Fundamentals Final(YOU GOT THIS!) Flashcards
How to care for orthostatic hypotension?
- move patient slowly
- dangle feet at side of bed
First task on shift?
Get report(SBAR)
- updates - VS - family issues
What to do after shift report?
review labs and medications
2 Delegation points of not delegating
- Dont delegate assessment
2. Dont delegate out of scope
What asessment is taken at beginning of shift?
What assessment is taken in middle of shift?
Head to toe assessment
Focused assessment
Who obtains VS when patient is out of ICU or surgery?
The Nurse
Prioritization
Stable vs unstable
ABCSPI (life threatening labs/VS after circulation)
How Old? When admitted? When was/is surgery? How many body systems involved?
What is a fever?
above 100.4 degrees
Infection indicators
prevention?
fever, increase WBC and RR, drainage, odor
hand hygiene, antibiotics/antibacterials
Putting PPE on order
Putting PPE off order
gown, mask, goggles, gloves
gloves, goggles, gown, mask
What does decreased bowel sounds indicate?
Ileus
TPN musts
- 2RNS must check TPN
- 10% dextrose if TPN runs out
- check BG q6h
- check placement of tubes by CXR and gurgling
Sleep interventions
Benzodiazapine?
teach to get to bed quickly, start low if elderly, environment is safe, BE CAUTIOUS of benzodiazapines in elderly, promote health habits
What to do if patient has skin wound?
turn patient
Eschar MUST be debrided
collect drainage for culture
How many L/min for face mask?
at least 5 L/min, 6-12 L/min
35-50%
easy to use and short term
How many L/ min for nonrebreather?
10-15 L/min
60-90%(high concentration)
reservoir bag must be inflated
How many L/min for nasal cannula?
1-6 L/min
24-44%
flow rates over 4/L min need humidification
easy, can talk and eat, comfortable
what is a vapotherm?
High flow nasal cannula, O2 is warm and humidified
What are venturi masks used for?
low concentration, specific amount
24-60%
What is a face tent used for?
Claustrophobic patients
Early S/S of hypoxia? Late?
Early: Fear,Anxiety,Tachycardia,not concentrated,dizzy,dyspnea,pale
Late: Decreased LOC, Fatigued, Cyanosis, Hypotension,
Inhaler Patient Teaching
Rinse mouth after using MDI Shake 5-6 times administer during inspiration hold breath for 10 seconds don't smoke clean equipment
How often are eye exams?
How often are ear exams?
q 2 years, or yearly if eye problems
yearly if in noisy environment
Cheyne-Stokes= Kussmaul= Eupnea= Tachypnea= Bradypnea- Apnea= Hypernnea- Orthopnea-
Cheyne-Stokes= alternate between apnea and deep. respiratory center problem Kussmaul=compensate for metabolic acidosis , deep and fast Eupnea= effortess Tachypnea= >20 Bradypnea= <12 Apnea= no breathing Hypernnea- abnormally deep Orthopnea- sitting up to breath
Different aphasias
Expressive= understand but cant communicate, use pictures to communicate Receptive= cannot understand Global= both expressive and receptive
Cognitive patient teaching
Affective patient teaching
Psychomotor patient teaching
Cognitive= knowledge Affective= communication, care Psychomotor= demonstration
Who gets consent for surgery?
Who is a witness and advocate of patient?
The Surgeon
The Nurse
How often to check 2 point and 4 point restraints?
2 point- q2h
4 point- every 15 minutes
Malpractice standards
Nurse had a duty
Duty was breached
Breach resulted in injury
UTI S/S, tests, interventions
Dysuria Hematuria Pain Frequency and urgency Small Volumes Increased RBC and WBC fever N/V
management: urinalysis, C&S
complications: pyelonephritis, drug tolerance, renal abcess
Interventions: assess VS, UA, C/S
administer antibiotics(trimethoprim/sulfamethoxazole), bladder analgesic(phenazopyridine/pyridium), atnispasmsic( Hycosamine), anticholinergicdrink fluids, cranberry juice
Teach to report S/S
prevention:
- wipe front to back
- drink fluids and cranberry juice
- urinate before and after sex
CAUTI S/S, tests, interventions
poor appetite sudden incontinence nocturia dysuria hematuria confusion Urosepsis (UTI found too late) Pulse Rises, BP drops, shock, death
Meds: antibiotics (Sulfonamides, Fluoroquinolones, Penicillin, Cephalosporin)
bladder analgesics: phenazopyridine (pyridium)
Macrobid/Macrodine
Antispasmodic: Hyoscyamine
Anticholinergic
Urolithiasis (Kidneys stones) S/S, tests, interventions
Ca levels are high
pain
pallor(skin color)/diaphoresis(sweating)
N/V hematuria
Narcotics, NSAIDS, antiemetics(ondansetron), and Alpha adrenergic blockers(tamsulosin)
straining
Management: noncontrast CT, KUB, and ultrasound
Surgery: lithotripsy, ureteroscopy, stent or nephro tube)
Pre care: NPO, bowel prep, IV for sedation
Post care: hydrate, first urine is bloody, strain, possible bruising
Bladder Cancer expectation
risk factors
intervention
Painless Hematuria, increase in frequency and urgency, nocturia
Smoking
Create diversion to bypass bladder
Types of incontinence
Stress: stretched/relaxed muscle (pregnancy) Urge: irritants (caffeine, nicotine) Overflow: enlarged bladder, diabetes Functional: unable to reach bathroom Reflex: spine or brain injuries
normal WBC value
5,000-10,000
Neutrophil:55-70% Bands:3-5% Eosinophils:1-4% Basophils: .5-1% Lymphocytes:20-40% Monocytes: 2-8%
What to avoid if neutropenic/leukocytopenia?
NO fresh flowers, fruits, and veggies
function of HGB and hematocrit
Transport Iron
Low HCT indicates what?
Iron deficiency anemia
normal platelet value
150,000-400,000
normal RBC value
- 2-6.1 MILLION
4. 2-5.4 women) (4.7-6.1 for men
normal HGB balue
12-18
Men:14-18
Women:12-16
normal HCT value
37-52%
Men:42-52%
Women: 37-47%
rule of three
RGB X3 = HGB
HGB X3 =HCT
what dos thrombocytopenia indicate
bleeding, brusing
where do patients lose potassium?
In stool
Dilute Potassium? Give IV PUSH?
Yes, Dilute
NEVER give IV PUSH
What to watch for in EKG in hyperkalemia? In hypokalemia?
Peak T waves
U waves
What conditions shows Chvostek(face react) and trousseaus signs (hand react)?
Hypocalcemia and Hypomagnesemia
What does high BUN indicate?
Dehydration
Normal BUN value
10-20
Normal Creatinine Value
.5-1.1
Normal BG value
70-110
What to give patient if Blood glucose is low?
Insulin and D50
Normal HGB A1C value and function
4-5.9%
Control Diabetes
What med is regulated with PT? antidote? what to look at?
Coumadin/Warfarin
Vitamin K
look at INR
What med is regulated with PTT? antidote?
Heparin
Protamine Sulfate
What does acidosis indicate? alkalosis?
Acidosis indicates hyperkalemia
Alkalosis indicates hypokalemia
Normal pH
7.35-7.45
Normal paCO2
35-45
Normal HCO3
22-26
IVP knowledge/interventions
Know allergies to shellfish and iodine dye
NEED consent
Check BUN & Creatinine
HOLD metformin/glucophage when giving dye
NPO before and after
Renal arteriogram knowledge/interventions
Know allergies to shellfish and iodine dye
NEED consent
Check BUN & Creatinine
HOLD metformin/glucophage when giving dye
PT and INR
Check for bleeding at site
CXR knowledge/interventions
diagnose pneumonia, check line placement
pregnant?
NO consent
CT scan knowledge/interventions
Know allergies to shellfish and iodine dye
NPO
Claustrophobic?
Pregnant?
MRI knowledge/interventions
NO metal
Sedation if nervous
KUB knowledge/interventions
abdominal, look for NG tube placement
NO consent
Thoracentesis knowledge/interventions
NEED consent
sit up, arms out
Paracentesis knowledge/interventions
NEED consent
lay on back
PO route knowledge/interventions
do NOT crush enteric coated meds
first pass effect
IM route knowledge/interventions
1 mL into Deltoid because only small amount
up to 2 mL in vastus lateralis(mid thigh)
up to 3 mL in ventrogluteal (hip)
shorter needle for deltoid
what does PR stand for ?
Per rectum
SubQ knowledge/interventions
Rotate sites, give .5-1 mL in shots
SL (sublingual) knowledge/interventions
need moist mouth
NO food or drink after/during
Under tongue
Buccal knowledge/interventions
No food or drink
Order of meds for inhaler
Bronchodilator(albuterol) then Steroid
Topical knowledge
rotate sites
wear gloves
bypass first pass effect
Optic meds. knowledge/interventions
Pull down lower lid
hold pressure
wait between drops
Otic meds knowledge/interventions
Adults: Pull up and back
Children under two: Pull down and back
Intradermal degress
5-15 degrees
Laxatives knowledge/interventions
AVOID long term use
Different types of laxatives
metamucil- bulkforming
dulcolax(bisacodyl)- irritant
colace(sodium docusate)- emoliant(lubricant), stool softener
PPI suffix function interventions
-prazole
inhibit gastric acid secretion
give in morning for prophylaxis(fight disease)
H2 Blocker Suffix function interventions
-dine
inhibit gastric acid secretion
Give at bedtime
avoid smoking and eating B12 foods
Benzodiazapines suffix function interventions What is antidote?
-zepam and -zolam
Suppress CNS activity, Treat Anxiety
Check LOC and RR
Do NOT mix with alcohol
Do NOT stop abruptly
Antidote: Romazacom
Narcotics/Opiates function
interventions
side effect
antidote
Treat Pain
check BP(BP typically drops), RR side effect: constipation, urine retention, GI distress, Respiratory down
Antidote: narcan
NSAID interventions
examples
watch for Ototoxicity and GI distress
aspirin
ibuprofen
Antiemetic function interventions
Prevent vomiting
No alcohol with phenergan
Monitor Hydration, I&O
Mouth Care
Antihistamine suffix function intervention
-ine
Prevent allergies
Cause drowsiness
Ace Inhibitor suffix function interventions
-pril
Relax veins to drop BP
Check BP prior to giving, do NOT give if too low
side effects:
-coughing
-fluid status altered
-promotes aldosterone
-potassium is retained (WATCH K Levels!)
Beta Blockers suffix
function
interventions
-lol
Decrease BP by decreasing HR
Check HR & BP( if below 60 HOLD beta blocker)
Loop Diuretics suffix
interventions
(-nide and -mide)
used for hypertensions
check fluid/electrolyte, I&O, and daily weight
(-lactone is K sparing)= spironolactone
Cardiac Glycoside suffix function interventions
-xin (Digoxin)
Decreases HR and increases contractions(output)
Monitor HR and dont give below 60
Antianginal (Nitroglycerine) function
dilate blood vessels, men should not be on viagra
Antibiotics interventions
check allergies fluids should not be exposed to sun DO NOT STOP EARLY TAKE FULL COURSE
What is kayexelate?
Treat hyperkalemia, poops K out
What is metformin?
Impacts kidney, hold on diagnostic tests
Purpose of Half-life
Determine dosing
Danger of protein binding
Increase risk of ototoxicity
more free drug
Schedule II drugs:
Need prescription
NO call for refill
not a controlled substance
Peak vs. trough
Peak is checked 60 minutes AFTER med is given
Trough is checked 30 minutes BEFORE Meds is given
Needle size SubQ vs. IM
SubQ=25-27 (shorter gauge)
IM=21 (larger gauge)
What labs are important to know kidney function?
BUN and creatinine
What does High BUN indicate?
Dehydration
What to do if Glucose is low? High?
Give D50
Give Insulin and D50
What is HGB A1C?
test 3 month period(120 days) of RBC life
Treats diabetes
How to catch Urinalysis?
Catch sterile technique, NOT by cup
What diagnostic tests need consent?
IVP and Renal arteriogram
Interventions for invasive diagnostic tests that use dye?
- Check allergies to dye and shellfish
- Check PT & INR (renal arteriogram)
- Check BUN & Creatinine
- Hold metformin if allergic
Cataract deficit
Cloudy, opaque lens that distorts passage of light
Glaucoma
Pressure against optic nerve, Halos seen
Diabetic Retinopathy
Spotted Vision from edema
Macular Degeneration
Decrease in central vision
Altered attention
Short Attention Span
Memory impairment
Head Trauma, meds
Disorganized thinking
Delirium: Fast onset
Dementia: Slow onset
Sundowners
How often are eye exams?
Every 2 years
Every year if eye problem
How often are ear exams?
Yearly
Acute Care checks
Orientation to environment
Safety measures
Controlling sensory stimuli
Restorative Care checks
Promoting self-care safely
Socialization
Kubler Ross Classical Behavioral stages
Denial Anger Bargaining Depression Acceptance
Grief Task Model
Acceptance of reality loss
Work through pan of grief
Adjust to environment
Relocate emotionally/move on
Factors that Influence Grief
Human Development Personal Relationships Nature of Loss Coping Strategies Socioeconomic Status Culture & Ethnicity Spiritual/Religious Beliefs Hope
Difference between Living Will and Durable POA/Health Care Proxy
Living Will: Written instructions about treatments on how you want to be kept alive, or medical treatments
Durable POA: Name a person to make decisions when you are unable to do so
Difference between Palliative and Hospice care
Palliative Care: Prevent, relief, reduce symptoms throughout entire course of illness
-Support Patient
Hospice is a multidisciplinary team that focuses on quality of life -focus on quality of life Hospice patients must be: 1. Terminally ill 2. Insurance Covered 3. 6 months or less to live
Different types of death
Death= Heart and lungs fail to function
Clinical Death= Heart, Lungs stop, no brain function
- brief time before organs die to perform CPR, not that effective
Brain death= Absence of brainstem reflexes(apnea, coma) heart & respirations stop
-can be on life support: ventilator and vasopressor to maintain heart and lung function
Strategies of Psychosocial Care Grief and Mourning Promote Spirituality Communication Provide Referrals
Grief and Mourning:
offer physical and emotional support. Provide presence
be realistic, accept situation
encourage reminiscence
Provide Spirituality:
find meaning in suffering without explaining loss
deal with it
look at hope
Communication:
remind family patient may still hear them
Provide Referrals:
Bereavement counseling
Steps of postmortem care
Pronouncement of death by APN or MD
Prepare patient for family visit
Allow family to see patient in private, customs( Call Chaplain)
Family chooses funeral home; nurse notifies to pick up body
Offer family to pack belongings
Prepare for transfer. Funeral home will bring stretcher. If to hospital morgue, wrap in shroud and ID
Core Elements of Framework
Caring, Connecting, and Empowering
Professional Standards of Nursing
Patient- Centered Health Promotion Teamwork/Collaboration Informatics/Innovation Evidence-based practice Professionalism Cultural competence Quality & Safety
Elements of human, impact on environment of each
Physiological Psychological Sociocultural Spiritual Environment
Distressing symptoms at end of life
Assess patient
Educate Family & Patient
Assurance
Antibacterial Interventions
Check allergy prior to administration
Obtain sample for culture prior to administration
Monitor labs (liver enzymes, kidney function, peak and trough)
Administer in relation to meals
Increase fluids
Monitor for S/S of allergies, toxicities, superinfection
Teach to take entire course as scheduled
What antibacterials to check peaks and troughs?
Glycopeptides (vancomycin) and Aminoglycosides
What diagnostic tests need consent?
IVP
Renal Arteriogram
CT scan
What diagnostic tests do nurses check BUN & Creatinine?
IVP and CT
What diagnostic test do nurses check PT & INR?
Renal Arteriogram, go into vessel
If medication error, what steps do nurses take?
Assess Call Report Compute (ACRC)
Coumadin time
Heparin Time
11-12.5 seconds
30-40 seconds
INR definition, values
time it takes blood to clot
- Healthy: .8-1.1
- Anticoagulants: 2-3
- Atrial Fibrilation/Heart Valve: 3-4
Circulatory Overload findings & interventions
Findings:
crackles
SOB
edema
Interventions: elevate HOB Reduce IV rate Monitor VS & labs Contact HCP
Infiltration findings & interventions
Findings:
cool and taught(tight) skin
Interventions:
Stop, discontinue, start new IV
Apply warm/cold compress
elevate extremity
Phlebitis findings & interventions
Findings:
redness, tenderness, pain, warm veins
Interventions: Do NOT massage apply warm compress Stop, Discontinue, Start new IV Contact HCP if needed
Local Infection findings & interventions
Findings:
heat, redness, swelling, drainage
Interventions:
Culture drainage
Stop, discontinue, Start new IV
Notify HCP
Bleeding findings & interventions
Findings:
fresh blood and pooling
Interventions:
Assess IV intact
Apply Pressure
Start new line if needed
Isotonic Fluids
9%NS (dehydration)
D5W
LR
Hypotonic Fluids
.45% NaCl (1/2 NS)
.2% NaCl (1/4 NS)
Hypertonic fluids
D5NS
D10W
D5LR
3%NaCl (for hypernatremia)
What is Intractable Pain?
Idiopathic pain?
Referred pain?
No treatment found
No cause found, hard to find
Shows up in different place
What is Atelactasis?
Collapse of Alveoli
S1 and S2?
S1: Mitral and Tricuspid close
S2: Aortic and Pulmonic close
Urinary Acute Care meds
Antimuscarinics- treat overactive bladder
Antibacterials- treat UTI
Urinary analgesics- treat pain
Urinary restorative Care
lifestyles changes (diet- avoid caffeine, citrus, artificial sweeteners, spicy food) Kegel exercises bladder retraining toilet schedule intermittent catherization
Diarrhea Care
MAINTAIN FLUIDS
bland diet
Anti Diarrhea Meds
Opiates (Paragoric, Lomotil, Imodium(loperamide)
Adsorbents (Peptobismol, Kaopectate, Charcoal)
Normal flora (lactobacillus acidophilus, Kefir)
Care for stoma
Odor Control
Body Image
What does -scopy indicate?
Direct Visualization
Ace Inhibitors
-pril
Capoten
Vasotec
Zestril
Beta Blockers
-lol
Lopressor
Inderal
Coreg
Antianginal
Nitrostat-SL
Nitrobid-ointment
Transderm nitro-patch
Nitroglycerin drip tidal-IV
Cardiac Glycoside
-xin
Lanoxin/Digoxin
Loop Diurectics
-mide & -nide
Lasix
Bumex
Thiazide
-thiazide
HCTZ
Diuril
K Sparing
-actone
Spirinolactone/aldactone
H2 blocker
-dine
Axid
Pepcid
Tagamet
PPI
-prazole
Nexium
Prilosec
Protonix
Benzodiazapine
-zepam, -zolam
Ativan
Valium
Xanax
Antiemetics
Phenergan(promethazine)
Zofran(Ondanstron)
Dramamine(Dimenhydrinate)
Chest tube care
Assess patient Keep system upright and below insertion level Assess tubes for kinks and loops Monitor Drainage Connections secure KEEP PATIENT MOVING
Antibacterial interventions
Check allergies Obtain sample for culture Monitor Lab Administer in relation to meals Monitor for S/S of allergic reaction, toxicity, superinfection Teach to take entire course Increase Fluid intake
Medications to check for peaks and trough
Glycopeptides (Vancomycin) & Aminoglycosides
