Midterm Flashcards
1
Q
droplet/contact precautions
A
gown
gloves
mask
eye protection
2
Q
AGMP precautions
A
N95 needed
3
Q
focused resp assessment
A
- general appearance
- colour
- resp rate/rhythm/depth
- resp effort/dyspnea
- tracheal position/thorax
- chest expansion/symmetry
- cough/sputum production
- breath sounds
- adventitious sounds
- O2 sat
- oxygen therapy
4
Q
adventitious sounds
A
- crackles (aka rales) -> coarse and fine
- death rattle
- pleural friction rub -> creaking floors
- rhonchi -> upper airway wheeze
- stridor -> high pitch, upper airway, only on inspiration
- wheeze -> musical, inspiration and expiration
5
Q
abnormal respiratory sounds
A
cheyne stokes breathing -> alternating between deep and shallow breathing , brain injuries, neurological
kussmaul breathing -> deep and rapid, DKA or metabolic acidosis
agonal or guppy breathing -> irregular, long pauses, gasping, not effective, end of life, last breaths
6
Q
titration of oxygen algorithm
A
maintain O2 sat at 92% and above
if lower, increase O2
if greater than 96% try to wean oxygen down
7
Q
low flow O2
A
inspiratory flow not met -> will be breathing in RA as well
ventilatory pattern influences FiO2 -> more variable percentage
measured in L/min -> titrate by 1-2 L
include: NP, simple mask, non-rebreather
8
Q
high flow O2
A
inspiratory flow met/exceeded
ventilatory rate doesn’t effect FiO2 -> more predictable
measured in % -> titrate by 5-10%
some are humidified
single or double flow -> 1 or 2 flow meters, increases amount of O2 delivered to pt.
includes: aerosol/ stars wars/ Venturi/ trash masks/ face tent/ T-piece/ airvo/ optiflow
9
Q
AquaPak Humidified O2 system
A
air entrainment port -> 28-98% FiO2
patient specific
connects to corrugated tubing
replace prefilled sterile water bottle as needed
change tubing Q7days
10
Q
aerosol mask
A
administers a specific FiO2 -> determined by air entrainment port on aquapak
corrugated tubing collects moisture
exhalation ports allows air from the room if oxygen were to be inadequate
11
Q
Star Wars mask
A
regular aerosol mask with two 6 inch pieces of corrugated tubing to be used as reservoirs
less air inhaled from the exhalation ports
generally requires a double flow system
ensure flowmeter(s) set as directed by RT
12
Q
trach mask
A
placed around the neck and tracheostomy to ensure adequate oxygen/humidification delivery
single or double flow
imprecise FiO2
13
Q
T-piece
A
attached to an endotracheal tube of trach tube
6inch reservoir tubing attached to the other side of the T
precise FiO2
single or double flow
14
Q
nursing care for oxygen therapy
A
label equipment with pt name and date
clean face mask and prongs
assess straps -> change when soiled
observe for pressure sores
complete resp/cardio assessment as per dr orders, per protocol, or PRN
ensure adequate sterile water and assess setting levels for high flow O2
assess tubing for excess h2o and empty as needed
15
Q
high flow O2 and eating
A
NP at 6L may be needed
have the mask available for in-between bites
16
Q
optiflow and airvo
A
high flow oxygen delivery systems used for pt with profound hypoxemia and/or mucocilliary clearance difficulties
heated and humidified gas at 37 degrees
can provide both low and high flow O2
nasal, mask, or trach interface
17
Q
benefits of optiflow and airvo
A
not considered AGMP
more comfortable
pt can eat and drink
precise oxygen concentration
decreased WOB
promotes ciliary movement and secretion clearance
18
Q
airvo ranges
A
flow range = 2-60 L/min
FiO2 range = 0.21 to 1.20 (21% to 100%)
19
Q
optiflow ranges
A
flow range = 10 -60 L/min
FiO2 range = 28% to 100%
20
Q
optiflow and airvo monitoring
A
resp and cardio assessments/ vital sign Q4h and PRN for the first 24 hours
after 24 hours monitor as determined by the team
monitor for change in WOB, oxygenation -> if declining changed notify RT, CCN, or MRP
monitor FiO2 setting, flow rate, temp, and sterile water bag at least every 4 hours
humidifier should be on “invasive mode” unless the client has a trach or aerosol mask on
RT or CCN are the only ones who can titrate, initiate (with dr orders) and discontinues it (with dr orders)
21
Q
e-sized cylinders
A
are often used in acute care as a transport oxygen cylinder
22
Q
how to calculate how long an O2 cylinder will last
A
PSI that is in the tank x the conversion factor divided by the L/min the client requires
23
Q
oropharyngeal airway
A
only use in pt with altered LOC -> can stimulate the gag reflex
do NOT tape airway in place
mouth care every 2 hours or as per protocol
may be suctioned PRN
remove and assess the mouth every 8 hours
24
Q
inserting an oral airway
A
- don gloves
- measure the oral airway from the centre of the mouth to the angle of the jaw or corner of mouth to earlobe
- smiley face up until it reaches the soft palate then rotate 180 degrees
25
nasopharyngeal airway
tolerated better by more alert pt than the oral airway
inserted into the nare
provide frequent oral and nasal care
reposition the airway in the other care every 8 hours if required
26
inserting a nasal airway
1. don gloves
2. measure the nasal airway from pt earlobe to the tip of the nostril
3. ensure the diameter of the airway is not larger than the nostril
4. lubricate airway with water soluble jelly
5. insert along the floor of the nostril with a slight twisting action, aim towards the back of the opposite eyeball
27
assessment and management of a trach
focused respiratory assessment
note the character of the secretions from the trach
presence of drainage on the trach dressings or ties
note the appearance of the incision/new stoma -> redness, swelling, purulent discharge, odour
28
bedside safety equipment for trachs
- suction
- oxygen equipment with humidification
- two replacement trach tubes -> one the same size, one smaller
- obturator and spare inner cannula
- 10 mL syringe
- tracheal dilators or forceps
- sterile gloves
- water-soluble lubricant
- spare ties
- normal saline nebula
- manual resuscitation device with appropriate airway and mask
* if jaw wired shut, have jaw cutters available at bedside
29
when would you need a chest tube?
- when pressure placed on the lung interferes with expansion
- when negative pressure needs to be restored
- when air or fluid needs to be drained
- may be used in chronic conditions
30
pleural space
where chest tubes are usually inserted -> in-between the membranes that line the lungs
upper anterior thorax for pneumothorax
lower lateral chest wall for fluid
31
assessing pt with chest tube
prioritize chest tubes during QPA
advanced resp assessment
advanced cardio assessment
pain -> give PRN analgesic
deep breathing and coughing every 2 hours -> may be contraindicated in lobectomy
assist with range of motion/mobilizing as needed
32
assess chest tube insertion site
look at the site q4h
is the dressing dry and secure?
no air leaks?
palpate and listen for subcutaneous emphysema
33
assess chest tube drainage system
- ensure closed drainage system
- ensure all connected are taped and secure as per policy
- tubing is free from kinks or compression
- no dependent loops
- drainage system below level of chest
- drainage system properly secured
- blue clamp is OPEN
- check for tidaling. with respirations
- ensure suction control dial is set to ordered level -> usually 20cm
- check for bubbling in air leak monitor
- record date/time/amount of drainage on the outside of the chamber
- record the amount/characteristic of drainage on the fluid balance sheet
34
chest tube bedside safety equipment
- 2 clamps -> non toothed or padded
- waterproof tape
do not clamp chest tube unless ordered by MRP, changing chamber, checking for leaks, or the tube is dislodged
35
if chest tube is disconnected from drainage system
EMERGENCY
1. have pt exhale
2. double clamp and/or submerge the end in 2cm of sterile water
3. clean ends with alcohol and reconnect immediately
4. unclamp
36
is chest tube is pulled out
EMERGENCY
1. cover insertion site with a gloved hand and call for help
2. cover site with sterile gauze and tape -> have pt exhale
3. only tape top and sides -> leave bottom open
4. cal MRP
37
if chest tube has an air leak
begin at dressing and clamp momentarily -> work towards the drainage chamber in 20 to 30 cm increments
each time you clamp check the water-seal/air leak monitor to see if bubbling stopped
once bubbling stops will tell you wear the leak is
38
clots blocking chest tube and bright red drainage
do not strip or milk the tubing
may need to change drainage system
notify MRP if needed
bright red drainage may indicate active bleed -> monitor amount of drainage and VS -> notify MRP
39
inter dermal injections
into the dermis
low blood supply, slow absorption
can administer very small amount of liquid -> 0.1 mL
needle length 1/4 to 1/2 inch, and 25 to 27 gauge
40
TB
airborne transmission
can be latent or active
TB most common in lungs, can infect other areas like brain, kidney, spine
tx includes combination of oral antibiotics for >6 months
isolation until no longer contagious
if going for a test, pt must wear a surgical mask
41
3 types of sputum collection
C&S -> identify organisms and drug sensitivities
cytology -> identify origin, structure, function, and pathology of cells, often requires serial collection of 3 early morning speciments
AFB (acid-fast bacillus) -> requires serial collection often for 3 consecutive days, test for TB
42
how to collect sputum
- collect in the morning, before eating
- offer mouth care, but not mouth wash
- don gloves
- pt takes deep breath and cough
- need 15 - 30 mL
43
goals of diabetes management
- promote well being
- reduce symptoms
- prevent acute complication of hyperglycemia and hypoglycemia
- delay the onset of and progression of long term complications
44
fasting blood glucose (FBG) levels
no caloric intake for at least 8 hours
< or = 6 mmol/L is normal
6.1 to 6.9 mmol/L is pre diabetes
= or > than 7.0 mmol/L is diabetes
45
hemoglobin A1c levels
glycated hemoglobin
measured to determine the average blood glucose levels over the last 3 moths
< 5.5% is normal
5.5 - 5.9% is risk of diabetes
6.0 - 6.4% pre-diabetes
6.5% and greater is diabetes
46
random plasma glucose
without regards to meals
< 11.1 mmol/L is normal
47
nova machine levels
4 (3.3) to 7.0 mmol/L is good
5-8 is the target range in hospital
6-10 is target range for critically ill
48
hypoglycemia S+S
- blood glucose <4
- cool, clammy skin
- rapid HR
- heart arrhythmias, faintness, dizziness
- nervousness, tremors, shaking
- hunger
- emotional changes
- numbness of fingers, toes, mouth
- slurred speech, unsteady gait
-changes in vision
- seizures, coma
symptoms are similar to someone who is intoxicated
49
causes of hypoglycemia
- insulin overdoes or sulphonylurea overdose or response to recent change in dose
- missed or inadequate meal
- unexpected exercise
- error in timing of dose
50
hyperglycemia S+S
- blood glucose greater than 11
- polyuria
- polydipsia
- polyphagia
- weakness, fatigue
- blurred vision
- headache
- N/V
- abdominal cramps
- glycosuria
51
causes of hyperglycemia
- inadequate doses of insulin
- infection
- stress
- surgery
- meds -> steroids, benzos
- variation in nutritional intake
- receiving PN or EN
- critical illness
52
blood glucose monitoring (BGM)
should be done within 30 mins before a meal (ac meal) or 2 hours after a meal (pc meal)
whole blood is used -> capillary, venous, arterial
if pt is on anticoagulants hold pressure for 5 mins after using lancet
53
BGM test strips
are good for 180 days after opening
54
BGM QC vials
are good for 90 days after opening
55
BGM results on the Nova
normal = 3.3 to 7.0 mmol/L
critical low = <2.6 mmol/L
critical high = > 25 mmol/L
56
cloudy and clear insulin
cloudy is usually longer acting insulin
clear is often shorter acting, but can also be longer acting
aspart and regular insulin are always clears
NPH is cloudy
glargine is clear
you can mix 2 insulin's together -> typically 1 short acting and 1 long acting
you need to draw up the clear insulin before you draw up the cloudy insulin
57
basal insulin
required to cover rise in blood glucose between meals and overnight
calculation depends on weight -> estimated dose is 1/2 of TDD
includes long acting and intermediate acting insulins -> NPH, degludec, and glargine
58
bolus insulin
required to cover rise in glucose due to meals
may use the pre-admission meal dose
usually 1/2 of TDD divided equally among the 3 meals
aspart
59
insulin correction dose
is used alone q4h is pt is NPO -> no regularly scheduled basal doses
60
ISF
insulin sensitivity factor
the higher the ISF the more sensitive the client is to insulin -> requires less insulin
1 = need more to do less
4 = need less to do more
ISF 4 = 4 units of 1 unit of insulin will decrease blood sugar by 4 mmol/L
61
ISF calculation
100 divided by the TDD
62
SC med administration
is absorbed more slowly than meds given by the IM route
require a dr order prior to administration of the med via sc route
this route is not recommended for severe, uncontrolled, escalating pain due to slow absorption
63
insulin pen needle size and length
needle sizes = range from 29 - 32
needle length = determined by assessment of pt adipose tissue -> typically is 4mm - 12mm (5/32 to 1/2 inch)
angle of insertion is usually 90 degrees for insulin pen
64
volume of SC medication
only small doses
0.5 to 1ml of water-soluble meds should be given subcu
up to 2mL is safe
65
angle of insertion for insulin pen
usually 90 degrees
pinching is only necessary when using a longer needed on someone slim to prevent IM injection
66
SC site selection for insulin
lateral outer upper arms
anterior and lateral thigh, butt, abdomen
pt should rotate injection site within the same body part to provide better consistency of the absorption of insulin -> 2.5 cm away from last injection site
abdomen has the quickest absorption for insulin
67
disinfection for a SC injection
disinfection of the site is not usually required
-> in home most people don't alcohol swab
-> in hospital alcohol swabs are usually used
68
cloudy insulins
always mix insulin suspensions
gently roll x10 and invert 10x
69
1 mL to 3 mL syringes
are typically used for subcut and IM injections
70
determining needle length and gauge
length of needle is dependent on assessment -> client weight and size, location of injection site
needle gauge is determined by -> viscosity of med, location of injection, type of injection
71
syringes with meds
must be labelled with
-> 2 patient identifiers
-> name of med
-> dose and volume
-> route
72
Subcut injections
usually less than 1 mL is injected via SC (safe up to 2mL)
syringe size = usually 1-3mL
needle size = usually 25G and 5/8 long
administer at a 45 degree angle is 2.5cm of tissue can be grasped
administer at a 90 degrees angle if 5 cm of tissue can be grasped
rotate administration site to minimize tissue damage, maintain absorption, and avoid discomfort
administer anywhere there is enough subcut tissue to pinch an inch
73
SC heparin injections
should be injected at least 5cm away from the umbilicus
heparin is injected at 90 degrees
assess abdomen for trauma prior to selecting injection site -> abdomen is preferred injection site as it absorbs slower due to fat, but other site can be used
heparin requires a IDC
74
LMWH profiled syringe
comes in a spring loaded pre-filled safety syringe with the needle attached -> there is an air bubble in the barrel
dont prime it and remove the air bubble -> if you have to remove some of the med ensure you add the bubble back
75
insulin syringes
are in units instead of mLs
needles come attached
usually 26 -31 gauge and 1/4 to 1/2 inches long
insulin is absorbed more quickly in
-> abdomen
-> then arms
-> them thighs and buttocks
76
drawing up long acting and short acting insulins
air into cloudy (long acting)
air into clear (short acting)
draw up clear
draw up cloudy
77
mixing 2 insulins into 1 syringe
NOT ALL INSULINS CAN BE MIXED
when inserting air into vials make sure not to touch solution with the needle
IDC must be done after drawing up the clear dose, and then again after drawing up the cloudy
must get the accurate dose when drawing up the second vial, if you have to push some back into the vial -> you have to restart entire process
78
priming a subcut butterfly
add an additional 0.36mL is first dose when initiating a SCBF to prime the line
79
inserting a SCBF
make sure to swab with chlorhexidine
insert at a 30-45 degree angle
make sure you label it with the med, concentration and date
80
IM injections
fairly quick absorption from muscle tissue
muscles can accept more fluid and irritating meds that should nit be given via subcut
usually 1-3mL syringe
usually 21-23G and 1/2 to 1 1/2 inch needle -> length is determined by the site and weight of pt and gauge is determined by viscosity of liquid
obese clients may need up to 3 inches
inserted at a 90 degree angle
site is determined by med and volume
81
ventrogluteal
preferred IM site in adults
landmark identifiers:
- greater trochanter
- iliac crest
- anterior superior iliac spine
typically up to 3mL - some cases 5mL
can give in side-lying, supine, or prone positions
82
deltoid
IM injection site
lateral aspect of the arm
landmark identifiers:
- acromion process -> injection 3-5cm below
- axilla -> in between these 2
83
vastus lateralis
side of the leg
typical up to 3mL - up to 5mL is ok
landmark identifiers:
- arterial lateral aspect of the thigh -> the middle third, hand above the knee below the hip -> go in the middle of that
- greater trochanter
- lateral femoral condyle
84
rectus femoris
anterior aspect of the thigh
up to 3mL, max 5mL
landmark identifiers:
- anterior aspect of the thigh
- anterior superior iliac crest
- patella
this location may cause considerable discomfort
85
dorsogluteal
DO NOT ADMINSTER HERE
risk of sciatic nerve damage
86
risks of IM injections
- pain
- bleeding
- abscess
- cellulitis
- tissue necrosis
- granuloma
- muscle fibrosis
- contractures
- hematoma
- injury to blood, vessels, bone, nerves
87
audible abdominal vascular sounds
in addition to regular bowel sounds -> bruits are sometime heard during auscultation, could indicate an aortic aneurysm, but also don't always indicate disease
88
EN
administration of nutrients directly into the GI tract
it is the preferred method for providing nutrition and should be used when the pts GI tract is functional
considered an advanced directive -> could be ethical complications
89
S+S of malnutrition
- mental confusion, irritability, unable to concentrate, listless
- lack of appetite and interest in food
- changes in skin colour
- dry, scaly skin, brittle, pale nails, dry, dull, sparse hair
- swollen and bleeding gum, decaying teeth
-eyes dry, sunken, hollow cheeks
- fatigue low energy
- distended abdomen, enlarged liver
- weight loss
- poor immune function
90
abnormal blood results in malnutrition
decreased:
- albumin/pre albumin and total protein
- Hgb/Hct (if anemic)
- iron/components
- lymphocytes (increased during infection)
- blood glucose
- K+ and calcium
- BUN and CR (increased if hypovolemic from dehydration)
- serum vitamin and mineral levels
Increased
- liver enzymes -> liver damage
91
re-feeding syndrome
this occurs in malnourished pt who are fed with high carb loads
carbs in the feed can cause a large increase in the circulating insulin level -> results in rapid and dramatic fall in phosphate, potassium and magnesium -> increases extracellular volume
body tries to switch from catabolic to using exogenous fuel sources -> increase in oxygen consumption -> increased resp and cardiac workload -> can lead to multiple organ failure, resp or cardiac failure, arrhythmias, rhabdomyolysis, seizures, coma
feeds should be started slowly and electrolytes closely monitored and adequately replaced to avoid this
92
pulmonary aspiration
signs
- increased SOP
- productive cough
- sputum
- difficulty swallowing
to prevent
- ensure head of bed is elevated with a continuous tube feed is running and for 1 hour after and intermittent feed
93
aspiration risk factors
- head of bed less than 30 degrees
- impaired LOC
- neurological deficits
- poor oral health
- Mal-positioned feeding tube
- age over 60
- delayed gastric emptying
94
tx of aspiration
- stop feed immediately and notify MRP
- lower head of bed and put client on left side to prevent further seepage of formula into lungs
- suction as needed
- monitor O2 sat and administer O2 if needed
- anticipate order for urgent chest x-ray
95
short-term feeding tubes
required for short term feeds -> 4-6 weeks
nasogastric tubes
- inserted down the nose and into the stomach
- requires intact gag and cough reflex to protect airway
- must have adequate gastric emptying
- can be hard bore and soft bore
hard bore :
Salem sump
- larger tube, double lumen
- 12 to 18 fr
- may be used for suction as the smaller vent lumen allows for inflow of air
Levin
- single lumen
- needs to be changed weekly
- often used with anti-reflux valve
soft bore:
- most common for EN
- usually 6-12 fr
- smaller, more flexible, less irritating
- may have weighted tip
- stylet to help with insertion
- need to be changed monthly
naso-enteric tubes
- inserted into the small intestine
- used in pt with increased risk of aspiration
96
anti-reflux valve
prevents gastric reflux or leakage through the vent lumen or a double lumen nasogastric tube
allows the passage of air into the vent lumen with atmospheric pressure exceeds stomach pressure -> when stomach pressure exceeds atmospheric pressure, the valve prevents flow of fluids through the tube
97
complication of nasal tubes
- aspiration
- misplacement of tube
- nasal pharyngeal irritation and pain
- sinusitis, sore throat, epistaxis
- perforation -> rare
- inadvertent lung placement
- intracranial placement
98
long term feeding tubes
G-tube or J-tube
- usually used for more than 6-8 weeks
- placed surgically or by laparoscopy through the abdominal wall into the stomach or jejunum
- usually longer NPO time before starting feeds
- larger incision
PEG tube or PEJ tube
- used for more than 6-8 weeks
- smaller incision
- uses an endoscope to visualize the inside of stomach, puncture made through skin, insert tube through puncture
- shorter NPO time
- has a catheter that has an external bumper
- has an internal inflatable rendition balloon to maintain placement
99
complications of G/PEG and J?PEJ tubes
- peristome infection
- leakage
- accidental tube removal
- tube blockage
- tube fracture
- peritonitis
- aspiration pneumonia
- bleeding
100
long term feeding tube balloon volume checks
don't check volume for the first 4 weeks after insertion
use a slip tip to avoid damage
remove all of the old water, measure and discard
with a new syringe draw up appropriate amount of water and re-inflate balloon to prescribed level
101
closed feeding systems/ continuous drip
- usually used when pt does not tolerate bolus feeds
- 1000 - 1500mL
- hang time up to 48 hours
- are essential when feeding are administered into the small bowel
- tubing change with bag change
- usually run using a pump
- always start at slow rate and increase as tolerated
102
open system/ bolus or intermittent feed
- used when pt can tolerate
- 250mL tetra packs or cans, or dry powder
- usually 300 - 500mL given several times per day
- given over at least 30mins
- must be given only in the stomach
- open system bags and tubing need to be rinsed with tap water, drained, and hung to dry following intermittent feeds
change bag and tubing, and syringes/bowels/cups every 24 hours
change attachments weekly
103
labelling feeding systems
- client info
-date and time
- initials
- enteral feeding formula type, rate, strength, and amount
104
EN formula hang times
tetra pack -> 8 hours
reconstituted powder formula -> 4 hours
closed system -> 48 hours
105
lab orders for EN
baseline
- CBC
- lytes
- urea
-creatinine
- random glucose
- calcium, phosphorus, magnesium
- albumin
daily x 3 days
- lytes
- urea
-creatinine
- random glucose
- phosphorus, magnesium
weekly x 3
- CBC
- lytes
- urea
-creatinine
- random glucose
- calcium, phosphorus, magnesium
- albumin
106
rate of EN administration
standard feed
25mL/h, if tolerate increased to 50mL/h after 8 hours
referring syndrome risk
25mL/h for minimum of 24 hours
do not increase rate until potassium, phosphorus, and magnesium are in normal levels
107
flushing feeding tubes
flush every 4 hours with 50mLs for continuous feeds
flush before and after meds with at least 15mL and flush 30mL after all meds
flush pre and post bolus feed
flush 50mL BID if feeding tube not in use
use tap water for routine flushes, and sterile water in immunocompromised pt and babies less than 3 moths
108
J-tubes
do not twist them -> will become twisted and blocked
109
