Skills Exam 4 Flashcards
When may SpO2 readings be inaccurate?
- anemia
- peripheral artery disease
- edema
- carbon monoxide poisoning
- tremors
- cold extremities
- nail polish
What are some questions you should ask yourself if you get a reading of less than 94%?
- 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?
Where can we assess for SpO2?
- fingers
- toes
- forehead
- earlobes
If you determine that the reading is <94%, this is a true reading, then you must do a quick assessment
this does not mean that they are in respiratory distress, it only means you are doing your job as the nurse and assessing appropriately
perform inspection
- respiratory rate, pattern, effort,
- color of lips
- accessory muscle use?
- chest symmetrical during expansion?
ask subjective questions
- feeling SOB?
- does the pt know their normal O2 range?
- is the pt speaking in complete sentences?
- mental status appropriate to baseline?
lung sounds?
clear? wheezes? crackles? stridor? rhonchi?
what are some interventions if your pt’s SpO2 level is <94%?
- sit pt in high fowlers or tripod
- encourage coughing and deep breathing, pursed lip breathing if necessary
if those interventions helped the patient, what is your next step?
notify the instructor of your assessment and interventions;
- SpO2
- assessment findings
- interventions performed and pt’s response
if those interventions DID NOT help your pt, what is your next step?
- 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?
if you need to administer a nebulizer treatment, what information should you communicate with your instructor?
- SpO2
- assessment findings
- interventions and pt’s response
- what you would like to do for the pt
reassess after interventions have been performed
- any changes from initial assessment?
- if pt has not improved, do not leave them
- report any changes in pt condition to instructor
documentation
- 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
if your pt has a respiratory distress episode, what should you do for the rest of your shift?
reassess SpO2 and perform focused assessment multiple times throughout your shift
what is room air?
a mixture of oxygen, nitrogen, carbon dioxide, etc
what affects oxygenation?
- physiological factors
- developmental factors
- lifestyle factors
- environmental factors
is supplemental oxygen considered a medication?
yes!
do you need an order to utilize supplemental oxygen?
yes!
when should oxygen be applied?
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
if you always jump to apply oxygen all the time what will happen to your pt?
they will become dependent on it
if your pt has an oxygen order, ensure the appropriate equipment is near by when you start your shift
- be observant
- diligently check the portable oxygen tank and regulator screen reading
oxygen range orders
apply oxygen at 2-4 LPM to keep O2 above 92%
check pulse ox frequently
not just twice a shift with vital signs
can you take portable oxygen in the shower with you?
ask yourself this; if my pt has a low oxygen and is symptomatic, is the priority a shower?
oxygen therapy precautions
- pure oxygen is flammable
- no smoking while on oxygen
- do not use petroleum jelly
- stay away from any/all flammable objects while on oxygen
titration of oxygen
the nurse may need to titrate the amount of oxygen provided based on the pt’s sxs
always allow adequate time between titration and assessment before titrating again
it takes time for the pt’s body to adapt to changes
increase is sxs have not improved and pt is requiring more O2
decrease if attempting to wean off the oxygen to determine if the pt can tolerate lower levels
can the assistive personnel place oxygen on the pt?
yes, they can put it on but they cannot turn it on, the nurse must set it up
can the assistive personnel titrate the oxygen?
no!
can the assistive personnel adjust the nasal cannula?
yes!
what are some oxygen delivering devices?
- nasal cannula
- high flow nasal cannula
- masks
nasal cannula
- 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
high flow nasal cannula
- 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
oxygen mask
- 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
non rebreather mask
- 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)
what is humidified oxygen?
it can humidify oxygen when using wall oxygen or oxygen concentrator, not a portable oxygen device
what type of oxygen devices will you see in a long term care setting?
- nasal cannula
- face mask
pt’s requiring non-rebreathers or high flow oxygen are most likely in what type of setting?
acute care
wall oxygen
- 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
portable oxygen tank
- 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
oxygen concentrator
- 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
nebulized mist treatment
- nebulizer device used to administer medication directly to the lungs
- pt uses handheld device or simple face mask
what are some oxygen delivery devices used to administer a NMT?
- nebulizer machine
- wall oxygen or air
when giving a NMT, you must assess and document the following
- lung sounds
- reports of SOB
- accessory muscle use
- work of breathing
- speaking in complete sentence?
- mental status
should assess pre treatment and post treatment
wait about 15-20 min post treatment before reassessment
non-invasive positive-pressure ventilation
- 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
intubation
- 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
is ventilation a short or long term intervention for respiratory distress?
short term, a tracheotomy tube will be placed
mechanical ventilation required
- 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
just to give your brain a break :) how do you count cows?
with a COWculator tehe
documentation
- 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
purposes of the health care record
- 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
interprofessional communication within the medical record
- 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
legal documentation
accuracy is one of the best defenses for legal claims
reimbursement
clarifies treatment rendered
auditing and monitoring
improves quality of care
education
helps anticipate care needed for the pt
research
contributes to evidenced based practice
differences between EHR and EMR
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
maintaining privacy, confidentiality, and security of the health care record
- 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
HIPPA restricts the disclosure of medical records
- depending on your role with the pt, you may only be able to access their electronic chart for specific pieces of information
only people authorized to care for the pt should have access to the ?
medical records
rules
- 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
each individual with access to the computerized information has a specific username and password
- 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
handling and disposing of information
- 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
narrative charting
- recording of all pt information, assessment data, care, interventions
- traditional methods
- free text entry
flow sheets
- 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
progress notes
narrative charting that is used when additional information needs to be discussed in the chart from the flowsheets
charting by exception
- 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
narrative note
writer freely documents information obtained from assessment, interventions performed, etc
focused charting
D-A-R format
- data
- assessment
- response
guidelines for quality documentation
factual
- clear, descriptive, objective information about what the nurse observes, hears, palpated, smells
- avoid vague terms
- no opinions
guidelines for quality documentation
accurate
- specific information with as much detail as possible
guidelines for quality documentation
current
- ensure entries are timely
- avoid delays in documentation as much as possible! chart as you go
- use 24hr time
guidelines for quality documentation
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
guidelines for quality documentation
complete
- ensure all information is present before you leave
documentation rules
- 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
narrative documentation rules
- 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
if you are utilizing a charting by exception piece of documentation, any information that needs additional details should be included in narrative charting
- 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
documenting communication with providers
- report findings to a provider
- telephone calls made to a provider
- telephone orders and verbal orders
narrative documentation rules
- 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
hand written charting rules
- 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
using abbreviations
- 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
errors on hand written charting
- 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
late entries
- 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
incident reports
- 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
if a pt falls
- the nurse will document the fall, assessment, interventions performed, notification of the physician
- the nurse will also file an incident report
okay one more joke i promise :) what do you call a dwarf cow?
condensed milk hahaha
