Unit 1 Exam Flashcards
How do you prioritize different patient scenarios?
ABCs
Maslow’s
How can you prevent aspiration if a patient is having nausea and vomiting?
Turn their head to the side
What situation would you call the doctor before completing an assessment?
Evisceration
RBC
What is the normal range?
Female 4.2 - 5.4
Male – 4.7 – 6.1
WBC
What is the normal range?
5,000 – 10,000/〖mm〗^3
H&H
What is the normal range?
Hematocrit
Female – 37% - 47%
Male – 42% - 52%
Hemoglobin
Female – 12 -16 g/dL
Male – 14 – 18 g/dL
K+
What is the normal range?
3.5 – 5 mEq/dL
Na+
What is the normal range?
135 – 145 mEq/dL
What could cause an RBC abnormal ?
High lvl -Dehydration, cigarette smoking, congenital heart disease, pulmonary fibrosis, renal cell carcinoma, polycythemia vera
Low lvl -Bleeding, anemia, malnutrition, overhydration, hemolysis, erythropoietin deficiency, leukemia, multiple myeloma, porphyria, thalassemia, sickle cell anemia
What could cause an WBC abnormal ?
high lvl: Infections, cigarette smoking, leukemia, inflammatory diseases, tissue damage, severe physical or mental stress
low lvl: Autoimmune disorders, bone marrow deficiencies, viral diseases, liver problems, spleen problems, severe bacterial infections, radiation therapy
What could cause an abnormal Hct?
High Level: Dehydration, hypoxia, cigarette smoking, polycythemia vera, tumors, erythropoietin abuse, lung diseases, blood doping, erythrocytosis, cor pulmonale
Low Level: Overhydration, nutritional deficiencies, blood loss, bone marrow suppression, leukemia, lead poisoning, Hodgkin’s lymphoma, chemotherapy treatment
What could cause an abnormal Hgb?
High Level: Dehydration, cigarette smoking, polycythemia vera, tumors, erythropoietin abuse, lung diseases, blood doping.
Low Level: Nutritional deficiencies, blood loss, renal problems, sickle cell anemia, bone marrow suppression, leukemia, lead poisoning, Hodgkin’s lymphoma.
What could cause an abnormal K+?
High Level: Infection, dehydration, Addison’s disease, injury to tissue, diabetes, acute or chronic kidney failure, hypoaldosteronism
Low Level: Anorexia nervosa, malnutrition, diarrhea, vomiting, poorly managed diabetes, hyperaldosteronism
What are implications of having an K+?
Hyperkalemia
• Monitor for arrhythmias, irritability, paresthesias, anxiety, and GI symptoms such as nausea and intestinal colic.
• Avoid potassium-saving diuretics, potassium supplements, or salt substitutes in patients with high renal insufficiency.
What could cause an abnormal Na+?
High Level: Cushing syndrome, diabetes insipidus, excessive fluid loss, malnutrition, dehydration
Low Level: Addison’s disease, renal diseases, cirrhosis, heart failure, ketonuria
What are implications of having an Na+?
Hyponatremia Monitor fluid losses and gains.
Monitor for GI symptoms (anorexia, nausea, vomiting, abdominal cramping) and CNS symptoms (lethargy, confusion, muscle twitching, seizures), and check urine specific gravity.
• Avoid giving large water supplements to patients receiving isotonic tube feedings.
• Take seizure precautions when hyponatremia is severe.
What are implications of having an Na+?
Hypernatremia
• Monitor fluid losses and gains, and check urine specific gravity.
• Monitor for excessive thirst, elevated body temperature, and changes in behavior such as restlessness, lethargy, and disorientation.
• Give sufficient water with tube feedings to keep serum Na+ and BUN at normal limits.
What are the 3 primary requirements that must be meet with informed consent
Adequate disclosure
Demonstrate sufficient comprehension
Voluntary
What is adequate disclosure?
This is our patient education. The patient must be given adequate information including the risks and benefits, what can happen if the procedure is done, what can happen if it is not done, etc…
What order of assessments are crucial post-surgery?
Airway/Breathing
Cardio-(AP, BP & peripheral vascular status)
What is pulse pressure?
the difference between the systolic and diastolic B/P - a narrowing pulse pressure can indicate hypoxemia or hypovolemia, the patient can be becoming shocky.
What are some red flags to consider post op?
B/P 25% higher or lower, a 15-20 point difference in AP or the development of bradycardia/tachycardia. Look for trends either up or down.
What are signs of hypovolemic shock?
AP increases while the B/P decreases.
What are the classifications of surgery based on urgency?
Purpose, risk factors and urgency
Surgery is classified as minor and major based on?
Risk
What anesthesia does not cause narcosis, but results in analgesia and reflex loss
Regional
A patient scheduled for a colonoscopy would most likely receive which type of anesthesia?
Conscious sedation
What are the nurse’s responsibilities in regard to obtaining the patient’s informed consent?
- Ensure is signed before pre-op meds given.
- Often witnesses signature.
- Answer questions.
- Contact MD PRN based on patient questions/concerns.
What measures can the nurse take to allay the patient’s anxiety related to an upcoming surgery?
o Answer questions o Good patient education o Therapeutic communication o Listen o Nonpharm measures – distraction, imagery, music o Meds – anti-anxiety as indicated
What is the purpose of Restorative surgery?
Improves the patient’s functional ability
What is the purpose of curative surgery?
Resolves a health problem by repairing or removing the cause
What is the purpose of diagnostic surgery?
Determines the origin or cause of a disorder
What is the purpose of palliative surgery?
Relieves symptoms of a disease but does not cure it
determine the category of Cleft palate/cleft lip repair surgery.
cosmetic
determine the category of a Hysterectomy surgery.
curative
determine the category of Repair of traumatic punctured lung surgery.
curative
determine the category of a Colostomy surgery.
palliative
determine the category of a Total joint replacement
restorative
determine the category of a Appendectomy
curative
Determine if the surgery is elective, urgent or emergent in a 22 year old scheduled for appendectomy?
emergent
Determine if the surgery is elective, urgent or emergent in a 77 year old scheduled for total knee replacement?
elective
Determine if the surgery is elective, urgent or emergent in a 55 year old scheduled for colon resection due to small bowel obstruction?
urgent
What transcultural considerations should the nurse recognize when preparing patients for surgery?
- Language barriers – intrepretor, materials in language patient can read
- Ask about specific cultural requests – ie: no blood transfusions
What are the advantages of a PCA?
o Better pain control
o Use less narcotics
o Do not have to wait for nurse
o Time savings for nurse
What measures can the nurse implement to help a new postoperative patient void?
- Increase fluids if able
- Position changes – up to void
- Run water
- Flush toilet
- Water over perineum
During the postoperative period, what are three signs or symptoms are called to the surgeon immediately?
- Resp complications
- Cardiac complications
- Wound dehiscence
Which medical conditions increase the risk of post-operative wound infections?
Obesity
• Diabetes
• Steroids
• any disorder that decreases immune function
What is malignant hyperthermia?
• Genetic metabolic disease - rare
• Rxn to inhalation anesthesia
• Hyperthermia with rigidity of skeletal muscles - life threatening
• S&S: temp, tachypnea, tachycardia, muscle contractions
It usually occurs about 10 to 20 minutes after surgery begins, but it can occur up to 24 hours after surgery.
What are the signs and symptoms of malignant hyperthermia?
• Hyperthermia with rigidity of skeletal muscles - life threatening
• S&S: temp, tachypnea, tachycardia, muscle contractions
It usually occurs about 10 to 20 minutes after surgery begins, but it can occur up to 24 hours after surgery.
What emergent interventions are implemented if malignant hyperthermia develops?
Emergent measures are implemented such as giving 100% O2 and regaining fluid and
electrolyte balance. The medication dantrolene sodium is given to inhibits muscular pathology.
What are the manifestations of pneumonia and how can pneumonia be prevented?
Fever, chills, chest pain, difficulty breathing, SOB, productive cough, crackles in lungs, wheezes
Use of IS, C & DB, early ambulation, good pain control
Epidural anesthesia
Injection of anesthetic agent into the epidural space, the spinal cord is never entered.
Epidural anesthesia – used surgeries lower 1⁄2 body =hip, perineum. legs
Nerve block
Injection of anesthetic agent into or around a nerve or group of nerves, results in blocked sensation and motor impulse transmission.
Nerve block limb surgery, for chronic pain
Topical anesthesia
Agents applied directly to an area of skins or mucous membrane
Topical Lidocaine, EMLA Stitches
. Local infiltration
Injection of anesthetic agent directly into tissue around an incision, wound or lesion.
Local infiltration - biopsy, wound sutures
Spinal anesthesia
Also called intrathecal block, injection of anesthetic agent into cerebrospinal fluid in the subarachnoid space.
Spinal anesthesia - lower abd, hip, perineal, leg surgery
Incentive spirometry (IS)
to promote complete lung expansion and to prevent pulmonary problems. the patient must be able to seal the lips tightly around the mouthpiece, inhale spontaneously, and hold his or her breath for 3 to 5 seconds for effective lung expansion. Goals (e.g., attaining specific volumes) can be set according to the patient’s ability and the type of incentive spirometer.
Breathing exercises (C&DB)
Coughing and splinting may be performed along with deep breathing every 1 to 2 hours after surgery. The purposes of coughing are to expel secretions, keep the lungs clear, allow full aeration, and prevent pneumonia and atelectasis. Coughing may be uncomfortable for the patient, but when performed correctly, it should not harm the incision. Splinting (i.e., holding) the incision area provides support, promotes a feeling 231of security, and reduces pain during coughing.
What is the Elective Urgency of surgery?
Examples?
Planned for correction of a nonacute problem Ex. Cataract removal Hernia repair Hemorrhoidectomy Total joint replacement
What is the “Urgent” Urgency of surgery?
Examples?
Requires prompt intervention; may be life threatening if treatment is delayed more than 24 to 48 hr Ex. Intestinal obstruction Bladder obstruction Kidney or ureteral stones Bone fracture Eye injury Acute chocystitis
What is the “Emergent” Urgency of surgery?
Examples?
Requires immediate intervention because of life-threatening consequences Ex. Gunshot or stab wound Severe bleeding Abdominal aortic aneurysm Compound fracture Appendectomy
Describe the extent of surgery for a simple surgery
Examples
Only the most overtly affected areas involved in the surgery
Simple/partial mastectomy
Describe the extent of surgery for Radical Surgery
Examples
Extensive surgery beyond the area obviously involved; is directed at finding a root cause
Radical prostatectomy
Radical hysterectomy
Describe the extent of surgery for Minimally invasive surgery (MIS)
Examples
Surgery performed in a body cavity or body area through one or more endoscopes; can correct problems, remove organs, take tissue for biopsy, re-route blood vessels and drainage systems; is a fast-growing and ever-changing type of surgery
Arthroscopy; Tubal ligation; Hysterectomy; Lung lobectomy; Coronary artery bypass; Cholecystectomy
What are the advantages of good post-operative pain control?
patient comfort and therefore satisfaction, earlier mobilization, fewer pulmonary and cardiac complications, a reduced risk of deep vein thrombosis, faster recovery with less likelihood of the development of neuropathic pain, and reduced cost of care.
Informed consent includes which information?
Type of surgery and reason
Who is present during surgery
Available options and risks – risks & benefits
Risks with surgery – potential outcomes
Risks of anesthesia
Review consent form in book for more details
Which is an abnormal level?
Male – RBC 4.9, Hct 50%, Hgb 16%
Female – RBC 3.8, Hct 34%, Hgb 9.8
Female normal RBC 4.2, Hct 37-47%, Hbg 12-16
Male normal 4.7 – 6.1, Hct 45-52, Hgb 14-18
Pre-op patient at risk for atelectasis
Resp, smokers, immobile
Pre-op patient at risk for poor wound healing
Poor nutrition, diabetics, obese
Informed consent is not valid for which of these patients: nursing home resident, emancipated minor, child under 16, patient who received pre-op vistaril and demoral, person who does not speak English
child under 16, patient who received pre-op vistaril and demoral,
Anticholinergics such as Atropine & scopolamine are given to
Decrease secretions, prevent post op complications
Nursing interventions with narcotics are?
Pre-dose assessment
Start low, go slow
Pain assessment pre/post
Non-pharm
What meds might be given pre-op and how do you know?
Insulin, seizure, steroids, HTN, cardiac, resp
The nursing implications with spinal anesthesia
Side effects
Headache, hypotension, urine retention Nursing implications Lay flat (decrease headache) Increase fluids Pressure to site Monitor output Caution narcotics
The advantages of balanced anesthesia are and what is it?
IV and inhalation meds give together
Advantages
Less general anesthesia; Decrease complications
Faster recovery from anesthetic ; Medications
Hypnotic evening before; Premedicate about 1 hr preop; Short acting barbiturate (Penthothal)
Inhaled gas; Muscle relaxant PRN
What are the first assessments in PACU?
ABC
How do you prevent post op pneumonia
Cough and deep breath IS Ambulation and reposition Splinting incision – ie:abd. Preop meds and NPO pre-op to prevent aspiration
How do you prevent post op DVT or PE
Ambulation and position changes Leg exercises Teds SCDs Anticoagulants – prophylactic
The S&S patient is in hypovolemic shock and what to do?
S&S
↑HR ↑R ↓ BP narrow pulse pressure ↓ O2 sats, cool, clammy, pale skin, concentrated urine
What are reasons for NG and nursing interventions RT to NG?
Decompress stomach, Assess COCA, comfort measures
Your patient can not void post op- what to do?
Fluids, tricks to void, bladder scan, may need straight cath
How do you instruct a patient to use IS (how, when, why)
Breath in – do not blow into device 10 times per hour when awake Do every time you are in room Set goals Assess compliance
How do you treat N&V – pharm & nonpharm
Antiemetics
Bland foods – soda, crackers
Aromatherapy
Do not advance diet too fast
Who does the first post op dressing change? Define wound drainage terms
Surgeon
Serous: clear yellow
Serosanguinous: pink
Sanguineous: red
Purulent
What is advanced diet as tolerated and how do you proceed
Start clear liquids, to full, and continue as patient tolerates back to normal diet
What is the difference between team and functional nursing?
Team leader makes assignments – is responsible to ensure tasks are done
Functional defined by facility roles/job descriptions – for example LPN is med nurse, aides give baths
Delegation is?
The transfer of responsibility for the performance of an activity from one individual to another while retaining accountability for the outcome” ANA
The 5 rights of delegation are?
Task, supervision, person, circumstance, directions (communication)
The LPN can independently do which part of the nursing process?
Assessment – no Diagnosis – no Define outcomes – no Plan interventions - no Evaluate – no
Interventions outside LPN scope of practice
Admin. infusions of Blood, TPN, chemo; Admin. of IV therapy to neonates; Admin. of IV push medications; Mixing IV medications; Initiation of TPN; Ongoing administration of TPN in central lines; Discontinuing central or arterial lines.
Arterial puncture & management of arterial lines; Advanced Cardiac Life Support (ACLS); Leading group therapy
A patient is scheduled for a total joint replacement. Based on urgency this surgery is classified as?
Elective
The nurse is caring for a patient who experiences a wound evisceration. The first action by the nurse is?
Call for help and instruct the person that responds to call the surgeon or Rapid Response Team
Three RNs, an LPN and two nursing assistants are working on a unit and have responsibility for 25 patients. Two RNs are doing patient assessments, the LPN is assigned to do all PO medications and treatments, one RN is doing all IV medications and assisting LPN with treatments as needed, and the nursing assistants are doing all vital signs and personal care. This type of nursing care delivery model would best be described as?
Functional Nursing
The nurse recognizes that a “basic patient situation” is defined by the Wisconsin Board of Nursing as?
The patient’s clinical condition is predictable
The nurse is working with a nusing assistant and a licensed practical nurse. Which of these tasks should not be delegated?
Routine oral medications Bed baths and oral care Evaluating the patient's progress Transporting a patient to dialysis Evaluating the patient's progress
The purpose of an appendectomy is classified as?
Curative
The nurse asks a preoperative patient to sign a surgical consent form as specified by the surgeon and signs the form after the patient. By this action the nurse is?
Witnessing the patient’s signature
What is the most reliable source in assessing a new post operative patient’s pain?
Patient’s self report of pain
Leadership is best defined as?
A process of interaction in which the leader influences others towards goal achievement
What is a nursing dx for someone who has had a wound dehiscence?
Skin Integrity Impairment
Hemoglobin
What is the normal range?
Hemoglobin
Female – 12 -16 g/dL
Male – 14 – 18 g/dL
Hematocrit
What is the normal range?
Hematocrit
Female – 37% - 47%
Male – 42% - 52%
5 Rights of Delegation
Right TASK
Right CIRCUMSTANCES
Right PERSON
Right DIRECTION/COMMUNICATION Right LEVEL of SUPEREVISION (evaluation, feedback, watching, directing, and correcting)
One important concept to consider in delegating to LPN’s
One important concept to consider is that LPNs do not assess – they can collect data to add to organizational assessment forms, but the act of assessment – as defined in the nursing process – is an RN function. The RN is responsible for developing and evaluating the POC.
Nurse Licensure Compact
allows “mutual recognition” of a nursing license between member states in the United States of America.
The WI Nurse Practice Act
includes
Assessment process
Dx of nursing or collaborative problems Creating a plan of care
Defining outcomes
Selection of nursing interventions
Choosing who will complete nursing
interventions (delegation) Evaluation of POC
Joined an “Nurse Licensure Compact” (27 states)
The State Board of Nursing
Created to “Protect the Public” Defines “scope of nursing practice” Oversees the licensing process & fees Responds to ?s RT practice issues Conducts disciplinary proceedings Certifies APRN Reviews nursing education & clinical enrichment programs Declares new rules and regulations.
Delegation is not:
Delegation is not: Not an abdication of responsibility for overall outcomes or Not a way to “get out of” doing work yourself.
What is the definition of delegation according the ANA?
According the ANA definition delegation is “The transfer of responsibility for the performance of an activity from one individual to another while retaining accountability for the outcome”
Time Management Strategies
Time Management Strategies Avoid priority traps – Doing whatever hits first – Taking the path of least resistance – Responding to the squeaky wheel – Completing tasks by default – Relying on misguided inspiration
Time Management
– 3 primary steps:
- Plan and prioritize
* Complete priority first, finish before starting next task • Reprioritize as needed
Patient Centered Care
Advantages & Disadvantages
Advantages Most convenient for patients Involves patient and family Expedites services Disadvantages Cost May be perceived as having less RNs
Patient Centered Care
focus is on the patient’s needs vs staff needs. The required care and services are available on the unit for the patient instead of the patient leaving unit for needed care. One hospital I have clinical at has their joint camp, a classroom for joint replacement patients on the unit. Another example is expanded dining room services, for example if a patient wants dinner at 7 pm even though it is usually served at 6 pm and the staff offer flexible meal times this is patient focused vs staff focused. The goal is increased flexibility for the patient vs. rigid timelines imposed by the organization and the way things are always done.
Case Managment
Collaborative process to meet the health needs of a patient in a cost effective manner
– Assessment, planning, facilitiation, advocacy – Critical pathways & Multidisciplinary action
plans guide care & decisions
– Inpatient and community resources
primary nursing advantages and disadvantages
primary nursing Advantages Develop trusting relationship with nurse Holistic vs shift approach Nurses like if adequate time Patients like Disadvantages High cost More difficult to schedule Perform tasks that others could do New or inexperienced nurses may lack skills needed for success in this model
In primary nursing the RN
In primary nursing the RN cares for patient and retains 24 hour accountability for the plan of care through out the patient’s admission. This type of model is often used in home health settings, but is not seen as frequently in hospitals as it was in the past.
What are disadvantages to team nursing
Disadvantages Communication
Care can feel disorganized, depersonalized to the patient
What are advantages to team nursing
Advantages
More cost effective
Meet needs of large group
More flexibility for the RN team leader to meet the needs of the patients
Modular nursing
Modular nursing or a mini team is a variation of of team nursing. In this module the unit has small teams, each including at least one RN, that cover the care for a set group of patients. Some organizations might call this “care pairs”.
How is Team nursing different from functional nursing?
Team nursing is different from functional nursing because the team leader can assign tasks beyond strictly defined roles, although the team leader still needs to ensure that tasks are within the staff member’s scope of practice. Team models are common on med/surg units and each unit often have several teams.
A team is a group
A team is a group of healthcare professionals responsible to provide care to a group of patients. The teams are headed by RN team leaders. The RN team leader is responsible for a group of patients and this RN is responsible for coordinating the cares of the patients on his or her team. The team members maybe RNs, LPNs, nursing assistants and other unlicensed assistive personnel.
functional nursing disadvantages
Disadvantage
Can feel disjointed for patient Fragmented care
Communication can be an issue
Miss subtle changes in condition of the patient
functional nursing Advantages
Advantages
Serve large numbers of patients Efficient
Staff become good at assigned tasks Good if RN shortage
Less costly
In functional nursing
In functional nursing work divided into functional roles such as giving baths, passing meds, completing assessments. In the type of assignment the scope of practice highly determines the tasks each staff person performs.
What are advantages and disadvantages of Total Patient Care nursing?
advantages Consistency More RNs Good rapport More likely to notice condition changes Disadvantages If nurse is not well prepared or inexperienced care could be unsafe More RNs – more costly
What is Total Patient Care ?
the nurse responsible for total care. This is a type of staffing that works well in specialized areas such as hospice or more acute settings such as ICU. There are advantages and disadvantages to total patient care.
What are the different Organizational Care Models ?
Total patient care Functional nursing Team nursing (modular) Primary nursing
Case management
What are 3 types of behavioral management styles?
Authoritarian, Democratic, Laissez-faire
What are different Nerve blocks? • Nerve blocks
– Epidural anesthesia
– Spinal anesthesia
– Field block
– Nerve block
What are different types of regional anesthesia? • Topical
• Local • Nerve blocks – Epidural anesthesia – Spinal anesthesia – Field block – Nerve block
What are some nursing implications of Regional anesthesia?
Nursing implications
– Lay flat (decrease headache) – Increase fluids – Pressure to site – Monitor output – Caution narcotics
What are some complications of Regional anesthesia?
Side Effects?
Complications
– Often associated with leakage of spinal fluid into
epidural space
– Others allergic rxn, incorrect delivery, overdose
• Side effects
– Headache, hypotension, urine retention
What is Regional anesthesia?
Advantages?
local anesthesia in which an anesthetic agent is injected around nerves so that the area supplied by these nerves is anesthetized. produces analgesia, relaxation, and reduces reflexes. The patient is awake and alert unless given other meds. Used surgeries arm, shoulder, abd, pelvis, legs
Advantages: Less risk of adverse rxn, no headache that can occur with spinal
