals

260
Q

How can you allow a person to speak with a fenestrated trach?

A

Remove the inner cannula
Deflate cuff
Cover opening of trach

261
Q

How does the nurse confirm placement of a trach?

A

Auscultate chest
Bilateral chest rise
Check location of tube ta teeth
Capnography (purple = O2, yellow = CO2)

262
Q

What should the nurse do after trach insertion and confirmed placement?

A

Assess respiratory q2h
Assess nasal/oral mucosa
Reposition q2h (side lying or semi-fowler)
Monitor cuff pressure to prevent necrosis
Move oral tube to other side of mouth q8h
Provide oral care q4h
Provide bite block
Communicate frequently
Provide humidification

263
Q

How do you change a trach or ET tube? (how many people and PPE)

A

Secure w/ 2 people (one to hold and one to tie)- if only 1 person, attach new ties first and then release the old one

PPE: mask, gown, gloves, goggles

264
Q

What emergency equipment is needed for a trach?

A 
Obturator
Suction 
O2
2 tubes (1 smaller)
BVM (reuscitation)
265
Q

What do you do if the patient is accidentally decannulated?

A

Call for help but dont leave pt
Replace tube or use obturator
Possible mechanical ventilation

266
Q

When should you use suctioning on someone?

A

When they lost the ability to swallow or their cough is not effective at mobilizing secretions

267
Q

What is the purpose of suctioning a patient?

A

Remove secretions and maintain gas exchange

268
Q

Closed vs open suctioning (risks, # of uses, sterility)

A

Closed- attached to vent, decreased risk of hypoxia (attached to MV) and infx, reusable sterile cath for 24h, need PPE but not sterile gloves

Open- risk for infx, hypoxia, and vagal stimulation, one time use with each cath, need for sterile gloves

269
Q

How do you suction a patient?

A

Pre-test suction
Only suction on way out
Hyperoxygenate before (deep breath or O2)
3 passes, 10-15 sec, 30-60 sec break between
Suction between 100-120 mmHg

270
Q

What is the first sign of hypoxia?

A

Restlessness

271
Q

What is the purpose of a chest tube thoracotomy and where is it inserted?

A

Inserted into pleural space to remove and prevent air, fluid, or blood from re-entering and promote lung re-expansion

272
Q

What is the difference between a pneumothorax, hemothorax, and pleural effusion and where are each found in the lungs?

A 
Pneumo = air, apex
Hemo = blood, base
Pleural = fluid, base
273
Q

What do you need prior to chest tube insertion?

A

Informed consent

274
Q

Why might you use a larger or smaller tube for a chest tube?

A

Small tube = air

Large tube = blood/fluid

275
Q

How do you confirm chest tube placement?

A

CXR

276
Q

What are the 3 chambers of a CDU?

A
  1. Water seal
  2. Collection chamber
  3. Suction chamber
277
Q

Water Seal Chamber (what is it, how does it work, what should you assess?)

A

Negative pressure system where a straw remains under 2 cm of water to create “seal” and prevent fluid or air from returning to pleural space
Assess for tidaling (increased volume with insp and decreased volume for exp- opposite for MV)
Assess for gentle intermittent bubbling (continuous = air leak)

278
Q

Collection Chamber (how does it work, how to assess, health promotion)

A

Fluid drainage system that should be kept below chest level
Assess drainage q1h for 1st 24h then q8h
Encourage positional changes, coughing, deep breathing

279
Q

Suction Chamber (when is it used, types, assessments)

A

Used to help pull secretions when fluid is thick
Wet or dry
Wet- regulated by ht of water (-20cm) and connected to suction on wall- assess for gentle bubbling and evaporation
Dry- no water, bellow with dial

280
Q

Emergency chest tube equipment

A 
2 kelly clamps 
1 vaseline gauze
1 4x4 gauze
250 ml normal saline 
new CDU
281
Q

Where should a CDU be placed?

A

Below level of chest

282
Q

What is a tension pneumothorax?

A

When air enters the pleural space with each breath and gets trapped&raquo_space; increases pressure and can result in lung collapse

283
Q

How can you prevent a tension pneumothorax?

A

NEVER clamp tubing on chest tube (prevents air escape)

NEVER strip or milk the chest tube (creates neg pressure)

Semester 2 (2 decks)

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