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Sprinig 2018 > N388 Unit 3 > Flashcards

N388 Unit 3 Flashcards

1
Q

Cyanosis

A

bluish/grayish discoloration of skin/mucous membranes

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

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2
Q

Dyspnea

A

difficulty breathing, labored breathing

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3
Q

Edema

A

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

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4
Q

Nocturia

A

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?

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5
Q

Orthopnea

A

can’t breathe lying flat, needs to sit up

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

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6
Q

Tachyn[ea

A

increased respiration

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7
Q

Presenting Problems: cardiovascular

A 
Chest pain
Cough
Cyanosis
Dyspnea
Edema
Fatigue
Nocturia
Orthopnea

associated symptoms: diaphoresis, nausea, dyspnea

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8
Q

Diaphoresis

A

Cold sweat

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9
Q

Cough

A

Frequency, duration, positional, productive, hemoptysis

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10
Q

hemoptysis

A

coughing up blood, quantity, # of tissues

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11
Q

productive cough

A

sputum produced? color, amount

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12
Q

Rales/crackles:

A

fine or coarse, often heard on inspiration

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13
Q

Rhonci

A

coarse, often heard on exhalation

Babbly brook, noisy sound of fluid, mucus in airway

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14
Q

Wheezes

A

high pitched sounds heard on inspiration or exhalation or both

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15
Q

Factors affecting oxygenation

A

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

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16
Q

Pulmonary Focused Assessment

A

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

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17
Q

atelactasis

A

Collapsed alveoli

Who is at risk? Clients who:
smoke
respiratory disease
obesity
post-surgery
hospitalized
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18
Q

need for oxygenation

A

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

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19
Q

Position interventions for breathing

A

Orthopneic
Tripod
Changing positions
Mobility

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20
Q

Deep breathing

A

Abdominal breathing
Pursed lip breathing
Coughing
Huff coughing

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21
Q

Breathing interventions

A

Position
Deep breathing
Incentive spirometer

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22
Q

Incentive spirometer

A 
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)
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23
Q

Positive pressure machines

A

CPAP: Continuous Positive Airway Pressure

BiPAP: Bilevel Positive Airway Pressure

Why positive pressure? Putting pressure in will prevent
collapse

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24
Q

Why supplemental oxygen

A

Treat hypoxia <92%

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25
Q

Causes of hypoxia

A

Anxiety, confusion, restlessness

26
Q

Oxygen as medication

A

Need order to…

Starting oxygen
Titrating
Delivery device

27
Q

Setting up oxygen

A

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

28
Q

oxygen devices

A 
Nasal cannula
Simple face mask
Non-rebreather mask
Partial rebreather mask
Venturi mask
Face tents
29
Q

Face tents

A

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

30
Q

Nasal cannula

A 
Common
Comfortable
Prongs face back/down
1-6 L/min flow rate
24-44% FiO2
Home oxygen
31
Q

Simple face mask

A 
Common in PACU
5-8 L/min flow rate
40-60% FiO2
Mixing at side ports
Short term use
32
Q

Non-rebreather mask

A 
Common in PACU
5-8 L/min flow rate
40-60% FiO2
Mixing at side ports
Short term use
33
Q

Partial rebreather mask

A

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

34
Q

Weaning oxygen device

A

Remember right device
As oxygenation improves
Consider weaning the delivery device

35
Q

Things to consider with needles

A

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

36
Q

Needles

A

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)

37
Q

Oxygen safety

A 
Beware of other fire sources
Electrical equipment
Heat sources 3-5 ft away
Avoid petroleum based products on face
Tubing
38
Q

Types of Injections

A

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

39
Q

Injection risks

A

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

40
Q

Intradermal Injections

A 
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)
41
Q

Subcutaneous Injections

A 
*rotate sites
Below skin, deeper levels of tissues
Recommended in abdomen only - insulin, heparin &amp; 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
42
Q

Ventrogluteal

A

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

43
Q

Vastus lateralis

A 
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
44
Q

IM sites

A

deltoid
ventrogluteal
vastus leteralis

45
Q

Nurses role in IM administration

A 
Look at patient: size, muscles, subcutaneous tissue
Medication: volume, viscosity
Determine:
Syringe size
Needle gauge
Needle length
Location for injection
Technique/angle of injection
46
Q

Special IM techniques

A

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

47
Q

GU System Focused

A

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

48
Q

GI System Focused

A

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

49
Q

Sexual history

A

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

50
Q

5 P’s of Sexual History

A

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

51
Q

PLILSSIT model for sexual history

A

Permission
Limited information
Specific suggestions
Intensive therapy

52
Q

Minors consent

A

Governed by state law and thus, variable!

Nurses’ duty to know laws of stat where care is delivered

53
Q

Strategies to reduce CAUTI

A

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

54
Q

Biofilm

A

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

55
Q

Guidelines for preventing CAUTI

A

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

56
Q

Wounds are

A

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

57
Q

Wound assessment & documentation

A 
Overall appearance
Color
Drainage
Size
Depth
Undermining and/or tunneling
Swelling
Pain
*Use clock for describing
58
Q

Factors influencing wound healing

A

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

59
Q

Pressure Injury

A

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

60
Q

Braden scale

A

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

61
Q

Device Related Pressure Injuries

A

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

62
Q

pressure ulcer prevention/nurse intervention

A

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

Sprinig 2018 (6 decks)

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