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201 Intro > EXAM 3 > Flashcards

EXAM 3 Flashcards

FLUID, ELECTROLYTE, ACID/BASE, ABG, MEDICATION ADMINISTRATION, ELIMINATION, SPECIMEN COLLECTION WEEKS 7-9

1
Q

HYPERNATREMIA

A

WATER DEFICIT

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2
Q

HYPONATREMIA

A

WATER EXCESS

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3
Q

S/S OF FLUID VOLUME EXCESS

A

WET SOUNDING
CONFUSION
DECREASED LOC
EDEMA

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4
Q

HYPOKALEMIA

A

DIARRHEA
REPEATED VOMITTING
USE OF POTASSIUM WASTING DIURETICS

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5
Q

HYPERKALEMIA

A

DECREASED URINE OUTPUT

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6
Q

HYPOCALCEMIA

A

ACUTE PANCREATITIS
NEUROMUSCULAR EXCITABILITY

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7
Q

HYPERCALCEMIA

A

CANCER PATIENTS

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8
Q

HYPOMAGNESEMIA

A

INCREASED NEUROMUSCULAR EXCITABILITY

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9
Q

HYPERMAGNESEMIA

A

NEUROMUSCULAR EXCITABILITY
LETHARGY
DECREASED DEEP TENDON REFLEXES

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10
Q

WHAT IONS DO ACIDS RELEASAE

A

HYDROGEN
H+

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11
Q

DEGREE OF ACIDITY IS REPORTED AS

A

PH
1.0 IS VERY ACIDIC
14.0 IS VERY BASE

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12
Q

NORMAL PH VALUE

A

7.0 IS NEUTRAL
NORMAL ARTERIAL BLOOD IS 7.35-7.45

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13
Q

WHAT ORGANS WORK TOGETHER TO KEEP THE ACID-BASE BALANCE

A

KIDNEYS AND LUNGS

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14
Q

CELLULAR METABOLISM PRODUCES WHAT?

A

CARBONIC ACID THAT GOES TO THE LUNGS AND METABOLIC ACIDS THAT GO TO THE KIDNEYS

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15
Q

RESPIRATORY ACIDOSIS

A
  1. LUNGS UNABLE TO EXCRETE ENOUGH CO2
  2. EXCESS CARBONIC ACID IN THE BLOOD DECREASES PH
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16
Q

RESPIRATORY ALKALOSIS

A
  1. LUNGS EXCRETE TOO MUCH CO2
  2. DEFICIT OF CARBONIC ACID IN THE BLOOD INCREASES THE PH
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17
Q

METABOLIC ACIDOSIS

A

KIDNEYS UNABLE TO EXCRETE ENOUGH METABOLIC ACIDS WHICH ACCUMULATE IN THE BLOOD

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18
Q

METABOLIC ALKALOSIS

A

KIDNEYS EXCRETES TOO MUCH METABOLIC ACIDS WHICH RESULTS IN DECREASED BLOOD BICARBONATE

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19
Q

CAUSES OF METABOLIC ALKALOSIS

HIGH PH AND HIGH BICARB

A

OVERUSE OF ANTACIDS
POTASSIUM WASTING DIURETICS
LOSS OF GASTRIC JUICES

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20
Q

CAUSES OF RESPIRATORY ALKALOSIS

HIGH PH AND LOW CO2

A

HYPERVENTILATION
ANXIETY
HIGH ALTITUDES
PREGNANCY
FEVER
HYPOXIA
PULMONARY DISEASE
VENTILATOR SETTINGS THAT ARE TOO HIGH OR TOO FAST

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21
Q

CAUSES OF RESPIRATORY ACIDOSIS

LOW PH AND HIGH CO2

A

HYPOVENTILATION
AIRWAY OBSTRUCTION
COPD
CHEST TRAUMA
DRUG OVERDOSE
PULMONARY EDEMA
NEUROMUSCULAR DISEASE

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22
Q

CAUSES OF METABOLIC ACIDOSIS

LOW PH AND LOW BICARB

A

DIABETIC KETOACIDOSIS
SALICYLATE OD
SHOCK
SEPSIS
SEVERE DIARRHEA
RENAL FAILURE

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23
Q

TACHYPNEA

A

DEEP AND RAPID RESPIRATIONS

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24
Q

NURSING Hx FOR ACIDOSIS/ALKALOSIS

A

AGE: VERY YOUNG OR VERY OLD
ENVIRONMENT: EXCESSIVELY HOT?
DIETARY INTAKE: FLUIDS, Na, K, Ca, Mg
LIFESTYLE: ETOH
MEDS: OTC AND HERBAL AND Rx

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25
Q

MEDICAL Hx FOR ACIDOSIS/ALKALOSIS

A

RECENT SURGERY (PHYSIOLOGICAL STRESS)
GI OUTPUT
ACUTE ILLNESS/TRAUMA- RESPIRATORY DISORDERS, BURNS, TRAUMA
CHRONIC ILLNESS- CANCER, HF, OLIGURIC RD

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26
Q

DAILY WEIGHT ASSESSMENT FOR ACIDOSIS/ALKALOSIS

A

INDICATOR OF FLUID STATUS
MAKE SURE TO USE SAME CONDITIONS

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27
Q

DO YOU COUNT IRRIGATION INI&O

ACIDOSIS/ALKALOSIS

A

NO, SUBTRACT IT

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28
Q

ISOTONIC IV SOLUTION

A

SAME EFFECTIVE OSMOLALITY AS BODY FLUIDS

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29
Q

HYPOTONIC IV SOLUTIONS

A

EFFECTIVE OSMOLALITY LESS THAN BODY FLUIDS THUS DECREASING OSMOLALITY BY DILUTING BODY FLUIDS AND MOVING H2O INTO CELLS

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30
Q

HYPERTONIC IV SOLUTIONS

A

HAVE AN EFFECTIVE OSMOLALITY GREATER THAN BODY FLUIDS AND DRIVES H2O OUT OF CELLS

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31
Q

WHAT SHOULD YOU BE CAUTIOUS OF WITH IV THERAPY

A

TOO RAPID OR EXCESSIVE INFUSION OF ANY IV FLUID HAS THE POTENTIAL TO CAUSE SERIOUS PROBLEMS
COULD CAUSE FLUID OVERLOAD OR MYOCARDIAL INFARCTION

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32
Q

SIGNS THAT IV ACCESS HAS GONE WRONG

A

BRUISING
INFECTION
EXTRAVASATION
INFILTRATION
PHLEBITIS

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33
Q

BLOOD COMPONENT THERAPY

A

IV ADMIN OF WHOLE BLOOD OR BLOOD COMPONENT
*TAKES 2 NURSES TO VERIFY
*STAY FIRST 15 MINUTES

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34
Q

TRANSFUSING BLOOD

A

CHECK,CHECK, CHECK
MONITOR
2 PEOPLE MIN

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35
Q

TRANSFUSION REACTIONS AND ADVERSE EFFECTS

A

IMMEDIATE = FEVER, CHILLS, NAUSEA, DYSPNEA, TACHYCARDIA, HYPOTENSION

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36
Q

DISCONTINUING PERIPHERAL IV ACCESS

IV THERAPY

A

IF IT LOOKS BAD… TAKE IT OUT
INFECTION, BRUISING, EXTRAVASION, INFILTRATION, PHLEBITIS… TAKE IT OUT

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37
Q

TIC TAC TOE METHOD

VIDEO 1

A

https://www.youtube.com/watch?v=URCS4t9aM5o (solving some problems)

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38
Q

TIC TAC TOE METHOD

VIDEO 2

A

https://www.youtube.com/watch?v=3neNB0w1P9M (partially compensated vs fully)

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39
Q

TIC TAC TOE METHOD

VIDEO 3

A

https://www.youtube.com/watch?v=URCS4t9aM5o (interpreting problems)

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40
Q

WHY DATE AN IV

A

USUALLY ONLY GOOD FOR 3 DAYS SO YOU NEED TO KNOW WHEN TO TAKE IT OUT– SAME FOR TUBING

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41
Q

SYMPTOMS OF METABOLIC ALKALOSIS

A

Level of consciousness/confusion, generalized weakness, decreased BP, skin turgor. Youshould assess for dehydration

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42
Q

WHY DOES ADVANCED AGE PUT A PATIENT AT RISK FOR FLUID AND ELECTROLYTE IMBALANCES

A

Dehydration: due to not feeling thirsty.

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43
Q

Na RANGE

A

Sodium (Na*): 136 to 145 mEq/ L

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44
Q

K+ RANGE

A

Potassium (K*): 3.5 to 5 mEq/L

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45
Q

Ca TOTAL RANGE

A

Calcium total (Ca*·): 9.0 to 10.5 mg/dL

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46
Q

Mg RANGE

A

Magnesium(Mg-): 1.3 to 2.1 mEq/ L

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47
Q

PO RANGE

A

Phosphorus (PO ):3.0 to 4.5 mg/dL

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48
Q

CI RANGE

A

Chloride (CI):98 to 106 mEq/ L

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49
Q

ABGs

A

PH
PACO2
PAO2
HCO3

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50
Q

pH RANGE

A

pH : 7.35 to 7.45

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51
Q

PaCO2 RANGE

A

PaC02 : 35 to 45 mm Hg

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52
Q

PaO2 RANGE

A

Pa02 : 8O to 100 mm Hg

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53
Q

HCO3 RANGE

A

HC03 (bicarbonate):21 to 28 mEq/L

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54
Q

HYPOCALCEMIA VIDEO

A

https://www.youtube.com/watch?v=Ry5Rh3wO8Sw

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55
Q

ABG CHARACTERISTICS OF RESPIRATORY ACIDOSIS

A

LOW PH
HIGH pCO2
RETENTION OF CO2 BY LUNGS

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56
Q

METABOLIC ALKALOSIS ABG CHARACTERISTICS

A

INCREASE IN BASE OR DECREASE IN ACID
INCREASE PH
INCREASE HCO3

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57
Q

S/S OF METABOLIC ACIDOSIS

A

HEADACHE
LETHARGY
ANOREXIA
DEEP, RAPID RESPIRATIONS (KUSSMAUL)
N&V
DIARRHEA
ABDOMINAL DISCOMFORT
COMA
DANGEROUS DYSRHYTHMIAS

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58
Q

S/S OF METABOLIC ALKALOSIS

A

CARDIAC DYSRHYTHMIAS AS A RESULT OF DECREASED K+
PHYSICAL WEAKNESS
MUSCLE CRAMPING
HYPERACTIVE REFLEXES
CONFUSION
CONVULSIONS
TETANY

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59
Q

HOMEOSTASIS

A

The body must maintain a delicate balance of acids and bases
.*  Metabolic and respiratory processes must work together to keep hydrogen ion (H+) levels normal and stable.

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60
Q

WHAT DOES THE PH OF BLOOD INDICATE

A

CONCENTRATION OF H+

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61
Q

To diagnose an acid-base imbalance, you need to ask yourself three questions

A

1) Does the pH indicate acidosis or alkalosis?
2) Is the cause of the pH imbalance respiratory or metabolic?
3) Is there compensation for the acid-base imbalance?

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62
Q

if compensation has been complete what would the ph result be

A

within normal range

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63
Q

If pH is within the normal range but the other parameters are not, you’re looking at

A

a case of complete compensation
.*  You will need to do one extra step to diagnose the origin of the imbalance.
*  You will be noting two pH values on the grid

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64
Q

how to notate 2 pH values on the grid

A

Record the one in the normal range as “pH(1)”
*  Recalculate pH using the exact midpoint of the normal range, or 7.40, for your reference point.
– Thus, a pH of less than 7.40 would indicate acidosis, and one greater than 7.40 would be alkalosis
*  Note this adjusted pH in the appropriate box as “pH(a)”

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65
Q

Treatment of any of these imbalances should be directed at

A

correcting the underlying cause with immediate care focused on correcting the pH level.

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66
Q

ISMP

A

(http://www.ismp.org/Tools/confuseddrugnames.pdf)

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67
Q

A DRUG IS

A

Any substance that alters physiologic function, with the potential of affecting health

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68
Q

A MEDICATION IS

A

a substance used in the diagnosis,
treatment, cure, relief, or prevention of health alteration. Regulated by the FDA.

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69
Q

A DRUG CAN BE ADMINISTERED FOR DIAGNOSTIC PURPOSES

A

e.g. assessment of liver function or diagnosis of myasthenia gravis

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70
Q

A DRUG CAN BE ADMINISTERED FOR PROPHYLAXIS

A

e.g. heparin to prevent thrombosis or antibiotics to prevent infection

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71
Q

A DRUG CAN BE ADMINISTERED FOR THERAPEUTIC PURPOSES

A

e.g. replacement of fluids or vitamins, supportive purposes (to enable other treatments, such as anesthesia), palliation of pain and cure (as in the case of antibiotics).

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72
Q

GENERIC NAMES

A

manufacturer who develops, help to recognize class (will see on NCLEX

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73
Q

DRUG CLASSIFICATION IS BASED ON

A

its desired effect on body system

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74
Q

MEDICATION FORMS

A

solid, liquid, topical, parenteral, sterile for body cavity instillation

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75
Q

THERAPEUTIC EFFECT

A

expected /predicted response on body system

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76
Q

ADVERSE EFFECTS AKA SIDE EFFECTS

A

are unintended and nontherapeutic effects, which can range from tolerable to harmful and sometimes to irreversible damage or death. Ex- GI bleeding from ASA (aspirin)

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77
Q

IDIOSYNCRATIC REACTIONS

A

opposite or different response than expected such as hyperactivity w Benadryl

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78
Q

SYNERGISTIC EFFECT

A

2 drugs cause greater body response when given together (positive or negative)

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79
Q

ALLERGIC REACTIONS TO MEDICATIONS

A

SESNSITIZED IMMUNE RESPONSE, UNPREDICTED, SIMPLE (ITCHING, HIVES, RASH, RHINITIS), OR ANAPHYLACTIC (EMERGENCY ABC PROBLEM, TX FOR BRONCHOSPASMS, WHEEZING, AND EDEMA)

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80
Q

PRURITUS

ALLERGIC RXNS

A

itching of the skin with or without rash.

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81
Q

ANGIOEDEMA

ALLERGIC RXNS

A

edema due to increased the permeability of the blood capillaries.

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82
Q

RHINITIS

ALLERGIC RXNS

A

Inflammation of mucous membranes lining nose; causes swelling and clear, watery discharge.

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83
Q

Pharmacokinetics

A

how meds enter & exit the body, are absorbed & distributed, reach their site of action, alter body processes, & are metabolized

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84
Q

Medication absorption

A

Passage of medication molecules into the blood from the site of administration

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85
Q

distribution of medication

A

After absorption, distribution occurs within the body to tissues, organs, and specific sites of action.

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86
Q

distribution of medication depends on

A

Physical and chemical properties of the medication

Physiology of the person taking it:
Circulation
Membrane permeability
Protein binding

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87
Q

medication metabolism

A

Medications are metabolized into a less-potent or an inactive form.
Kidneys, blood, intestines, and lungs play a role.

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88
Q

biotransformation

medication metabolism

A

Biotransformation occurs under the influence of enzymes that detoxify, break down, and remove active chemicals.

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89
Q

medication excretion

A

Medications exit the body through the:
Kidney- urine
Liver- bile
Bowel- stool
Lungs- gases
Exocrine glands- lipid-soluble meds
Chemical makeup of medication determines the organ of excretion.

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90
Q

toxic concentration

A

adverse or prolonged effect

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91
Q

therapeutic range

A

mec- wants a constant blood level

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92
Q

below the minimum effective concentration

A

concentration is too low to cause therapeutic effect

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93
Q

Therapeutic range-

A

constant blood level between mec & toxicity

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94
Q

peak

A

Peak is considered the maximal therapeutic level, max serum dose, time varies.

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95
Q

trough/level

A

A trough is the lowest therapeutic level.

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96
Q

onset

A

body response time

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97
Q

biological half life

A

is the time it takes for excretion to lower the blood concentration of a drug to decrease by 50%. Determines how often med is given.

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98
Q

plateau

A

occurs when a medication blood serum concentration reaches therapeutic effect and remains there

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99
Q

Time-critical medications-

A

30 minutes before or after scheduled time; non-time critical- within 1 hour of time due

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100
Q

Vancomycin 1 gm is due at 0800. When should the nurse draw the trough level?
a. 0600 b. 0730 c. 0900 d. 1000

A

b

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101
Q

A postoperative patient is receiving morphine sulfate via patient-controlled analgesia (PCA). The nurse assesses that the patient’s respirations are depressed. The effects of the morphine sulfate can be classified as:
a. therapeutic b. synergistic c. allergic d. adverse

A

d

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102
Q

Medication Rights

A

Right patient
Right medication
Right dose
Right time
Right route
Right documentation
Other rights (assessment, evaluation, refusal, education)

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103
Q

Standing or routine:

types of orders in acute care agencies

A

Administered until the dosage is changed or another medication is prescribed

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104
Q

single (one time)

types of orders in acute care agencies

A

Given one time only for a specific reason

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105
Q

now

types of orders in acute care agencies

A

When a medication is needed right away, but not STAT

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106
Q

prn

types of orders in acute care agencies

A

Given when the patient requires it

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107
Q

stat

types of orders in acute care agencies

A

Given immediately in an emergency

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108
Q

prescriptions

types of orders in acute care agencies

A

Medication to be taken outside of the hospital

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109
Q

According to The Joint Commission the goal of medication reconciliation is

A

to develop, update, coordinate, and communicate accurate client medication information during transitions of care.

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110
Q

Polypharmacy-

increase risk of adverse reactions, interactions

A

5 or more meds on a nonhospitalized client

May be meds with same actions or chemical class or to treat same illness

Risk of drug-drug or drug-food interactions

Taking herbal or nutritional supplements

OTC meds
Multiple pharmacies, providers

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111
Q

Topical administration:

A

Medications applied to the skin and mucous membranes generally have local effects.
Applied to skin
Rectal
Vaginal
Otic
Optic
Nasal

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112
Q

Oral Administration

A

Easiest and most desirable route
Food may decrease therapeutic effect. Empty stomach- 1 hr before or 2 hrs after meals.

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113
Q

aspiration precautions with oral medications

A

With tube feeding, if medication is to be given on an empty stomach, allow at least 30 minutes before or after feeding.
Risk of drug-drug interactions is higher.

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114
Q

enternal or small bore feedings

oral administration

A

Verify that the tube location is compatible with medication absorption.
Dissolve or pierce simple gelatin capsules.
Do NOT crush sustained release or enteric coated & double-check capsule before opening b/c interferes with design of med and/or increases potency.

Follow American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines.

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115
Q

Sublingual Administration

A

Administer to patient sitting
Dissolves under tongue
Don’t swallow drug, eat, drink, or smoke until after absorbed

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116
Q

patient teaching of administering meds via inhalation

A

Exhale 1st and then Inhale slowly, hold for 5-10 sec. to disperse med to get full effect. 30 sec. between puffs. Teach to rinse & spit after using inhaled steroids to decrease risk of developing thrush. Teach to monitor usage to know when to reorder.

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117
Q

Topical Medications- Skin

A

Transdermal patches:
Remove old patch before applying new.
Document the location, time & date of application of the new patch.
Document removal of the old patch as well.
Ask about patches during the medication history.
Apply a label to the patch if it is difficult to see.

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118
Q

Nasal Instillation (Topical)

A

Nasal drops are effective in treating sinus infections.
saline safer than decongestant spray which vasoconstricts and can increase BP
rebound effect- worsens nasal congestion.

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119
Q

Eye instillation

A

Artificial tears, vasoconstrictors.
Avoid touching the cornea- very sensitive, pain fibers.
Avoid the eyelids with droppers or tubes to decrease the risk of infection.
Pull down conjunctival sac and press lacrimal duct.
Never allow a patient to use another patient’s eye medication.

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120
Q

topical medications- ear

A

Structures are very sensitive to temperature. Room temp to prevent vertigo, dizziness, nausea.

Young child <3yrs- pull outer ear down & back, Older children & adults- pull ear up and back

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121
Q

ear instillation

A

Use sterile solutions in case ear drum is ruptured.
Drainage may indicate eardrum rupture.
Never occlude the ear canal.
Do not force medication into an occluded ear canal.

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122
Q

Topical Medications: Vaginal Instillation

A

Perineal care, assess for drainage.

Gloves, aseptic technique.

Supp- foil wrappers, refrigerate to prevent melting, avoid handling.

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123
Q

Topical Medications: Rectal Instillation

A

Rectal suppositories are thinner and more bullet-shaped than vaginal suppositories.

The rounded end prevents anal trauma during insertion.

Keep in fridge and avoid handling- may melt.

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124
Q

Identify the route of administration for ear drops.

A. Sublingual B. Parenteral C. Topical D. Intravenous

A

c

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125
Q

Suppositories should be stored in a
A. Locked box B. Pxyis drawer C. Dark area D. Refrigerator

A

d

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126
Q

Which medication could be administered via a nasogastric or PEG tube?
A. Extended release B. Sustained release C. Gelatin capsule D. Enteric coated

A

c

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127
Q

parts of the syringe and needle

A

bevel
shaft
barrel
tip
plunger
gauge number
hub
know where to measure
know where to avoid touching

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128
Q

needle description for id

A

1/4-3/4 inches long
27-25 gauge

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129
Q

needle description of im

A

25-18 gauge
1-1.5 inches long

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130
Q

needle description for subcu

A

3/8-5/8 inches long
27-25 gauge

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131
Q

Preparing an injection from an ampule

A

Snap off ampule neck
Aspirate medication into syringe using filter needle to prevent small glass fragments from entering syringe

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132
Q

Preparing an injection from a vial

A

If dry, use solvent or diluent as needed. Some meds unstable in solution so left as powder until reconstituted/dissolved w sterile water or normal saline for use.
Inject air into vial to create positive pressure to make med removal easier.

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133
Q

Insulin Administration –Patient Teaching

part 1

A

It is administered by subcutaneous injection and occasionally IV because the GI tract breaks down and destroys an oral form of insulin.

Rapid, short, intermediate, and long-acting (basal- lasts 24 hrs)

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134
Q

Insulin Administration –Patient Teaching

part 2

A

Timing of insulin attempts to mimic normal pattern of release of insulin from pancreas- before meals (ac) and at bedtime (hs).

Rotate vial to resuspend soln rather than shake- creates air bubbles

Rotate injection sites to avoid lipodystrophy- loss of fat cells, can be a lump or small dent in skin from repeated injections, interferes with insulin absorption.

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135
Q

mixing insulins video

A

https://www.youtube.com/watch?v=EW55TFDFrZ0

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136
Q

high risk of insulin

insulin

A

Verify insulin doses with another nurse while preparing the injection.

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137
Q

don’ts for mixing insulin

A

Do not mix insulin with any other medications or diluents unless approved by the health care provider

Never mix basal insulins- insulin glargine (Lantus) or insulin detemir (Levemir) with other types of insulin.

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138
Q

Regular Insulin Correctional Scale-AC & HS for high BG

A

blood glucose (mg/dL) = insulin (units)
61-150 = 0
151-200 = 3
201-250 = 5
251-300 = 8
301-350 = 10
351-400 = 12
greater than 400 = 15 and contact dr

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139
Q

Before injecting, know:

A

The volume of medication to administer
The characteristics and viscosity of the medication
The location of anatomical structures underlying the injection site

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140
Q

The subcutaneous route

injection site

A

under loose connective tissue, with minimal vascular supply and some pain receptor presence.

The injection site chosen needs to be free of skin lesions, bony prominences, and large underlying muscles or nerves.

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141
Q

preferred subcutaneous injection sites include

A

the outer posterior aspect of the upper arms, the abdomen from below the costal margins to the iliac crests, and the anterior aspects of the thighs.

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142
Q

The site most frequently recommended for heparin injection is

A

the abdomen.

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143
Q

angle for subcutaneous injections

A

Pinch an inch, give at 45 degree angle; Pinch 2 inches, give at 90 degrees.

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144
Q

Enoxaparin (Lovenox)

A

prevents DVTs! Subcutaneous route. ALWAYS 90 degrees in Abdomen; hold 10 seconds after injecting.

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145
Q

Administration of low-molecular-weight heparin (LMWH) requires special considerations. When injecting the medication,

A

use the right or left side of the abdomen at least 2 inches from the umbilicus
Administer LMWH lovenox (enoxaparin) in its prefilled syringe slowly with the attached needle at 90 degree angle
do not expel the air bubble in the syringe before giving the medication
leave in place 10 seconds after administering.
Do not rub skin.
Hold pressure at site.

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146
Q

im sites

A

ventrogluteal
vastus lateralis
deltoid

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147
Q

deltoid for im

A

Palpate the lower edge of the acromion process, which forms the base of a triangle in line with the midpoint of the lateral aspect of the upper arm. The injection site is in the center of the triangle, about 3 to 5 cm (1 to 2 inches) below the acromion process. Locate the site by placing four fingers across the deltoid muscle, with the top finger along the acromion process. The injection site is then three finger widths below the acromion process.

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148
Q

vastus lateralis for im

A

Position in a supine or lateral position with knee and hip flexed to relax muscle. Place palm of hand over greater trochanter of patient’s hip with the wrist perpendicular to femur. Use right hand for left hip, and use left hand for right hip. Point the thumb toward the patient’s groin and the index finger toward the anterior superior iliac spine; extend the middle finger back along the iliac crest toward the buttock. The index finger, the middle finger, and the iliac crest form a V-shaped triangle; the injection site is the center of the triangle.

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149
Q

ventrogluteal for im

A

Anterior lateral aspect of thigh, and extends in an adult from a handbreadth above knee to a handbreadth below greater trochanter of femur.
Use middle third of muscle for injection. The width of muscle usually extends from the midline of thigh to midline of outer side of thigh. Lying flat with knee slightly flexed or in sitting position relaxes muscle.

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150
Q

why im

A

Muscle is less sensitive to irritating and viscous medications.

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151
Q

max capacity of im for adults

A

Adults: 2 to 5 mL can be absorbed, 3 or less mL per injection is preferred.

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152
Q

assessing and prepping im sites

A

Assess site, find landmarks away from nerves. Aspirate 5-10 seconds to assess for blood vessel before injection of the medication. Use 90 degree angle for insertion

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153
Q

when to use ventrogluteal for im

A

involves the gluteus medius; it is situated deep and away from major nerves and blood vessels. **preferred and safest site for all adults, children & older infants. Recommended for vol > 2mL & for viscous, irritating meds.

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154
Q

when to use vastus lateralis for im

A

often used for infants less than 7 months and for very thin patients or patients who do not walk secondary to paralysis, etc.

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155
Q

when to use deltoid for im

A

Use this site for small medication volumes (Less than 2mL).

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156
Q

z-track video

A

https://www.bing.com/videos/search?q=video+on+z+track&view=detail&mid=CF857160FA29E8B35631CF857160FA29E8B35631&FORM=VIRE

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157
Q

Z-Track Method in IM Injections

A

Pull on the overlying skin during intramuscular injection to move tissue laterally to prevent later tracking (return of the medication to the skin surface). One hand holds skin 1 to 1.5 inches laterally or downward; other hand injects at rate of 10 seconds per mL. Then, keep needle inserted for 10 seconds to allow med to evenly disperse, rather than channel back. Release skin after withdrawing needle. Creates zig-zag path.

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158
Q

For needle gauges, the larger the number, the larger the size.
True or False?

A

false

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159
Q

Injections: Intradermal

A

Used for skin testing (TB, allergies)
Slow absorption from dermis to avoid anaphylaxis
Skin testing requires the nurse to be able to clearly see the injection site for changes

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160
Q

Injections: Intradermal

needle and angle

A

Use a tuberculin or small hypodermic syringe for skin testing. 27 or 25 gauge
Angle of insertion is 5 to 15 degrees with bevel up.

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161
Q

Injections: Intradermal

sites and expectations

A

A small bleb will form as you inject; if it does not form, it is likely the medication is in subcutaneous tissue, and the results will be invalid. Sites are hairless, light pigmentation, free of lesions. Ex- inner forearm, upper back.

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162
Q

subcutaneous medication capacity

A

no more than 1.5 ml

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163
Q

im medication capacity

A

ventrogluteal- 3 ml
deltoid- 2 ml
vastus lateralis- 1-3 ml

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164
Q

id medication capacity

A

ventral aspect of the forearm- 0.1 ml

165
Q

Large-Volume Infusions

A

Safest and easiest method of IV administration
Large volumes (500 or 1000 mL) are used. Common- NS, D5W, lactated Ringer’s. Vitamins or Potassium Chloride can be added.
If infused too rapidly, patient is at risk for overdose and/or fluid overload.

166
Q

Intermittent Intravenous Injections

A

Intermittent venous access (saline lock)

167
Q

intermittent iv injections

flushing

A

Flush often, before and after use if not continuous fluids.
Cover saline lock with an antimicrobial cap

168
Q

Infiltration or Extravasation

A

is when IVF is infusing into tissues outside of the vein.

169
Q

phlebitis

A

is inflammation in the walls of a vein. Thrombophlebitis is blood clot formation at the site of the inflammation.

170
Q

cellulitis

A

is usually a bacterial infection at the site and has similar S&S of phlebitis and tx but is more severe. Tx is similar but includes antibiotics, antipyretics, analgesics if needed.

171
Q

Why are needle gauges sizes backwards?

A

The basic answer is that for wire and needles, you are counting how many of those things in that size will add up to one inch when lined up next to each other on a ruler. So more needles in an inch means the needles are thinner.

172
Q

urethra length in women

A

4-6.5 cm
1.5-2.5 inches

173
Q

urethra length in men

A

20 cm
8 in

174
Q

The glomeruli filtrate and return

A

99% of plasma components back into the vasculature. One percent of plasma filtered is seen as urine.

175
Q

ENDOCRINE FUNCTION OF KIDNEY

erythropoietin

A

stimulates RBC production & maturation in bone marrow

176
Q

endocrine function of the kidney

synthesis of vitamin d

A

Synthesis of VITAMIN D as stimulated by parathyroid hormone. PTH also helps regulate CALCIUM & PHOSPHATE levels within kidneys

177
Q

Chronic kidney disease can cause

A

anemia, hypertension, & electrolyte imbalances.

178
Q

bladder contraction and relaxation

A

Bladder contracts during urination and urinary sphincters relax during urination.
Bladder contraction closes off ureter openings and opens urethral sphincters.

179
Q

bladder capacity

A

holds 600-1000 ml urine

180
Q

urge to void

A

Urge to void for Adults (250-450 mL in bladder) Children (50-200 mL) (q 2-4h)

181
Q

patterns of voiding

A

Vary by individual
Usually after waking up, around meals, before bed, 5–6 times/day

182
Q

growth and development

factors influencing urination

A

Children- control at 18-24 mos.- nerves innervated, pregnancy, normal aging process)

183
Q

surgical procedures

factors influencing urination

A

NPO, anesthetics decrease bladder contractility, sensation= retention

184
Q

medications

FACTORS INFLUENCING URINATION-

A

diuretics, anticholinergics- increase retention, sedatives- reduce cognition, meds can change the color of urine

185
Q

diagnostic exams

factors influencing urination

A

such as cystoscopy which causes trauma to urethra and hematuria

186
Q

muscle tone

factors influencing urination

A

weakened pelvic or abdominal muscles, muscle atrophy or trauma. Women usually sit, squat while men stand

187
Q

Conditions of the lower urinary tract –

A

urethral narrowing, altered innervation of bladder, weakened pelvic or perineal muscles (females- pregnancy related)

188
Q

benign prostatic hyperplasia

A

enlarged prostate (obstruction) can cause urinary retention, incontinence

189
Q

COMMON URINARY ELIMINATION PROBLEMS

A

Catheter-associated UTIs- CAUTIs- one of most common HAI
Urinary Incontinence
Urinary Diversions (see slide)

190
Q

urinary retention

A

unable to fully empty bladder (often from BPH)
Post-void residual (PVR)- bladder scan to measure urine left in bladder after voiding

191
Q

urinary tract infections

A

Infections- (often E.coli from colon) Females- at risk
Upper (kidneys) or Lower (bladder, urethra)
Pyelonephritis, bacteriuria, bacteremia (urosepsis)
Symptoms are dysuria, hematuria, cystitis (bladder)- urgency, frequency, incontinence, foul urine odor, fever, chills, flank pain
Delirium in older adults

192
Q

Stress incontinence-

A

coughing, sneezing, laughing, or physical activity causes urine leakage

193
Q

Urge incontinence-

A

a strong need or urge to urinate c leakage

194
Q

Reflex incontinence-

A

urine leakage due to nerve damage

195
Q

Overflow incontinence-

A

incomplete bladder emptying- bladder overfills- when full, leads to leakage

196
Q

Functional incontinence-

A

physical inability to reach the toilet in time

197
Q

Urinary frequency- >

A

4-6 times/day

198
Q

Nocturia –

A

voiding at night

199
Q

Urgency –

A

sudden strong desire to void

200
Q

Dysuria –

A

painful or difficult voiding

201
Q

Urinary hesitancy –

A

delay in initiating voiding

202
Q

Neurogenic bladder –

A

nerve pathway not intact, doesn’t sense fullness, or control sphincters

203
Q

Dribbling-

A

leaking small amounts

204
Q

Hematuria-

A

blood in the urine

205
Q

Polyuria (diuresis)

A

Production of abnormally large amounts of urine

206
Q

Polydipsia

A

Extreme thirst; associated with polyuria

207
Q

Anuria

A

Absence of urine production

208
Q

Oliguria

A

Decreased urine output
May signal impending renal failure
Less than 30 mL/h for more than 2 h is a cause for concern.

209
Q

ASSESSMENT OF THE URINARY SYSTEM

part 2

A

Urine typically sterile
Average Output is 1-2L/day
NURSE observes for MINIMUM of 30 ml/ h
If urine output is < 30 mL/ h for more than 2 hours, assess for blood loss & call Health Care Provider.

210
Q

Skin and mucus membranes-

A

pink, warm, dry, smooth, intact, look for breakdown suggesting incontinence or poor hygiene, overall good turgor (no tenting)

211
Q

Kidneys-

A

place hand on posterior flank & other hand on abdomen & gently squeeze

212
Q

Bladder-

A

if full, felt above symphysis pubis (Bladder scan- ultrasound)

213
Q

Urethral meatus-

A

pink, small slit like opening – observe discharge, redness, lesions

214
Q

urinalysis (ua)

A

Specific gravity- 1.005-1.030—Concentration of urine (Lower SG- diluted, Higher SG- dehydrated
No Glucose, Ketones, RBCs, minimal WBCs

215
Q

Ultrasound-

A

need full bladder, scan also after voiding to check for residual urine before catheterization

216
Q

Xray-

A

(KUB) kidney, ureter, bladder- no special prep

217
Q

X-Ray- Intravenous pyelogram

A

(use contrast dye- assess for all allergies including to shellfish/iodine or previous rxn to contrast dye, Usually NPO & requires bowel prep to clean out & be able to see urinary tract),X-rays as dye travels through urinary tract, abnormalities, calculi, tumors, cysts. Encourage fluids after. Delayed reaction possible. Facial flushing is normal with dye

218
Q

Computerized tomography of abdomen & pelvis (CT)-

A

cross-sectional images to assess for tumors or obstruction.
If using contrast dye- assess for allergies to shellfish/iodine, NPO X 4h.

219
Q

cystoscopy

invasive

A

endoscopy of bladder with lighted tube- biopsy, contrast dye in bladder.
May be NPO.
Blood in urine (pink-tinged) after test for 1-2 days.

220
Q

peritoneal dialysis

esrd

A

Surgically inserted abdominal catheter into peritoneal cavity
OSMOSIS, DIFFUSION & ULTRAFILTRATION,
around 4 exchanges per day or overnight cycling. Sterile Procedure–Risk for infection.

221
Q

hemodialysis

esrd

A

artificial kidney circulates blood as electrolyte fluid bathes it & removes wastes & excess fluid
OSMOSIS, DIFFUSION, & ULTRAFILTRATION. Usually 3Xwk, 4 h treatments.
Risk for infection, fluid overload– may need fluid restriction, electrolyte imbalances.

222
Q

TYPES OF URINARY DIVERSIONS

A

A- Continent urinary reservoir,
B- Urostomy, ileal conduit

223
Q

URINARY DIVERSIONS

A

One or both ureters is connected to abdominal wall opening (stoma) or tube into renal pelvis.
Diversions can be via Nephrostomy tube into kidney or ureters
Ureterostomy.
Can be continent or incontinent-
urine stored in pouch or body-catheterize pouch.
Skin care/ pouching. Body image issues, sexuality.

224
Q

suprapubic catheter

A

is a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder in individuals with obstruction of normal urinary flow.

225
Q

routine catheter changes

A

is Foley catheter with fluid in balloon to hold catheter in bladder. Infection prevention through hygiene, PO fluids, emptying drainage bag when ½ full.

226
Q

PLANNING, GOALS, AND OUTCOMES

urinary elimination

A

Drink 2-3L daily
Limit caffeine, alcohol, acidic drinks, artificial sweeteners
Limit fluids 2h before bedtime
Regulate bowels
Full urinary continence with 8 weeks of starting a pelvic exercise program (Kegel).
Stop smoking
Good voiding habits

227
Q

uti prevention

A

wear cotton panties, cleanse front to back,
no bubble baths or feminine hygiene sprays or douches, tight clothing,
void after sexual intercourse,
drink at least 2-3L of water daily,
no excessive dairy products, and have a glass of cranberry juice each morning

228
Q

IMPLEMENTATION: RESTORATIVE CARE

A

Strengthening pelvic floor muscles- Kegel Exercises
Bladder retraining- reduce frequency, less dribbling
Habit training- improve voluntary control- functional incontinence
Self-catheterization- aseptic technique-chronic disorders such as spinal cord injury
Maintenance of skin integrity- cleansing, barrier cream
Promotion of comfort- clean & dry, reduced symptoms

229
Q

IMPLEMENTATION

urinary elimination

A

Toileting schedule- q 2-3 h, before/after meals, tried in initial incontinence r/t cognitive/ mobility impairment, consistency, individualized

Pelvic exercises for sphincter control (Kegel Exercises)

Prevent urinary tract infections

Catheterization- Intermittent (Straight, In & Out) or Indwelling (Foley)

230
Q

Preventing Cath-Associated UTI (CAUTI)

part 1

A

closed drainage systems- free drainage by gravity. Urine should flow unobstructed.

Securement device- females to inner thigh.

231
Q

Preventing Cath-Associated UTI (CAUTI)

part 2

A

Maintain daily fluid intake of at least 2-3L if not contraindicated.
Catheter irrigation and instillations- Continuous bladder irrigation
Intermittent/ Straight cath or indwelling (5 French for infant, 16 fr for adult)
Removal of indwelling catheter- Smoothly & slowly, Withdraw plunger slightly & allow to drain by gravity. Make sure catheter is intact after removal.

232
Q

Preventing CAUTI

part 3

A

Male Incontinence Device/Condom catheters. Change condom cath Q 24h. PrimoFit

Monitor urine for amount, color, clarity, and odor.

Patient education very important regarding catheter and decreasing CAUTI

Smallest catheter size possible. Discontinue as soon as possible.

Keep bag below bladder for drainage. Never let bag touch the floor.

Empty bag Q 4-8 h or when ½ full

233
Q

SAFETY GUIDELINES

urine elimination

A

Follow principles of surgical and medical asepsis

Identify patients at risk for latex allergy (i.e., patients with history of hay fever; asthma; and allergies to certain foods such as bananas, grapes, apricots, kiwi fruit, and hazelnuts).

Identify patients with allergies to povidone-iodine (Betadine). Provide alternatives such as chlorhexidine.

234
Q

Peristalsis

A

moves food, cardiac sphincter at end of esophagus & stomach entrance- stops stomach reflux

235
Q

stomach-

A

storage, mix with digestive juices (HCl, mucus, pepsin, intrinsic factor) into chyme. Mucus protects stomach from acid

236
Q

Anus –

A

Internal & external sphincters- involuntary & voluntary control, sensory nerves

237
Q

age- infancy

bowel elimination

A

Infancy- small stomach, rapid peristalsis,

238
Q

diet

bowel elimination

A

Fiber- bulk-forming foods such as whole grains, fruits, veggies- help remove fats & waste products more efficiently & decrease risk of colon cancer, may also produce gas- esp onions, broccoli, cauliflower, beans. Gas stretches abd walls, increases colon motility- may be painful post-op. Spicy foods can increase peristalsis, cause indigestion, or loose stools. Food intolerances- GI distress, diarrhea, gas, cramps

239
Q

fluid intake

bowel elimination

A

DAILY GOAL- Men- 3.7 L, Women- 2.7 L
Enough for soft stools, fruit juices soften stools & increase peristalsis, prune juice- high fiber, warmed fluids- stimulate peristalsis

240
Q

physical activity

bowel elimination

A

promotes peristalsis, immobility slows it down.
Early & frequent ambulation after surgery, illness. Weakened abdominal & pelvic floor muscle tone- can’t bear down or control sphincter well, increased risk for CONSTIPATION.
Long-term illness, spinal cord injury, neurological diseases

241
Q

Psychological factors-

bowel elimination

A

Depression-slow GI activity- constipation. Anxiety/ emotional stress increase digestion & peristalsis leading to gas distention, diarrhea.
Stress worsens GI diseases such as IBS, ulcers, Crohn’s disease, ulcerative colitis

242
Q

Position during defecation-

bowel elimination

A

squatting, sitting to lean forward, exert abdominal pressure, contract gluteal muscles. 30-45 degrees for bed pan use, BSC if possible, ambulating to bathroom

243
Q

Pain-

bowel elimination

A

hemorrhoids, rectal surgery, anal fissures (split in tissue), abdominal surgery

244
Q

Pregnancy-

bowel elimination

A

etus pressure on rectum, decr peristalsis- constipation, straining- hemorrhoids

245
Q

Surgery & Anesthesia-

bowel elimination

A

general anesthetic agents stop or slow peristalsis- block parasympathetic nerve impulses. Any surgery that directly manipulates intestines STOPS peristalsis temporarily & causes ILEUS- for 24-48 hrs. Ambulation, activity, eating helps return to normal function.

246
Q

Medications-

bowel elimination

A

opioids - pain control- slow peristalsis- constipation.
Antibiotics kill normal flora- diarrhea.
Laxatives or Cathartics soften stool, increase peristalsis. Laxatives- 1st fiber, 2nd osmotic.
*Avoid stimulant laxatives long-term bc of intestine dependency due to decreased reflex to defecate.

247
Q

Diagnostic tests-

bowel elimination

A

clear view of gastric mucosa- NPO, clear liquids, laxatives or enemas to cleanse stool

248
Q

constipation

A

Constipation SYMPTOM- of low-fiber diet, poor liquid intake, decreased activity, medications

SIGNS- infrequent BM (<3/wk), hard & dry stools that are difficult to pass. Decreased peristalsis- fecal mass exposed longer to intestinal walls- more water loss

249
Q

impaction

A

Impaction- unrelieved constipation & unable to expel the hardened feces in rectum. (Debilitated, confused, unconscious- dehydrated, weak or unaware of defecation need, stool dry & difficult to pass)

250
Q

signs of impaction

A

Sign- inability to pass stool for several days in spite of urge to defecate
Oozing of liquid stools, feces leaks from above impaction. Anorexia, N&V, abd distention & cramping, rectal pain

251
Q

Incontinence-

bowel elimination

A

inability to control passage of feces and gas from anus. Risk for Skin breakdown

252
Q

Flatulence-

A

gas accumulation within intestinal lumen. Mouth- belching or Anus- flatus. Abd fullness, pain, cramping, esp if slower peristalsis. Ambulation helps.

253
Q

Diarrhea-

A

faster peristalsis, increase in stool #, liquid, unformed stool.

254
Q

causes of diarrhea

A

infectious agent such as bacteria, viruses, parasites; emotional distress, tube feedings;
GI disorders. Infectious agents must shed through diarrhea but also lose bicarbonate,
Antibiotics destroy normal GI flora & allow
C.difficile to overgrow. SOAP & H2O handwashing essential to remove spores. Bleach 10% solution to clean surfaces

255
Q

Hemoccult stool-

A

small sample (FOBT- fecal occult blood test) Guaiac- 3 samples
No NSAIDS within 7 days of testing
Avoid Vitamin C, fruits, fruit juices for 3 days
Don’t eat red meats within 3 days of testing
Positive results require flexible sigmoidoscopy or colonoscopy

256
Q

Endoscopy –

A

Lighted FiberopticTube to visualize esophagus, stomach, and small intestine (Upper GI tract). Can remove polyps for biopsy. Anesthetic to throat, some clear liquids ok, NPO before & until gag reflex returns

257
Q

Colonoscopy-

A

NPO, bowel prep- Tube in to visualize LI/ colon, remove polyps for biopsy or find source of bleeding

258
Q

Upper GI series (barium swallow) X-ray-

A

NPO, drinks barium-opaque contrast solution, clear liquids and laxative day before; shows pharynx, esophagus, stomach.

259
Q

Lower GI series X-ray-

A

barium enema- NPO, barium into anal opening, shows large intestine.

260
Q

Amylase & Lipase –

A

serum blood tests for hepatitis, pancreatitis (most accurate results after fasting – NPO)

261
Q

Abdominal x-ray-

A

obstruction or abnormality, no prep

262
Q

Colorectal transit study-

A

how food moves through colon, swallows capsule with radiopaque markers, X-ray on 5th day

263
Q

Computerized tomography- CT scan-

A

cross-section views, Oral and/or IV sedation-contrast dye- assess for any/all allergies for IV (older idea was for shellfish allergies) NPO 4-6 h before- depends on if oral contrast is used

264
Q

MRI-

A

magnet and radio waves to see inside body, NPO 4-6 h before, NO METAL objects on/in pt

265
Q

ati review

A

elimination
comfort
teaching and learning/ patient ed
fluid and electrolyte balance
tissue integrity
mobility

266
Q

Implementation in acute care settings

bowel elimination

A

Routine time for defecation (Urge most likely one hour PC- GASTROCOLIC REFLEX mass peristalsis, Offer bedpan, BSC, BRP after each meal)
Safety & comfort
Privacy & modesty
Abdominal tightening exercises 4X day
Ambulation, activity (Best way to stimulate peristalsis)
Low-residue foods for diarrhea- white rice, potatoes, bread, bananas, cooked cereals (BRAT diet)
Skin integrity – no-rinse spray, barrier cream, assess skin around wafers of ostomies

267
Q

medications

Implementation in acute care settings- bowel

A

Laxatives- bulk forming, stool softeners, osmotic- saline-based laxative, stimulant cathartics. Suppositories- may act more quickly than oral meds. (Goal- soft, formed brown stool w/o pain or difficulty) Chronic use- weakens bowel’s response to distention from feces-promotes dependency on laxatives.
Antidiarrheal agents- slow motility, reabsorb fluid
Antiflatulent agents- merge gas bubbles & help to pass

268
Q

ng tube

Implementation in acute care settings- bowel

A

(Decompression, compression, enteral feeding, lavage) Clean- NOT sterile technique, Placement check= pH < 5 or less for stomach, X-ray- gold standard to verify placement, NG tube measured before placement from tip of nose to ear lobe to xyphoid process, water-soluble lubricant used for insertion(less toxic than oil if aspirated), Document length of tube extending from nares to help with placement check.

269
Q

bowel training

Implementation in acute care settings

A

Bowel training, Chronic constipation, fecal incontinence 2nd to cognitive impairmt- timed toileting, hot drinks such as tea or juices (prune), privacy, nonhurried, exercise as able
*make sure to take them when they have the urge

270
Q

Ostomies- Ostomy-

A

temporary or permanent opening (stoma) surgically created in abdominal wall to allow passage of fecal matter

271
Q

Stoma should be

A

pink or beefy red- NEVER purple or black or pale—— Call HCP immediately if so! Skin care- priority & body image. Skin wafer around stoma, bag to collect stool.

272
Q

Colostomy-

A

piece of large intestine; more formed stool from colon

273
Q

ileostomy-

A

piece of small intestine (More liquid, diarrhea like stool from small intestine) so increase fluids (drink 8oz for each emptying of bag). Avoid indigestible fiber- popcorn, corn, pineapple, Chinese cabbage, raw mushrooms, fresh pineapple. These foods may be eaten in small amounts, chewed well, and when drinking fluids with the foods.

274
Q

enema implementation

A

Position client in left Sims
Insert tube 3-4 inches for adult, 2-3 in for child.
Hold tube 12-18 inches above anus as fluid instills. Clean not sterile technique. If c/o cramping, lower container & briefly pause solution. Ask to retain for as long as possible.

275
Q

Tap water or hypotonic-

enema

A

Stimulates BM- Risk of water toxicity

276
Q

Soapsuds-

enema

A

Irritant promotes bowel peristalsis

277
Q

Normal Saline-

enema

A

safest due to equal osmotic pressure, Volume stimulates peristalsis

278
Q

Low-volume hypertonic-

enema

A

commercially prepared, used for clients who can’t tolerate high-volume enemas

279
Q

Oil-retention-

enema

A

lubricates rectum & colon for easier stool passage

280
Q

Medicated enema-

A

such as w/antibiotics to dwell for 1-3 h

281
Q

IV ONSET

A

iv = 3-5 minutes

282
Q

IM ONSET

A

im = 3-20 minutes

283
Q

SC ONSET

A

= 3-20 minutes

284
Q

PO ONSET

A

po = 30-45 minutes

285
Q

WHERE DOES MOST BIOTRANSFORMATION OCCUR

A

IN THE LIVER

286
Q

WHEN DO YOU MEASURE TROUGH

A

by lab draw just prior to the next scheduled dose (approximately 30 min before next dose).

287
Q

what subq injection site offers the fastest absorbption

A

abdomen

288
Q

max capacity for im in Children, older adults, thin patients: up to 2 mL
Small children and older infants: up to 1 mL
Smaller infants: up to 0.5 mL

A

up to 2 mL

289
Q

max capacity for im in Small children and older infants:

A

up to 1 mL

290
Q

max capacity for im in Smaller infants:

A

up to 0.5 mL

291
Q

when do you NOT aspirate an im injection

A
  • except don’t aspirate prior to giving immunizations (CDC, 2021)
292
Q

injection: iv

piggyback

A

By “piggyback” infusion of a solution containing the prescribed medication and a small volume of IV fluid through an existing IV line

293
Q

factors affecting urination

older adults

A

Older adults- Decreased thirst, ability to delay voiding, & bladder capacity. Increased urgency, incidence of overactive bladder & contractions, loss of bladder contractility (strength). Incontinence due to chronic illness, medications, mobility issues, cognition, nocturia.

294
Q
A
295
Q

crede method

A

manual compression of bladder to help with emptying

296
Q

info for inserting catheterizing males

A

insert catheter at 90 degree angle to straighten urethra & ease insertion,
insert until bifurcation to ensure balloon not inflating in prostatic urethra,
secure to upper thigh or lower abdomen.

297
Q

cath care

A
298
Q

coude catheter

A

curvature at end to maneuver through enlarged prostate (Requires special training for insertion).

299
Q

PureWick catheter for women-

A

gauze w/ suction tube connected to suction, canister- Change Q 8-12h

300
Q

age-elderly

bowel elimination

A

Elderly- decreased chewing ability, Arteriosclerosis decreases GI blood flow, Innervation decreases esophageal emptying & peristalsis, Decreased perineal & sphincter muscle tone, taste bud atrophy, decreased gastric acid.

301
Q

when should the nurse take the client to the bathroom while bowel training

A

planned times
after a meal
when they have the urge

302
Q

what does a bowel training program focus on

A

identifying times in the client’s pattern to promote self control of defacation

303
Q

if a client with a ng tube is reporting anxiety, discomfort, and feeling bloated, what should you do

A
  1. check to see if suction equipment is working
  2. later it might be necessary to get order for anxiety meds, irrigation, or removing and reinserting, but not at first
304
Q

what should nurse teach about sl nitroglycerin tablets for angina pectoris

A
  1. should be taken prn
  2. if first dose doesn’t relieve pain, seek emergency care and possibly 2 more tabs at 5 minute intervals
  3. take 1 taab at first indication of pain
  4. do not drink/eat until dissolved and observed
305
Q

what kind of drainage tube makes a pt more prone to hypokalemia

A

ng tube to suction

306
Q

diet considerations for a client with chronic kidney disease and a new Rx for epoetin alfa

A
  1. increased iron
  2. decreased protein
  3. decreased potassium
  4. decreased salt
307
Q

what are the procedures for administering a unit of packed rbc

A
  1. 2 RNs, 1 RN and 1 PN, cannot use an AP (assistive personell)
  2. might premedicate with antipyretic but not an antiemetic
  3. infuse over 4 hr to prevent bacteria growth
  4. remain with pt for first 15-30 minutes
308
Q

what should the nurse do if the client reports that the doctor didn’t tell them they were supposed to receive xyz?

A

check the client’s medical record for the prescription/order

309
Q

why should you not crush an enteric-coated aspirin

A

you might get a stomach ache or indigestion
the coating prevents breakdown in the stomach and decrease the possibility of gi distress

310
Q

if a client states they are having abdominal cramps during a tap water enema, what should you do to relieve discomfort

A

lower the height of the solution container to slow the flow momentarily. this allows the intestinal spasms to pass and then continue at a slower rate

311
Q

causes of constipation

A
  1. excessive laxative use
  2. ignoring the urge to defecate
  3. inadequate fluid intake
312
Q
A
313
Q

if urine is dark amber, cloudy, and has an unpleasant order, what might you suspect is wrong

A

uti
there is presence of wbcs, rbcs, and bacteria

313
Q
A
313
Q

what time/place should you complete your final medication check

A

at the bedside before administration

314
Q

you are giving an enema. client reports mild cramping and asks you to stop so he can go to the bathroom. what should you do

A

slow the flow of solution briefly to prevent cramping

315
Q

what is the first action you should take when preparing to discontinue an indwelling urinary catheter

A

position client in supine position

316
Q

if client has impaired renal function, when should you notify the provider

A

urine output of 175 mL over 8 hrs. this is less than the norm of 30 ml/hr. it indicated fluid imbalance, decreased fluid volume, possibly inadequate renal perfusion

317
Q

procedures for administering a z track injection

A
  1. pull skin 1-1.4 inches down or to the side
  2. insert needle quickly and smoothly
  3. 90 degree angle
  4. aspirate for 5-10 seconds
318
Q

exam 3. med admin, elimination, electrolyte MATH REVIEW ATI

A
319
Q

instructions for regular and nph insulin

A
  1. keep the open vial at room temp to reduce tissue injury and lipodystrophy
  2. inject into subq tissue
  3. not necessary to aspirate
  4. mix compatable solutions to reduce qty of injections
320
Q

rules for auscultating client bowels

A
  1. clamp ng tube during auscultation
  2. perform auscultation between meals
  3. auscultate for 3.- minutes
  4. auscultate prior to palpating to prevent alterations
321
Q

heparin

A
  1. effects begin within minutes
  2. does not dissolve clots
  3. stops new clots from forming
322
Q

warfarin

A

usually started after heparin
po
does not dissolve clots

323
Q

when should you auscultate bowel sounds

A

after inspection
before percussion

324
Q

teaching for client with asthma that has just been prescribed inhaled beclomethasone

A
  1. does not cause cardiac side effects
  2. is an inhaled glucocorticoid
  3. not administered with food
  4. rinse after administration to reduce fungal growth
  5. caffeine does not interact with this
325
Q

labs reflecting acute pancreatitis

A

calcium- decreased
rbc- decreased
wbc- increased
magnesium- decreased
amylase- increased

326
Q

amylase

A

enzyme that changes complex sugars to simple sugars for body use
produced by pancrease and salivary glands
released into mouth, stomach, and intestines to aid in digestion
with pancreatitis- elevates 12-24 hr and remains elevated 2-3 days

327
Q

how do you open a glass ampule

A

tap the top
place a sterile gauze around the neck
break off the top by bending it toward your body

328
Q

if you notice a crushed bupropion xl was administered crushed in applesauce, what should you do

A

initiate an incident report

329
Q

insulin glargine is a long duration insulin meaning it has a duration of

A

18-24 hours and is administered once a day

330
Q

order of conducting an assessment

A
  1. ask Hx
  2. inspect
  3. auscultate
  4. palpate
  5. percuss
331
Q

administering heparin

A
  1. use 25-26 gauge needle
  2. 3/8 inch or shorter needle
  3. inject into abdomen above the level of the iliac crest
  4. do not massage for 1-2 minutes
332
Q

what should a nurse ask before an intravenous pyelogram for kidney stones

A

if pt is allergic to shellfish because the dye may cause reaction

333
Q

standards for administering medication

A
  1. verify med against Rx and med label
  2. scan bar code on med and arm band
  3. check orders and confirm dosage in pdr
  4. document after administering
334
Q

standards of administering enemas

A
  1. don clean gloves
  2. assist to left sims position
  3. hang container no more than 18 inches above
  4. only insert up to 4 inches
335
Q

if an iv site becomes red, swollen, and painful, what is the first action you should take

A

discontinue the iv line

336
Q

standards for transdermal nitroglycerin to treat angina pectoris

A
  1. apply new patch each day
  2. apply patch in the morning and leave for 12-14 hrs before removing in the evening
  3. rotate sites to reduce local skin irritation
  4. has delayed onset so good for prophylaxis but not for immediate relief
337
Q

where do you administer a sublingual medication if patient has an ng tube

A

still under the tongue

338
Q

when placing an ng tube, what should you expect the ph to be

A

4.0

339
Q

a stool test for guaiac is to check for what substance

A

blood

340
Q

how do you test stool for steatorrhea

A

send total qty of stool at one time to lab

341
Q

how do you test for bacteria in stool

A

collect in a culture tube with sterile and aseptic technique

342
Q

how do you test stool for parasites

A

warm stool samples over a period of days for evaluation

343
Q

technique for instilling eardrops in a 5 year old

A

pull auricle up and out

344
Q

technique for instilling eardrops in a child under 4

A

pull auricle down and back

345
Q

standards for inserting indwelling urinary cath into female

A
  1. use non dominant hand to separate labia
  2. dominant hand handles cath during insertion
  3. coat tip with water soluble lubricant for comfort and tissue protection
346
Q

standards for plan of care for dehydrated pt receiving continuous iv

A
  1. monitor vs q2h
  2. over 240 mL or 8 oz oral fluids every 4 hours
  3. check iv site and monitor infusion q1h
347
Q

teaching for client prepping for cystoscopy

A
  1. increase fluids post procedure
  2. you may have pink tinged urine post procedure
  3. dark red urine should be reported because indication of bleeding
348
Q

what actions should a nurse take when caring for pt 1 day postop of a transurethral resection of prostate TURP and has continuous bladder irrigation in place

A
  1. do not add amount of bladder irrigation to output
  2. use sterile technique when preparing irrigation solution- many pt are older with other chronic diseases making more susceptible
  3. ensure drainage tubing is patent and without obstruction or kinks is correct
  4. if pt reports continual need to void, you will not need to contact dr because they already have an indwelling catheter that is giving this sensation
  5. you may have a few small clots or pink tinged drainage but should contact dr if urine is bright red, ketchup like, large clots
349
Q

teaching about urge incontinence

A
  1. dr may prescribe anticholinergic to suppress contractions and increase bladder capacity
  2. limit fluids in the evening to prevent overload while sleeping
  3. restrict caffein because it is an irritant
  4. you won’t need catheterization or vaginal repair as these are used in other types of incontinence
350
Q

urinary catheterization is used in

A

reflex incontinence

351
Q

anterior vaginal repair is used to treat…

A

stress incontinence

352
Q

indications that a dehydrated patient is responding to Tx

A
  1. decreased Na
  2. decreased K+
  3. urine specific gravity 1.005-1.030
  4. decreased hct to normal range
353
Q

what s/s would you find in an infant with severe dehydration from acute gastroenteritis

A
  1. sunken anterior fontanel
  2. hyperpnea
  3. 13 % weight loss
  4. capillary refill greater than 4 seconds
354
Q

blood tinged urine in a catheter bag can indicate

A

bladder infection

355
Q

prostate enlargement is an indication of

A

urinary hesitancy of difficulty initiating stream of urine

356
Q

dehydration is a manifestation of

A

oliguria or a diminished urinary output

357
Q

pernicious anemia is caused by

A

lack of intrinsic factor which is needed to absorb vit b12 from the gi tract. b12 is also needed to form rbc.

358
Q

hematuria

A

blood in urine

359
Q

uti symptom specific to the elderly

A

confusion

360
Q

uti symptoms of all ages

A
  1. urinary retention
  2. low back pain
  3. inconfinence
361
Q

what output indicates oliguria

A

less than 400 mL in 24 hr or less than 30 mL/hr

362
Q

indications of fluid overload

A
  1. 5 lb weight gain in 24 hours (acceptable is 2 lb or less per day)
  2. distended neck veins
  3. o2 level less than 92
  4. adventitious lung sounds indicating pe
  5. edema
363
Q

what findings are associated with urinary retention when pt is experiencing prostatic hypertrophy

A
  1. feeling pressure
  2. tenderness over symphysis pubis
  3. distended bladder
  4. voiding 30 mL frequently
364
Q

a client with a new ileal conduit is at risk for what

A
  1. anxiety
  2. disturbed body image
  3. impaired skin integrity
  4. infection
365
Q

collecting a stool sample

A
  1. use non sterile object like a tongue blade unless culture where you would need sterile swab
  2. sterile container is not necessary but should collect in dry container free of urine
  3. place in clean biohazard bag that is labeled and prevents contamination and spillage during transport
  4. send immediately to lab
366
Q

sudden onset of urinary incontinence in the elderly is often caused by

A
  1. cystitis
367
Q

nephrosclerosis

A

degenerative kidney disorder than can cause kidney ischemia and fibrosis

368
Q

uremia can cause

A

n&v
fatigue

369
Q

diverticulitis can cause

A

abdominal pain
nausea
leads to perionitis

370
Q

a client should contract pelvic muscles to

A

improve strength and manage urinary incontinence
kegels

371
Q

you should sip water to assist in inserting what type of catheter

A

ng tube

372
Q

when should you ask pt to exhale slowly

A

when auscultating lung sounds

373
Q

what should you have a pt do when inserting an indwelling catheter

A

bear down

374
Q

what findings indicate need for catheterization of a paraplegic

A
  1. dribbling urine
  2. overflow incontinence
  3. indication of bladder distention
375
Q

is urge incontinence an indicator of bladder distention

A

no

376
Q

can a paraplegic pt feel urgency or dysuria

A

unlikely

377
Q

when should intermittent catheterization be performed

A

prescribed schedule
bladder distention
dribbling present

378
Q

why should a nurse perform intermittent catheterization

A

prevent bladder trauma or infection

379
Q

appropriate schedule for intermittent catheterization

A

regular schedule to drain flacid bladder with no longer than 8 hr between catheterizations

380
Q

what can ivp provide info about

A

cause of hematuria so rbc in a ua is not a contraindication

381
Q

high frequency sound waves are used during

A

a renal ultrasound

382
Q

what kind of diet would a pt have post ivp

A

clear liquids

383
Q

what will a pt be encouraged to do post ivp

A

intake fluides to promote elimination of the dye

384
Q

expectations after removing an indwelling catheter in the elderly

A
  1. temporary urinary retention
  2. if client does not urinate for 6-8 hrs after removal, reinsertion may be necessary
  3. urinary frequency might be temporary but a couple of days indicates possible uti
  4. there should be no blood in the urine nor should it be highly concentrated
385
Q

what lab results indicate a therapeutic effect of epoetin alfa for chronic renal disease

A

hematocrit
hct
the therapeutic effect of this med is enhanced rbc production which is reflected in an increased rbc, hgb, and hct

386
Q

what kind of medication is epoetin alfa

A

antianemic
indicated in those with anemia due to reduced production of endogenous erythropoietin which may occur with end stage renal disease or myelosuppression from chemotherapy

387
Q

manifestations of urinary retention

A

voiding a small amount of urine (less than 100 ml) frequently (2-3 qh) and dribbling of urine

388
Q

elevated bun is a manifestation of

A

kidney disease

389
Q

painful urination is a manifestation of

A

uti

390
Q

positive glucose in the urine is a manifestation of

A

diabetes mellitus

391
Q

during the oliguric phase of acute kidney injury, the nurse should expect

A
  1. increased serum concentration of creatine
  2. increased serum concentration of K+.
  3. hyperkalemia- could rise quickly and become life threatening
  4. increased serum concentration of Mg
392
Q

foods eliminated from a diet for pt with ulcerative colitis

A

dried apricots
high fiber foods

encourage cooked cabbage, bananas and other low fiber foods

393
Q

diet for a pt with pre dialysis end stage kidney disease

A

limit phosphorous to 700 mg/day
limit protein to 0.55-0.6 g/kg/day
reduce foods high in K+
reduce foods high in Na

394
Q

indications of fluid volume excess

A

bounding pulse
crackle of lungs
pitting edema
urine specific gravity greater than 1.030

395
Q

teaching for adolescent with spina bifida

A
  1. cath q4hr
  2. infrequent cath can result in stasis and uti
  3. maintain increased fluid intake
  4. suppository to stimulate bowel mvmt ever 1-2 days as appropriate
396
Q

expectations of a client that has had vomitting and diarrhea for 3 days

A

poor skin turgor
tachycardia
hypotension
dark urine
flat neck veins

397
Q

teaching in regards to colostomy

A
  1. ileostomy adaptation can occur over time
  2. frequent draining
  3. stoma should be pink to chery red but never pale, bluish, or dark
  4. the skin around the stoma should be normal and not red
398
Q

ileostomy adaptation

A

small intestine begins to perform some of the absorption function previously completed by the colon. causes a stool volume decrease. stool becomes thicker and paste like and turns yellow/gree/brown. reduces frequency of drainage

399
Q

if a pt receives hemodialysis
Tx, what lab results would a nurse expect

A

rbc unaffected
protein unaffected
Ca increased
decreased K+

400
Q

expected lab values for a pt with acute kidney injury

A

increased K+ (hyperkalemia)
decreased ph
metabolic acidosis
hypocalcemia
high Ca
high PO
elevated bun

401
Q

if a pt receives peritoneal dialysis, what should the nurse monitor in regards to periotonitis

A

diminished/absent bowel sounds
N&V
abdominal tenderness
anorexia
restlessness
confusion
tachycardia
oliguria

402
Q

peritonitus

A

inflammation of the peritoneum
complication of peritoneal dialysis

403
Q

teaching for urinary catheterization with new nurse

A

relieves urinary retention
never for nurse/staff convenience
good for measuring residual urine after urination
no for routine urine specimen
good in case of open perineal wound

404
Q

steps for preparing sterile field

A

hand hygiene
package to work surface
open away
open sides
open closest to you
use inner surface as sterile field

405
Q

when do you empty an ileal conduit

A

2/3 full to prevent leakage, skin irritation and infection

406
Q
A

201 Intro (9 decks)

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