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The "Fun" class > Skills Exam 4 > Flashcards

Skills Exam 4 Flashcards

1
Q

When may SpO2 readings be inaccurate?

A
  • anemia
  • peripheral artery disease
  • edema
  • carbon monoxide poisoning
  • tremors
  • cold extremities
  • nail polish
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2
Q

What are some questions you should ask yourself if you get a reading of less than 94%?

A
  • is this a true reading?
  • are the fingers cold?
  • has the pulse ox been sitting long enough to get a true reading?
  • do I need to switch fingers?
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3
Q

Where can we assess for SpO2?

A
  • fingers
  • toes
  • forehead
  • earlobes
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4
Q

If you determine that the reading is <94%, this is a true reading, then you must do a quick assessment

A

this does not mean that they are in respiratory distress, it only means you are doing your job as the nurse and assessing appropriately

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5
Q

perform inspection

A
  • respiratory rate, pattern, effort,
  • color of lips
  • accessory muscle use?
  • chest symmetrical during expansion?
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6
Q

ask subjective questions

A
  • feeling SOB?
  • does the pt know their normal O2 range?
  • is the pt speaking in complete sentences?
  • mental status appropriate to baseline?
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7
Q

lung sounds?

A 
clear?
wheezes?
crackles?
stridor?
rhonchi?
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8
Q

what are some interventions if your pt’s SpO2 level is <94%?

A
  • sit pt in high fowlers or tripod

- encourage coughing and deep breathing, pursed lip breathing if necessary

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9
Q

if those interventions helped the patient, what is your next step?

A

notify the instructor of your assessment and interventions;

  • SpO2
  • assessment findings
  • interventions performed and pt’s response
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10
Q

if those interventions DID NOT help your pt, what is your next step?

A
  • do not leave the pt, call for assistance or wheel the pt to the nurses station
  • do they need oxygen or a nebulizer treatment? (is there an order for O2?, how much?, apply if appropriate)
  • is there an PRN medications available?
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11
Q

if you need to administer a nebulizer treatment, what information should you communicate with your instructor?

A
  • SpO2
  • assessment findings
  • interventions and pt’s response
  • what you would like to do for the pt
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12
Q

reassess after interventions have been performed

A
  • any changes from initial assessment?
  • if pt has not improved, do not leave them
  • report any changes in pt condition to instructor
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13
Q

documentation

A
  • document pt’s Spo2 and full initial assessment
  • document interventions performed, pt’s response, and assessment after
  • document all information you reported to your instructor
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14
Q

if your pt has a respiratory distress episode, what should you do for the rest of your shift?

A

reassess SpO2 and perform focused assessment multiple times throughout your shift

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15
Q

what is room air?

A

a mixture of oxygen, nitrogen, carbon dioxide, etc

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16
Q

what affects oxygenation?

A
  • physiological factors
  • developmental factors
  • lifestyle factors
  • environmental factors
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17
Q

is supplemental oxygen considered a medication?

A

yes!

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18
Q

do you need an order to utilize supplemental oxygen?

A

yes!

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19
Q

when should oxygen be applied?

A

during acute disturbances in oxygen status

  • O2 stats lower than baseline
  • RR elevated
  • SOB
  • accessory muscle use
  • nasal flaring
  • retractions
  • decreased mental status
  • other interventions have failed
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20
Q

if you always jump to apply oxygen all the time what will happen to your pt?

A

they will become dependent on it

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21
Q

if your pt has an oxygen order, ensure the appropriate equipment is near by when you start your shift

A
  • be observant

- diligently check the portable oxygen tank and regulator screen reading

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22
Q

oxygen range orders

A

apply oxygen at 2-4 LPM to keep O2 above 92%

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23
Q

check pulse ox frequently

A

not just twice a shift with vital signs

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24
Q

can you take portable oxygen in the shower with you?

A

ask yourself this; if my pt has a low oxygen and is symptomatic, is the priority a shower?

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25
Q

oxygen therapy precautions

A
  • pure oxygen is flammable
  • no smoking while on oxygen
  • do not use petroleum jelly
  • stay away from any/all flammable objects while on oxygen
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26
Q

titration of oxygen

A

the nurse may need to titrate the amount of oxygen provided based on the pt’s sxs

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27
Q

always allow adequate time between titration and assessment before titrating again

A

it takes time for the pt’s body to adapt to changes

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28
Q

increase is sxs have not improved and pt is requiring more O2

A

decrease if attempting to wean off the oxygen to determine if the pt can tolerate lower levels

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29
Q

can the assistive personnel place oxygen on the pt?

A

yes, they can put it on but they cannot turn it on, the nurse must set it up

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30
Q

can the assistive personnel titrate the oxygen?

A

no!

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31
Q

can the assistive personnel adjust the nasal cannula?

A

yes!

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32
Q

what are some oxygen delivering devices?

A
  • nasal cannula
  • high flow nasal cannula
  • masks
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33
Q

nasal cannula

A
  • place prongs into nares
  • tubing then goes behind ears and wraps around neck
  • oxygen delivered from 0.1 LPM- 6 LPM
  • can dry the nose with higher rates or long term use
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34
Q

high flow nasal cannula

A
  • oxygen delivered from 6 LPM- 15 LPM
  • delivers up to 100% concentration of oxygen
  • used to treat respiratory failure
  • may be used in place of a simple face mask or non rebreather
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35
Q

oxygen mask

A
  • can cause claustriphobia or anxiety
  • cannot eat with it on
  • should only be used for short periods of time
  • oxygen delivered from 5-10 LPM
  • delivers 40-60% oxygen concentration mixed with RA
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36
Q

non rebreather mask

A
  • oxygen delivered up to 15 LPM
  • delivers 100% oxygen concentration
  • mask with a reservoir bag attached for continuous inhalation of oxygen
  • side vents on mask are one way- exhaled air is exiting, inhaled air is from oxygen bag
  • used in respiratory distress/ hyperventilation
  • can use a NRB not connected to oxygen for a pt who is hyperventilating (brown bag scenario)
37
Q

what is humidified oxygen?

A

it can humidify oxygen when using wall oxygen or oxygen concentrator, not a portable oxygen device

38
Q

what type of oxygen devices will you see in a long term care setting?

A
  • nasal cannula

- face mask

39
Q

pt’s requiring non-rebreathers or high flow oxygen are most likely in what type of setting?

A

acute care

40
Q

wall oxygen

A
  • attaches to the wall
  • connected to a main source of oxygen in the building
  • never runs out
  • mainly seen in hospital setting and some nursing homes
  • use the dial and floating ball to titrate amount of oxygen delivered
41
Q

portable oxygen tank

A
  • specific amount of pressurized and compressed oxygen comes in each tank
  • a regulator must be used
  • never runs out
  • the dial on the left is used to titrate the amount
  • when using the oxygen device, humidification is not an option
42
Q

oxygen concentrator

A
  • machine pulls room air into the device
  • delivers purified oxygen at a specific rate
  • never runs out of oxygen
  • must be plugged in to the wall and turned on
  • able to humidify this oxygen
  • mostly see this device in home setting or LTC
43
Q

nebulized mist treatment

A
  • nebulizer device used to administer medication directly to the lungs
  • pt uses handheld device or simple face mask
44
Q

what are some oxygen delivery devices used to administer a NMT?

A
  • nebulizer machine

- wall oxygen or air

45
Q

when giving a NMT, you must assess and document the following

A
  • lung sounds
  • reports of SOB
  • accessory muscle use
  • work of breathing
  • speaking in complete sentence?
  • mental status
46
Q

should assess pre treatment and post treatment

A

wait about 15-20 min post treatment before reassessment

47
Q

non-invasive positive-pressure ventilation

A
  • continuous positive airway pressure
  • bilevel positive airway pressure
  • commonly used to aide in breathing while asleep among pt’s with sleep apnea, COPD, or obese
  • used during respiratory distress and before intubation
48
Q

intubation

A
  • performed during respiratory distress, failure, or inability for pt to maintain adequate oxygenation
  • pt is sedated and paralyzed, then an ET tube is inserted into the mouth, down the throat and into the trachea
  • a ventilator is connected to the end of the ET tube to assist in ventilation
49
Q

is ventilation a short or long term intervention for respiratory distress?

A

short term, a tracheotomy tube will be placed

50
Q

mechanical ventilation required

A
  • ventilators are machines that provide oxygenation and ventilation
  • used when pt are unable to breath effectively on their own
  • uses positive pressure to push oxygenated air into the lungs
51
Q

just to give your brain a break :) how do you count cows?

A

with a COWculator tehe

52
Q

documentation

A
  • vital aspect of nursing
  • nursing documentation systems
  • should reflect current standards of nursing practice and minimize the risk of errors
  • need to be efficient enough to allow members of the health care team to efficiently document and retrieve clinical data
  • must document all nursing care provided
53
Q

purposes of the health care record

A
  • facilitates interprofessional communication among health care providers
  • legal record of care provided
  • justification for financial billing and reimbursement of care
  • auditing, monitoring, and evaluation of care provided
  • education and research
54
Q

interprofessional communication within the medical record

A
  • the quality of pt care depends on your ability to communicate with other members of the health care team
  • when a plan is not communicated to all members of the health care team, care becomes fragmented, tasks are repeated, and delays or omissions in care often occur
55
Q

legal documentation

A

accuracy is one of the best defenses for legal claims

56
Q

reimbursement

A

clarifies treatment rendered

57
Q

auditing and monitoring

A

improves quality of care

58
Q

education

A

helps anticipate care needed for the pt

59
Q

research

A

contributes to evidenced based practice

60
Q

differences between EHR and EMR

A

electronic health record
- integrates all pt information into one record, regardless of the number of times a pt enters a health care system
electronic medical record
- record within and individual visit/admission

61
Q

maintaining privacy, confidentiality, and security of the health care record

A
  • nurses are legally and ethically obligated to keep all pt information confidential
  • protect health information
  • only discuss the pt’s status with members of the health care team
  • can use data for research or continuing education, but need permission
62
Q

HIPPA restricts the disclosure of medical records

A
  • depending on your role with the pt, you may only be able to access their electronic chart for specific pieces of information
63
Q

only people authorized to care for the pt should have access to the ?

A

medical records

64
Q

rules

A
  • the pt’s privacy must be protected from anyone not on the health care team
  • the pt has a right to his or her medical information
  • the pt must five permission for family to have access to any medical data
  • treatment info can be shared so that insurance companies can examine charges appropriately
65
Q

each individual with access to the computerized information has a specific username and password

A
  • password should be strong and changed frequently
  • never share username or password
  • always log off after use
  • never walk away with an open screen
  • never document under another individuals username and don’t let someone document under yours
66
Q

handling and disposing of information

A
  • safeguard any information that is printed
  • do not print pt information for personal needs
  • do not print for clinical
  • never copy down a pt’s full name or DOB, use initials and room numbers
  • destroy when no longer needed
  • de-identify all pt data
67
Q

narrative charting

A
  • recording of all pt information, assessment data, care, interventions
  • traditional methods
  • free text entry
68
Q

flow sheets

A
  • graphic records, organized by body systems
  • quickly and easily enter assessment data
  • facilitate documentation of routing, repetitive care
  • if a change in pt status, you must expand documentation of routine care and assessments
69
Q

progress notes

A

narrative charting that is used when additional information needs to be discussed in the chart from the flowsheets

70
Q

charting by exception

A
  • includes standards of normal assessment findings and routine care
  • it there is an exception to the normal assessment finding the nurse must discuss it in the attached narrative charting, in detail
71
Q

narrative note

A

writer freely documents information obtained from assessment, interventions performed, etc

72
Q

focused charting

A

D-A-R format

  • data
  • assessment
  • response
73
Q

guidelines for quality documentation

A

factual

  • clear, descriptive, objective information about what the nurse observes, hears, palpated, smells
  • avoid vague terms
  • no opinions
74
Q

guidelines for quality documentation

A

accurate

- specific information with as much detail as possible

75
Q

guidelines for quality documentation

A

current

  • ensure entries are timely
  • avoid delays in documentation as much as possible! chart as you go
  • use 24hr time
76
Q

guidelines for quality documentation

A

organized

  • notes should be clear, concise, to the point, in a logical order
  • if you are documenting about a complex situation; think about the situation that occurred, the order which is occurred, and the words you want to use to describe it. then begin charting
77
Q

guidelines for quality documentation

A

complete

- ensure all information is present before you leave

78
Q

documentation rules

A
  • all documentation entries must have a date and time
  • the author of the entry must be clearly identified
  • for hand written charting, the author must sign their full name with credentials
  • correct spelling is imperative
79
Q

narrative documentation rules

A
  • always chart when you receive report from another individual. include name and credentials.
  • always chart when you relinquish care and provide report to another individual
  • do not chart what you stated in report or what report information was given to you
  • always chart when you assume care of the individual. include age, sex, you identified the pt, and what you verified this information against
80
Q

if you are utilizing a charting by exception piece of documentation, any information that needs additional details should be included in narrative charting

A
  • patient complaints
  • nursing interventions
  • reassessments
  • change in pt status with supportive details, nursing response, what you did for the pt
  • education provided
  • pt response to education
  • pt refusal of treatment
  • nurses response to pt’s refusal
  • information communicated to others
81
Q

documenting communication with providers

A
  • report findings to a provider
  • telephone calls made to a provider
  • telephone orders and verbal orders
82
Q

narrative documentation rules

A
  • provide factual information only
  • if subjective information is included, utilize words to explain what the pt told you
  • avoid using subjective terms or judgements
  • be accurate, complete, and organized
  • if an order was questioned, record clarification was sought
  • chart only for yourself, not for others
  • do not narratively write identifying information
83
Q

hand written charting rules

A
  • start each new entry with the full date, time, and end with a full signature and title
  • sign at the end of each page of charting
  • do not use white-out
  • write within the lines provided
  • do not leave blank spaces between the end of your writing and your signature
  • write legibly in permanent black ink
84
Q

using abbreviations

A
  • abbreviations may be utilized in documentation to save time
  • abbreviations must be used carefully to avoid misinterpretation
  • health care institutions should have a list of standard abbreviations, symbols, and acronyms to be used by all members of the health care team
85
Q

errors on hand written charting

A
  • draw one single horizontal line through the word or initial to the upper right hand corner of the error
  • write correct information following the error
  • never write information above the error
  • don’t attempt to squeeze information in between words
  • if an error isn’t identified until after the entry is written and signed out, cross out the entire sentence and write a late entry
  • do not restart the entire narrative page because an error was made
86
Q

late entries

A
  • if the nurse forgot to chart a specific piece of information during a specific time, a late entry may be made
  • enter the current date and current time
  • identify that the entry is a late entry
  • the longer the time lapse of the late entry, the less reliable the information becomes
87
Q

incident reports

A
  • an incident or occurence is any event that is not consistent with the routine, expected care of a pt or the standard procedures in place
  • used to improve quality, safety, and overall pt care
  • not part of the pt chart
  • incident reports must be followed up by a manager, risk management
88
Q

if a pt falls

A
  • the nurse will document the fall, assessment, interventions performed, notification of the physician
  • the nurse will also file an incident report
89
Q

okay one more joke i promise :) what do you call a dwarf cow?

A

condensed milk hahaha

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