Scenario Test Flashcards
Blood transfusions Signs & Symptoms
Circulatory Overload (7)
Dyspnea Crackles at lung bases Tachycardia Hypertension Cough Increased venous pressure Distended neck veins
Blood transfusions Signs & Symptoms
Acute Hemolytic Transfusion (13)
Acute Hemolytic Transfusion
Severe pain in chest and kidney area
Increased temp (up to 105) & heart rate
Chills, headache, nausea, dyspnea, anxiety
Pain & heat along vein receiving blood
Hypotension, low back pain, possibly death
Disseminated intravascular Coaugulation
Blood transfusions Signs & Symptoms
Allergic reaction (severe) (8)
coughing, nausea, vomiting, respiratory
distress, wheezing, hypotension, LOC,
cardiac arrest
Blood transfusions Signs & Symptoms (5)
Febrile non-hemolytic
Flushing, chills, headache, muscle pain
Fever greater than 1 degree above baseline
Blood transfusions Interventions
Circulatory Overload
- Stop or slow infusion as ordered
- Elevate patient’s head
- Notify health care provider
- Administer diuretics as ordered
Blood transfusions Interventions
Acute Hemolytic Transfusion
- Stop transfusion
- Remove blood product
- Maintain IV access
- Notify health care provider
- Monitor Vitals q 15min.
- Administer ordered therapy
- Insert foley
- Monitor in and out
- Assess for shock
- dialysis may be required
- obtain blood and urine sample
- Document
Blood transfusions Interventions
Allergic reaction (severe)
- This in a LIFE-THREATENING REACTION
- STOP TRANSFUSION
- maintain IV access
- Notify health care provider and blood bank
- Administer antihistamines, corticosteroids, epinephrine, and antipyretics as ordered
- measure and document vital signs until stable
- Initiate CPR if necessary
Blood transfusions Interventions
Febrile non-hemolytic
- Stop transfusion
- Administer antipyretics as ordered
- Monitor temperature q 4 hr.
Blood transfusions Onset
Circulatory Overload
Anytime during or within 1-2 hours
Blood transfusions Onset
Acute Hemolytic Transfusion
5-15 min.
Blood transfusions Onset:
Febrile non-hemolytic
30 from start of transfusion to 6hrs after
Blood transfusions Onset
Allergic reaction (severe)
5-15 min
IV Precautions
Because IV meds are immediately available to the bloodstream once administered:
CHECK FOR (6)
- recommended dilutions and rate of admin
- adverse reactions
- for allergic reactions
- phlebitis
- speed shock
IV COMPLICATIONS
Systemic (4)
•Fluid overload/deficit
◦fluid overload
◾pulmonary edema (crackles)
◾peripheral edema
•Air embolism
◦sudden onset
◦SOB
◦chest pain
•Septicemia and other infection
◦fever
•Catheter damage/breakage (foreign body embolus)
◦check tip of IV catheter after removal
◦chart “catheter removed, tip intact)
IV COMPLICATIONS
Local (6)
•Infiltration and extravasation
◦extravasation
◾infiltration that causes cell death to surrounding tissue
◾eg. chemo
•Phlebitis
◦redness going up the vein
•Thrombophlebitis
◦dislodged clot
•Hematoma
◦bruising and accumulation underneath
- Clotting and obstruction, precipitation, malposition
- Dislodgement
IM volume for infants
0.5 ml
IM volume for Toddler
1-2 ml
IM volume for Preschool and older children:
2-3 ml
IM volume for Adolescent and adult
3-5 ml
Type of Injection
Intradermal (ID)
25-27 gauge
3/8 to 5/8 length
Volume 0.01-0.1
Sites forearm and upper back
Type of Injection
Subcutaneous (SC)
25-27 gauge and 26- 30 for peds
5/8 - 1” length
Volume 0.5 - 1 ml
Sites - outer aspects of arms, abdomen, anterior aspects of thigh
Type of Injection
Intramuscular (IM)
18 - 25 gauge
1/2 to 3” length
Volume 0.5-5
Recommendations for Mixing Insulins
Cloudy, clear, clear, cloudy
inject air into cloudy ( NPH - intermediate), inject air into clear (Toronto, Humulin, or Novolin -R) withdraw from clear, withdraw from cloudy
IM deltoid injection land marking
Locate the Acromion Process and go three fingers below
IM Ventrogluteal injection land marking
Locate the greater trochanter, place palm on trochanter, point thumb to groin, and index finger to the anterosuperior iliac spine, and middle finger to the iliac crest
IM Vastus lateralis injection land marking
Locate the greater trochanter with one hand and the knee with the other. Anterior lateral aspect of thigh is the injection site
Supplies for Wound Care
16 items
1.Sterile Gloves
2.blue pads
3.clean gloves
4.Cleaning solution (check expiration date)
5.Sterile dressing Tray
6.Sterile kidney basin
7.2-3 Abdominal Pads
8.4x4 and 2x2
9.packing
10.scissors
11.syringe
12.irrigation tip
13.Tape
14.measuring tape
15.pen & paper
16hand sanitizer
Supplies for Catheter
10 items
- basin, soap
- wash cloth, towel
- catheter tray
- clean gloves x 2
- sterile gloves x 2
- blue pads
- catheter bag + tube
- hand sanitizer
- pad + pen
- tape
Supplies for Ostomy
14 items
- stethoscope
- clean gloves
- basin
- facecloth
- towel
- measuring tool
- scissors
- barrier paste
- pouch and flange
- pouch closure clip
- ostomy belt ?
- adhesive remover
- skin barrier
- ostomy deordant
Supplies for NG tubes
16 supplies
- NG tube
- water soluble jelly
- pH test strips
- tongue depressor
- flashlight
- emesis basin
- Tape or bone
- safety pin
- tube for suction to container
- glass of water with straw
- suction equipment
- clean gloves
- elastic
- measuring cup
- 60 cc catheter tip syringe
- connection two way tip
what are the 6 rights?
- Patient
- Medication
- Dose
- . Time
- Route
- Documentation
Oral suctioning for Infant to 1
60-80
Oral suctioning for 2-5
80-100
Oral suctioning for 6-12
100-120
Oral suctioning for 13- adult
100-150
Post Op Memo
09:30 hrs: Received client from recovery awake and oriented x 3 spheres. Vital signs within normal limits. Client rates pain as a 1/10. Abdominal dressing dry and intact. Jackson pratt in situ draining sanguineous fluid. NG tube in situ and draining small amount of yellowish drainage. Foley catheter in situ and draining clear yellow urine, 350 cc in drainage bag. IV infusing well at 125 cc/hr of NS, 650 TBA. IV site intact and patent. —————————————-MWalsh, RN
Suture Removal Memo
- 21:00 hrs: 10 interrupted sutures removed as per orders. Incision cleansed with NS. No puffiness noted. Small reddened area at proximal end. 5 ½ inch steri-strips applied. Client tolerated well. —————————————M. Walsh, RN
Discontinue Saline Lock memo
- 10:00 hrs: D/c’d saline lock as per doctor’s orders. Cannula tip remains intact. Pressure applied for 2 minutes. Insertion site cleansed. Band-Aid applied. Client tolerated procedure well. ——————————MWalsh, RN
NG tube insertion Memo
- 09:45 hours: #16 F NG tube inserted in right nare for a small bowel obstruction. Prompt returns of brown fluid obtained. pH of gastric aspirate is 4. NG tube connected to intermittent low suction. Client tolerated procedure well. Client sent to x-rays for CXR.————–MWalsh, RN
NG tube irrigation Memo
- 09:45 hours: Client c/o of abdominal distention and nausea. NG output decreased. NG tube irrigated with 50 ccs of NS. No resistance met. Obtained prompt returns of 60 ccs of brownish fluid. NG tube reconnected to intermittent low suction. Client tolerated procedure well. ————————-MWalsh, RN
NG discontinue Memo
- 09:45 hours: #16 F NG tube discontinued from right nare as per doctor’s order. Catheter tip intact. 400 cc of dark green gastric content discarded. Cleansed client’s face, provided mouth care. Change in diet explained to client. Client tolerated procedure well. ———MWalsh, RN
Chest tube Memo
- Chest tube remains in situ. Dressing dry and intact at insertion site. Chest tube draining 150 ml of sanguinous fluid in last hour, no clots present. Vital signs within normal parameters. Gentle bubbling present in the three-chamber water-seal system. Suction remains at -20 cm. Air entry remains decreased in left lower lobe. Client states no respiratory difficulty. Remains comfortable. ———————————–MWalsh, RN
Stoma care memo
- 09:45: Removed the two-piece pouching system from the ileostomy for 100 ccs of brown semi-liquid content. End stoma remains brick red. Skin surrounding stoma is dry and intact. Area cleansed with warm tap water. New appliance measured and cut to fit stoma. New two-piece pouching system applied. Client tolerated procedure well. MWalsh, RN`
Foley insertion Memo
16 French 2-way indwelling catheter inserted as per pre-op orders. 600ml of clear, pale urine obtained. Balloon inflated with 10cc of sterile water. Specimen sent to lab for a C&S. Catheter attached to drainage bag. Client tolerated procedure well. MWalsh, RN
Foley Removal Memo
#16 French 2-way catheter removed as per order. Specimen sent to lab for C&S. Discarded 400cc of dark amber urine from drainage bag. Meatus intact. Pericare given. Client tolerated procedure well\_\_\_\_\_\_\_\_MWALSH, RN
Post operative Leg exercises
Have client assume supine position and demonstrate passive ROM exercises
Rotate ankle 5 times
Alternate dorsiflexion and planter flexion of both feet
Have client flex and extend knees 5 times
Alternate leg raises 5 times
Q2h
Repositioning Client
every 2 hours
Incentive Spirometer
Semi fowlers or high fowlers
With mouth on mouthpiece, inhale and hold breath for as long as tolerated
repeat 10-20 times every hour
Controlled coughing
2 slow, deep breaths, inhale through nose, and exhale through pursed lips
Inhale deeply the 3rd time and held breath for the count of 3. Fully cough 2 to 3 consecutive coughs without inhaling in between from belly
Splint if abdominal surgery
Diaphragmatic Breathing
place hands on anterior rib cage
slow deep breaths for a count of 3 and exhale through pursed lips
repeat 3-5 times every hour while awake
Insulin Admin sites
abdomen, arms, thighs, buttocks,
Ear drops
Side lying 5-10 min
Eye drops
Gentle Pressure 30 secs
Run IV at
50ml/hr to keep vein open
Women foley
12-14 French
2-3 inches add 1-2 once urine is out
Men Foley
16-18 French
7-9 inches add 1-2 once urine is out
S T O M A
S- set up equipment T-take off equipment O- observe stoma and skin M- measure stoma A- assemble & apply
