N388 Unit 3

Question 1

Cyanosis

Answer 1

bluish/grayish discoloration of skin/mucous membranes

Q’s: Have you ever noticed (or anyone told you) that your skin is pale or bluish?

Question 2

Dyspnea

Answer 2

difficulty breathing, labored breathing

Question 3

Edema

Answer 3

Accumulation of fluid

Q’s: Do you have any swelling of your feet and legs? Onset, time of day, how much, does it going away

Grading scale for pitting edema

Question 4

Nocturia

Answer 4

increased urination at night; wakes people to pee

Q’s: Do you awaken at night with the sudden urgent need to urinate? how long has this been occurring?

Question 5

Orthopnea

Answer 5

can’t breathe lying flat, needs to sit up

Q’s: how many pillows do you sleep on?

Question 6

Tachyn[ea

Answer 6

increased respiration

Question 7

Presenting Problems: cardiovascular

Answer 7

Chest pain
Cough
Cyanosis
Dyspnea
Edema
Fatigue
Nocturia
Orthopnea

associated symptoms: diaphoresis, nausea, dyspnea

Question 8

Diaphoresis

Answer 8

Cold sweat

Question 9

Cough

Answer 9

Frequency, duration, positional, productive, hemoptysis

Question 10

hemoptysis

Answer 10

coughing up blood, quantity, # of tissues

Question 11

productive cough

Answer 11

sputum produced? color, amount

Question 12

Rales/crackles:

Answer 12

fine or coarse, often heard on inspiration

Question 13

Rhonci

Answer 13

coarse, often heard on exhalation

Babbly brook, noisy sound of fluid, mucus in airway

Question 14

Wheezes

Answer 14

high pitched sounds heard on inspiration or exhalation or both

Question 15

Factors affecting oxygenation

Answer 15

Age, environment, lifestyle, health status, medications, stress

Question 16

Pulmonary Focused Assessment

Answer 16

Subjective
Difficulty breathing? Shortness of breath? Constant? Duration? Position? Does shortness of breath interfere with activities of daily living?
Do you have a cough? Frequency, duration, positional, productive, hemoptysis
Objective
Vital signs & Pulse oximetry
Inspection (can they speak in full sentence, work of muscles)
General survey: work of breathing, obvious distress, speak in full sentences, respiratory rate, accessory muscle use, nasal flaring in infants,
Auscultation: Adventitious breath sounds

Question 17

atelactasis

Answer 17

Collapsed alveoli

Who is at risk? Clients who:
smoke
respiratory disease
obesity
post-surgery
hospitalized

Question 18

need for oxygenation

Answer 18

Collapsed alveoli (atelectasis), Damaged alveoli, shallow breathing, positioning, immobility

Question 19

Position interventions for breathing

Answer 19

Orthopneic
Tripod
Changing positions
Mobility

Question 20

Deep breathing

Answer 20

Abdominal breathing
Pursed lip breathing
Coughing
Huff coughing

Question 21

Breathing interventions

Answer 21

Position
Deep breathing
Incentive spirometer

Question 22

Incentive spirometer

Answer 22

Position and breath
Seal lips around mouthpiece
Take slow and steady breath
Hold for 3 seconds
Breathe out normally
10 times an hour (i.e., during commercial breaks)

Question 23

Positive pressure machines

Answer 23

CPAP: Continuous Positive Airway Pressure

BiPAP: Bilevel Positive Airway Pressure

Why positive pressure? Putting pressure in will prevent
collapse

Question 24

Why supplemental oxygen

Answer 24

Treat hypoxia <92%

Question 25

Causes of hypoxia

Answer 25

Anxiety, confusion, restlessness

Question 26

Oxygen as medication

Answer 26

Need order to... Starting oxygen Titrating Delivery device

Question 27

Setting up oxygen

Answer 27

LPM = liters/minute FiO2 = fraction of inspired Consider humidification @ > 4LPM Don’t delegate to NAP

Question 28

oxygen devices

Answer 28

``` Nasal cannula Simple face mask Non-rebreather mask Partial rebreather mask Venturi mask Face tents ```

Question 29

Face tents

Answer 29

Humidification Not too tight or confining 4-8 L/min 30-50% FiO2

Question 30

Nasal cannula

Answer 30

``` Common Comfortable Prongs face back/down 1-6 L/min flow rate 24-44% FiO2 Home oxygen ```

Question 31

Simple face mask

Answer 31

``` Common in PACU 5-8 L/min flow rate 40-60% FiO2 Mixing at side ports Short term use ```

Question 32

Non-rebreather mask

Answer 32

``` Common in PACU 5-8 L/min flow rate 40-60% FiO2 Mixing at side ports Short term use ```

Question 33

Partial rebreather mask

Answer 33

High levels of O2 delivery 6-10 L/min 40-60% FiO2 Rebreath ⅓ of expired air

Question 34

Weaning oxygen device

Answer 34

Remember right device As oxygenation improves Consider weaning the delivery device

Question 35

Things to consider with needles

Answer 35

Giving less than 1 ml? Use a tuberculin or 1 mL syringe Giving an IM injection? YOu need a longer needle- based on musculature/body size Vials Liquid medication Dry powder- reconstituted with diluent Do not shake- Bubbles Before drawing up med alcohol swab for 15 seconds For multi-dose vials: date, time, initial ``` Ampules Glass Filter needle needle to give and needle to inject!! Safety Tap top of ampule ``` Needle safety No recapping of USED needles Slide into cap and top it after

Question 36

Needles

Answer 36

Hollow Size: length in inches The longer the needle the farther it goes Gauge: diameter The larger the gauge the smaller the needle (Ex:16-25 = largest to smallest)

Question 37

Oxygen safety

Answer 37

``` Beware of other fire sources Electrical equipment Heat sources 3-5 ft away Avoid petroleum based products on face Tubing ```

Question 38

Types of Injections

Answer 38

Skin (Intradermal- ID)- i.e., TB test Subcutaneous (SC) - below skin but not muscle Muscle (Intramuscular, IM) Intravenous (IV)

Question 39

Injection risks

Answer 39

Fibrosis, nerve/bone/blood damage, abscess, tissue necrosis, muscle contraction, gangrene, pain

Question 40

Intradermal Injections

Answer 40

``` Small volume - TB syringe Small needle size 25-27 gauge Length: ¼ to ⅝ inch long Bevel up- 5-15 degree angle Location: smooth flat area of skin, forearm, areas of back Uses: PPD, allergy and other skin tests Bleb forms (looks like blister) ```

Question 41

Subcutaneous Injections

Answer 41

``` *rotate sites Below skin, deeper levels of tissues Recommended in abdomen only - insulin, heparin & enoxaparin 45 to 90 degree angle Syringe appropriate to amount Size: 25 gauge (or smaller 27, 29) Length: ⅜ to ⅝ inch long A lot of body? Can do SQ ```

Question 42

Ventrogluteal

Answer 42

Preferred site for adults Gluteus medius muscle Deep and away from major nerves and blood vessels 1-3 mL/injection for average, well-nourished adult 90 degrees Size: 21-22 gauge Length 1.5 inches

Question 43

Vastus lateralis

Answer 43

``` Preferred in children Muscle is thick and well developed Middle third of muscle .5-2mL volume 90 degrees Adult: Size: 21-22 gauge Length: 1-1.5 inches PEDS: Size 22-25 gauge Length: ⅝ to 1 inch ```

Question 44

IM sites

Answer 44

deltoid ventrogluteal vastus leteralis

Question 45

Nurses role in IM administration

Answer 45

``` Look at patient: size, muscles, subcutaneous tissue Medication: volume, viscosity Determine: Syringe size Needle gauge Needle length Location for injection Technique/angle of injection ```

Question 46

Special IM techniques

Answer 46

Z track Seals medicine in muscle tissue Prevents irritation and discoloration of subcutaneous tissue Air lock Less irritating with needle withdrawal Only a few meds

Question 47

GU System Focused

Answer 47

Presenting problems: Bleeding, change in skin integrity (ulcers, erythema), discharge, dysmenorrhea, dyspareunia, erectile dysfunction, hematuria, incontinence, LMP, pain, prolapse, retention, UTI Subjective Sexual history Objective Inspection of the GU system Urine (color, quantity) Urinary retention: inspect and palpate at symphysis pubis, bladder scan

Question 48

GI System Focused

Answer 48

Presenting problems Ascites, anorexia, constipation, dehydration, diarrhea, distension, dysphagia, flatus, emesis/vomitus, hemorrhoids, hernia, incontinence (fecal), jaundice, nausea, pain, vomiting Subjective Diet prefences/24 hours recall H/W/BMI Bowel patterns ``` Objective Physical assessment of abdomen and GI system I, P, P, A Acute problems: objective data Bowel sounds Flatus Vital signs I and O Skin turgor and mucous membranes Physical assessment of GI system and abdomen ``` Other GI related terms Food security/insecurity (SDOH) Enteral nutrition Parenteral nutrition - delivered through central lines Medical nutrition therapy - use of diet to soothe medical issue NPO vs. fasting NPO- strict, dysphagia, OR/GI issue Fasting- usually can have water, may be for a test

Question 49

Sexual history

Answer 49

Is this an expectation of the nurse in this setting? Importance of sexual health to overall health Legitimate part of a health assessment Consider cultural influences and modify questions and approach as needed

Question 50

5 P's of Sexual History

Answer 50

Partners (do you have sex with men/women/both) Practices (do you have oral/vaginal/anal sex?) Protection from STI (monogamous, serial monogamous) Past history of STIs Prevention of pregnancy

Question 51

PLILSSIT model for sexual history

Answer 51

Permission Limited information Specific suggestions Intensive therapy

Question 52

Minors consent

Answer 52

Governed by state law and thus, variable! | Nurses’ duty to know laws of stat where care is delivered

Question 53

Strategies to reduce CAUTI

Answer 53

Properly secure catheter to minimize movement Maintain closed system Keep catheter and collecting tube free from kinking Keep urine collecting bag below the level of the bladder and off the floor Empty the urine collecting bag regularly

Question 54

Biofilm

Answer 54

complex group of microorganisms that functions within a slimy gel coating on medical devices

Question 55

Guidelines for preventing CAUTI

Answer 55

Insert under strict aseptic technique Hand hygiene when touching any component of urinary system Secure indwelling catheter Use Soap & Water

Question 56

Wounds are

Answer 56

Wound is a disruption in the normal structure and function of the skin and underlying soft tissue and can be related to a variety of etiologies; they are continuous throughout the lifespan, intentional vs. unintentional, open vs closed, acute vs. chronic

Question 57

Wound assessment & documentation

Answer 57

``` Overall appearance Color Drainage Size Depth Undermining and/or tunneling Swelling Pain *Use clock for describing ```

Question 58

Factors influencing wound healing

Answer 58

Age, diet, obesity, chronic diseases, smoking, tissue perfusion, medications, wound stress

Question 59

Pressure Injury

Answer 59

is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device; the injury can present as intact skin or an open ulcer and may be painful The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear

Question 60

Braden scale

Answer 60

Used for predicting pressure sore risk - 18 and below = @ risk

Question 61

Device Related Pressure Injuries

Answer 61

result from a medical device creating localized tissue compensation Key interventions: Secure with minimal pressure against underlying tissue Use soft dressings or foam around rigid edges If possible, remove/reposition device daily and assess skin underneath

Question 62

pressure ulcer prevention/nurse intervention

Answer 62

Reposition Every 2 hours while in bed/every 1 hour while in char Use pillows or wedges Use static air boots and/or cushions ``` Perform routine and PRN skin care Routine peri-care May require condom cath or fecal management device Moisture barrier ointment or paste Assess skin folds for moisture ``` Decrease friction and shear Use lifting devices to move patients Keep head of bed at greater than 30 degrees Nutrition Encourage a protein- rich diet and hydration Consult dietitian Mobility Encourage frequent movement/ambulation Consult physical and occupational therapy