NU 301 exam 4 Flashcards
When caring for a preoperative surgery patient you should determine their expectations on…
the surgery and road to recovery
A surgery patients nursing history should contain advanced directives which are
What the patient wants done if something goes wrong
When appointing a power of attorney… Must it be done before, during, or after hospitalization?
Before
What medical diagnosis are increased surgical risks?
Diabetes and Hypertension
Report any concerns about the patient’s understanding of the surgery to the…
operating surgeon or anesthesia provider.
Surgery cannot be legally or ethically performed until a patient fully understands a surgical procedure and all implications, except…
A medical emergency
Who’s responsibility is to to explain the procedure, associated risks, benefits, alternatives, and possible complications, before obtaining the patient’s oral and documented informed consent. The patient must also be informed about who will perform the procedure
The surgeon
After the patient or power of attorney signs the consent form, place it in the …
medical record
How can you minimize risk for surgical wound infection?
-antibiotics
-skin antisepsis
-clipping instead of shaving hair
How can you maintain a normal fluid and electrolyte level in a surgery patient?
-fasting before surgery
-IV fluid replacement
-Paternal nutrition
How long do patients typically need to fast before surgery?
12 hrs
What prep do colonoscopy patients need the day before surgery?
bowel prep
What must patients do hygiene wise before surgery?
hibicleanse
Can you wear makeup, fingernail polish or acrylics during surgery?
no
Can you wear prostheses during surgery?
no
What should you do with a patients valuables during surgery?
Valuables need to be locked up if there is no family member to keep up with it (labeled with name and room number)
What two things must you obtain before any surgery?
vital signs and consent
What is an antiembolism devise?
Antiembolism: SCD Sequential compression device. Pump up air to compress calves making blood flow back up to the heart and preventing stagnation / Ted hose go on before SCD. Patients must be measured because if they are too tight the can cut of circulation. Usually measured during preop
What medications do patients usually receive pre-op?
nausea meds
What should you document during hand-off?
Document the name of nurse giving hand-off report, what happened in OR, last vital signs, complications, how they did during surgery
Who must mark the site of surgery with the skin marker?
Patients have to mark their spot with skin markers, if they are not mentally there (dementia, autism) use a legal guardian, if none the surgeon must do it.
Why would you not share skin markers between patients?
Staff and MRSA live on the skin
What are some characteristic of agents that depress the central nervous system?
Depression of consciousness
Loss of responsiveness to sensory stimulation (including pain)
Muscle relaxation
What are the two types of anesthesia?
general and local
\What is balanced anesthesia?
anesthesia- simultaneous use of both general anesthetics and adjuncts.
Differentiate between general and local anesthesia
General is fully put to sleep and intubated
-Local is just numbing the area that is being worked on. Given a little medicine to be put in sleepy phase
How can you maintain respiratory function in a post-op patient?
turn, cough, deep breathe
How can you check a patient’s neurological function?
Check neuro function by squeezing hands, checking pupils with pen light, alert and oriented x4 (Name? DOB? Where are you at?)
What may be a factor in difficulty waking a patient up?
overmedication
What are PCA pumps?
PCA pump: Allows patient to administer pain medicine but will only allow dose in certain intervals (usually 30 mins to an hour). Educate family members that they can not press button. Nurses must document how much patients have used at end of shift.
How can you promote normal gastrointestinal function?
Ambulation (MUST HAVE A PHYSICIAN’S ORDER)
After what surgeries may coughing and deep breathing be contradicted?
after brain, spinal, head, neck, or eye surgery.
Bariatric patients may have more improved lung function and vital capacity in what positions?
he reverse Trendelenburg or side-lying position.
What are some signs of venous thromboembolism?
pain, tenderness, redness, warmth, or swelling in the upper or lower extremities
After hip surgery educate the patient not to..
abduct or adduct legs.
What two disorders give false positives with the Homan’s sign?
Achilles problems and plantitis
What should the nurse do if the post-op pt is having severe calf pain?
assess, call physicians, immediate ultrasound of lower extremity
What can Lovenox prevent?
DVT
What are some components of culture?
-Norms, values, and traditions
-Ethnicity, race, nationality, and language
-Gender, sexual orientation, location, class, and immigration status
What is intersectionality?
Belonging simultaneously to multiple social group
What is oppression?
A system of advantages and disadvantages tied to our membership in social groups
Culture affects how an individual defines…
the meaning of illness
Culture and life experiences shape a person’s world view about?
health, illness, and health care.
What is ethnocentrism?
The belief that our own group or culture is superior to all other groups or cultures
What is cultural competence?
Defined as the enabling of health care providers to deliver services that are respectful of and responsive to the health beliefs, practices, and cultural and linguistic needs of diverse patients.
What are some ways to become culturally competent?
Value diversity
Conduct a cultural self-assessment
Manage the dynamics of difference
Institutionalize cultural knowledge
Adapt to diversity
What does cultural competency help eliminate?
health care disparities
What are some examples of cultural competency? (5)
- Respecting a patient’s health beliefs and understanding the effect of the patient’s beliefs on health care delivery
- Shifting a model of understanding a patient’s experience from a disease happening in the patient’s organ systems to that of an illness occurring in the context of culture
- Ability to elicit a patient’s explanation of an illness and its causes
- Ability to explain to a patient the health care provider’s perspective on the illness and its perceived causes
- Being able to negotiate a mutually agreeable, safe, and effective treatment plan
What is a bias?
a predisposition to see people or things in a certain light, either positive or negative
What is the first step in patient centered care?
Becoming more self-aware of your biases and attitudes about human behavior is the first step in providing patient-centered care
What is culture sensitivity?
knowledgeable about the cultures prevalent in the community.
ethnic background can cause variations in..
drug metabolism
What is spirituality?
Defined as an awareness of one’s inner self and a sense of connection to a higher being, nature, or some purpose greater than oneself.
Spirituality helps individuals achieve the balance needed to maintain health and well-being and cope with illness.
What is faith?
Faith can be defined by a culture or religion- belief in something or relationship with a higher power.
When is hope present?
When a person has the attitude of something to live for and look forward to, hope is present.
what brings hope?
A spiritual person’s faith
Hope is a concept that includes…
anticipation, optimism, and comfort.
What is the difference between religious care and spiritual care?
-Religious care: helping patients maintain faithfulness to their belief system and worship practices
-Spiritual care:
helping people identify meaning and purpose in life, look beyond the present, and maintain personal relations as well as a relationship with a higher being or life force
How would you assess a patient’s fellowship and community?
Ask about support networks
How would you assess a patient’s ritual and practices?
ask about life practices used to assist in structure and support during difficult times
To assess, evaluate, and support a patient’s spirituality, the best action a nurse can take is to:
A. assist the patient to use faith to get well.
B. refer the patient to the health care facility chaplain.
C. provide the patient with a variety of religious literature.
D. determine the patient’s perceptions and belief system.
D
By understanding the patient’s perceptions and belief system, the nurse is able to provide patient-centered care for the patient.
What must be included in a cultural assessment? (9)
-Cultural Background
-Health and wellness beliefs/practices.
-Family patterns
-Verbal and nonverbal communication
-Space and time orientation
-Nutritional patterns
-Meaning of pain
-Death rituals
-Care of ill family members
Can you use a patient’s family or friends as an interpreter?
NO
Should you direct questions to the patient or interpreter?
patient
Should you interrupt the interpreter?
no
When using an interpreter who should you make eye contact with?
patient
What is a double-barrel question?
“do you have any nausea, vomiting or diarrhea?”
Single each symptom out in its own question
acute pain (transient)
is protective, usually has an identifiable cause, is of short duration and has limited tissue damage and emotional response; usually resolves with or without treatment, it has a predictable ending
chronic pain (persistent)
pain that is not protective and has no purpose, but it has a dramatic effect on a person quality of life, may or may not have an identifiable cause. last longer than 6 months.
Ex: headache, fibromyalgia, peripheral neuropathy
intractable pain
pain that is hard to treat or manage
referred pain
pain is in part of the body separate from the source of pain and assumes any characteristics. Ex: kidney stones which refer pain to groin, or MI which causes referred pain to the jaw, left arm and shoulder
radiating pain
pain that feels as though it travels or move down or along body part. It is intermittent or constant. Ex: low back pain from ruptured disk radiating down leg
neuropathy pain
abnormal processing of sensory input by the peripheral or central nervous system treatment usually includes adjuvant analgesics
phantom pain
pain that feels like it is coming from a body part that is no longer exist. Ex; leg amputation
How to assess for pain in someone who can’t tell you that they are in pain
-Facial expression(clenched teeth, lip bitting, wrinkle forehead)
-vital signs (elevated pulse and BP)
-vocalizations: crying/moaning, grunting
-body movement: restlessness, immobilization, muscle tension, increased movement of hands and fingers
-social interaction: avoidance of conversation
distraction
a way of helping a child cope with a painful or difficult procedure. Aims to take the child or adults mind off the procedure by concentrating on something else. works best for short, intense pain lasting a few minutes such as during an invasive procedure or waiting for analgesia to work
guided imagery
Method of pain control in which the patient creates a mental image, concentrates on that image, and gradually becomes less aware of pain.
hypnosis
a trance-like state in which you have heightened focus and concentration. Usually done with the help of a therapist using verbal repetition and mental images.
NSAIDS
treat mild-to-moderate acute intermittent pain such as that from headache or muscle strain. can upset stomach overtime and cause hepatoxicity
What is the difference between NSAIDS and Narcotics
Narcotics is an opioids
Narcotics
treats moderate to severe pain
side effects of narcotics
nausea/vomiting
constipation
CNS depression
Respiratory depression
NARCAIN
Antidote for narcotic induced respiratory depression
How to assess client that has pain and is confused
Watch facial expressions such as grimacing or frowning.
-vocal response,
-facial movements(grimacing, clenched teeth)
-body movements(restlessness, pacing
-social interactions(do they avoid conversation)
how to handle pain for a client who has a disease that it terminal such as cancer
- Can be acute or chronic
-The pain is normal resulting from stimulus of an undamaged nerve and/or neuropathic, arising from abnormal or damaged pain nerves.
-Cancer pain is usually caused by tumor progression and related pathological processes, invasive procedures, toxicities of chemotherapy, infection, and physical limitations.
-More than 75% of patients with advanced cancer experience pain, yet research shows that appropriately one third of patients still do not receive pain medication proportional to their pain intensity.
-Opioids are given to patients who deal with cancer pain.
Advance directives
Communicates wishes regarding end of life care.
types of advance directives
living will
health care proxies
durable powers of attorney
providers order
living will
expresses wishes regarding medical treatment in the event the client becomes incapacitated and facing end-of-life.
Durable Power of Attorney
a legal document that designates a person or people of one’s choosing to make health care decisions when a patient is no longer able to make decisions on his or her own behalf; client’s designated a healthcare proxy
provider’s order
patient’s are a full code unless the provider writes a “do not resuscitate (DNR)” or “allow natural death (AND)”
Criminal Negligence
conduct that falls below the generally accepted standard of care of a reasonably prudent perso
tort
civil wrongful acts or omissions made against a person or property
intentional tort
assault, battery, false imprisonment(restraints)
quasi-intentional tort
invasion of privacy, defamation of character(slander and libel)
unintentional tort
negligence, malpractice
Misdemeanor
a crime that causes injury but does not inflict serious harm; minor crime
malpractice
one type of negligence and often referred to as professional negligence. When nurses fall below standards of care
Nurse owed a duty
Nurse did not carry out the duty
Client was injured
The injury was a result of nurses failure to do the duty.
normal value for potassium
3.5-5.0 mEq/L
normal values for calcium
8.4-10.5
normal values for sodium (Na)
136-145
normal values for chloride (cl)
98-106
RBC normal value
4-6
Hemoglobin normal value for female and male
female: 12-16
Male: 14-18
Hematocrit normal values for male and female
Female: 37-47%
Male: 42-52%
elevated hematocrit levels means
dehydration
WBC normal level
5,000-10,000
Platelet normal level
150,000-400,000
symptoms of hypokalemia
Alkalosis
-Shallow Respirations
-Irritability
-Confusion, Drowsiness
-Weakness, Fatigue
-Arrhythmias-Tachycardia
-Lethargy
-Thready Pulse
-Low Intestinal Motility
Nausea, Vomiting, Ileus
symptoms of hyperkalemia
Muscle twitches-cramps-paresthesia
-Irritability & anxiety
-low BP
-EKG changes
-Dysrhythmias-Irregular rhythm
-Abdominal cramping
-Diarrhea
-cardiac arrest
-dialysis may be required if potassium levels are too high
symptoms of hypocalcemia
Chvostek’s sign
Trousseau’s sign
numbness and tingling of fingers
muscle twitching and cramping
-chron’s disease
-pancreatitis
symptoms of hypercalcemia
watch immobile pt
-fatigue
-weakness
-lethargy
-anorexia
-nausea
constipation
-kidney stones
-bone pain
-bone cancer
-paget disease
-hyperthrodism
-hypothyrodism
symptoms of hyponatremia
-fluid overload
-lethargy
-headache
-confusion
-apprehension
-seizures
-coma
-water moves into the ICF; cells swell
-need food high in sodium: milk and cheese
symptoms of hypernatremia
-confusion
- coma
- lethargy
- thirst
- seizures
Hypernatremia
-most serious electrolyte imbalances
-causes significant neurologic, endocrine, and cardiac disturbances
-causes hypertonicity of the blood
-cells become dehydrated
-Administer IV fluids for dehydration
potassium has reciprocal action with
sodium
symptoms of hyporchloremia
fluid loss
-dehydration
-weakness or fatigue
-difficulty breathing
-diarrhea or vomiting
symptoms of hyperchloremia
fatigue
-weakness
-excessive thirst
-dry mucous membrane
-high blood pressure
Who governs nursing
board of nursing
lasix
is used to treat hypertension. Lowers blood pressure by helping your body eliminate sodium and water through urine. Can cause you to eliminate more potassium in your urine causing hypokalemia due to low levels of potassium
symptoms of IV filtration
Pallor
edema
cool to touch
damp dressing
slow IV rate
what is the goal of the PCA
maintain a constant plasma level
safety guidelines for PCA
The patient is the only person who should press the button to administer the pain medication when PCA is used
-Monitor the patient for signs and symptoms of oversedation and respiratory depression.
-Monitor for potential side effects of opioid analgesics.
- 2 nurses have to check the pump after Dr. order medication
All patients on a PCA pump must be on what?
pulse oximetry
If a nurse gives a pain medication when do they need to follow up with the patient and see if the pain medication was effective
30-1hr
If the patient is still in pain after receiving pain medication, what should be done?
Notify the physician, another dose may need to be ordered
what is a huge side effect of narcotics
respiratory depression
What do you do if you get a nursing assignment beyond your scope of practice
Notify the charge nurse give reason for the refusal and determine if other alternatives such as reassignment is available. Also document refusal and why refused.
What is way you can give potassium?
It will have to be on an IV pump
Can you push IV potassium?
No patient will die in seconds
Know the nursing process for assessing pain and administering medication.
Obtaining a complete pain history (Onset, location, aggravating/alleviating factor)
-look for Nonverbal signs of pain such as:
Elevated pulse and BP
Crying, moaning
Grimacing
Guarding
perception of pain.
A clinical test for hypocalcemia. A light tap over the facial nerve, in the front of the ear, will cause contraction of facial muscles.
Chvostek’s sign
Tests for hypocalcemia. The client’s thumb and index finger will draw together (carpopedal spasm) when a blood pressure cuff is inflated above systolic pressure for 3 minutes.
Trousseau’s sign
What would be typical assessment findings in a dehydrated patient.
Delayed capillary refill
Delayed skin turgor
Abnormal respiratory patterns
Dark urine
peak concentration
this is the high serum level of medication and usually occurs just before the last of the medication is absorbed(30-60 minutes after administration)
Draw 1 to several hours after the drug is administered.
trough concentration
the lowest amount of drug detected in the serum. Occurs just prior to the time in which the med. is to be given again. the lowest amount of a drug detected in the serum.
Draw immediately before the next dose of the drug is administered.
phlebitis
edema, throbbing, pain at time, redness, red line up arm, slowed rate
treatment for phlebitis
stop infusion; elevate site; warm or cold compress; restart in different location
cellulitis
pain, warmth, edema, induration, red streaking, chills.
treatment for cellulitis
stop infusion; elevate site; warm or cold compress; restart in different location; may need ANTIBIOTIC
fluid overload
distended neck veins, HTN, SOB, crackles, edema
treatment for fluid overload
Raise HOB; Monitor vitals; diuretics
How often should a nurse rotate site for patient with an IV
every 72 hours
what pain rating scale is used for children
Wrong Baker Faces Scale
superficial or cutaneous pain
pain resulting from stimulation of skin, pain is of short duration and localized. It is usually a sharp sensation.
Ex: needlestick, small cut or laceration
deep or visceral pain
pain that is diffuse and radiates in several directions. last longer than superficial pain.
Ex: crushing sensation(angina pectoris), burning sensation(gastric ulcer)
what must be assessed to see if a patient needs opioid
assess her or her level of participation in ADL’s, physical therapies, family activities, and work related functions. Family members are often included in the the office visit to provide input about patient functional level
people who have oliguria(decreased urine output)
who are at high risk for hyperkalemia
people who have acute pancreatitis and Chron’s disease
who frequently develop hypocalcemia
people with lung and breast cancers develop
hypercalcemia
rapidly replaces fluids loss from dehydration, shock, hemorrhage, burns, or trauma; a large gauge catheter is used (18G)
bolus
rapid or severe dehydration leads to
seizures
sleep required for neonates
16 hours
infants sleep
15 hours
toddlers sleep
12 hours
school aged sleep
9-12 hours
adolescents sleep
8-10 hours
middle adults sleep
7-9 hours
older adults sleep
varies
