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Acute Care Nursing 1 > Acute Care Nursing 1 > Flashcards

Acute Care Nursing 1 Flashcards

1
Q

What are the requirements of a medication prescription?

A 
Must be legible
Must contain:
 - start date
 - medicine
 - route
 - dose
 - frequency / dose times
 - indication (if appropriate)
- prescriber name, signature, contact details
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2
Q

What are the high risk medications as specified by APINCHS

A

A - antimicrobials
P - potassium and other electrolytes / psychotropic medication
I - Insulin
N - narcotics/opioids
C - chemotherapeutic agents
H - heparin and other anticoagulants
S - systems (eg safe administration of liquid medications)

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3
Q

What are the 6 rights of medication administration?

A 
1 - right patient
2 - right medication/drug
3 - right dose
4 - right route
5 - right time
6 - right documentation
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4
Q

Sites for subcutaneous injections

A
  • anterior abdominal wall (5cm clear of umbilicus and any scars)
  • anterior aspects of the upper arms
  • anterior aspects of the thighs
  • scapulae
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5
Q

Sites for intramuscular injections

A
  • deltoid (upper arm)
  • dorsogluteal (buttock)
  • rectus femoris (anterior quadricep)
  • vastus lateralis (lateral anterior quadricep)
  • ventrogluteal (hip)
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6
Q

How to locate the ventrogluteal injection site

A
  • place palm of hand against the greater truncator of the femur and index finger on the anterior on the anterior superior iliac spine of the pelvis
  • abduct the middle finger posteriorly along the iliac crest
  • inject between the V of the two fingers
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7
Q

Potential complications of IMI

A
  • fibrosis and contractures of the muscles
  • nerve injuries/palsy/neuropathy
  • arterial puncture/haematoma formation
  • local irritation/infection/abscess
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8
Q

What is the maximum injection volume for each injection site

A
  • deltoid = 2mL (EXCEPT Invega Trinza, 2.6mL)
  • ventrogluteal = 2.5mL
  • dorsogluteal = 3mL
  • vastus lateralis = 5mL
  • rectus femoris = 5mL
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9
Q

What vital signs should be conducted?

A
  • respiration rate
  • oxygen saturation
  • heart rate/rhythm/strength
  • blood pressure
  • temperature
  • level of consciousness
  • pain
  • cognition
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10
Q

What aspects of respiration should be assessed?

A
  • rate (breaths/min)
  • rhythm
  • depth and symmetry
  • effort
  • audible sounds
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11
Q

Types of audible/abnormal breath sounds

A
  • stridor: high-pitched breath sound
  • stertor: laboured snoring sound
  • wheezing: high-pitched and squeaking
  • crackles, bubbles, gurgles
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12
Q

Types of abnormal breathing patterns

A
  • apnoea: absence of breathing
  • tachypnoea: resp rate greater than 20 breaths/minute
  • bradypnoea: resp rate less than 10 breaths/minute
  • dyspnoea: shortness of breath, difficulty breathing
  • hypoventilation: reduced rate and depth of breathing
  • hyperventilation: rapid deep breathing
  • Cheyne-Stokes: slow and increased depth of breathing with periods of apnoea. Sign of dying
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13
Q

Clinical conditions affecting oxygen sats

A
  • severe hypoxia
  • abnormally high pH
  • hypotension
  • arrhythmias
  • hypothermia
  • pharmacological vasoconstrictions
  • peripheral oedema
  • jaundice/hyperbilirubinaemia
  • low perfusion states/poor peripheral circulation/peripheral vascular disease
  • anaemia
  • carbon monoxide exposure
  • medical conditions such as COPD
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14
Q

Pulse sites

A
  1. temporal pulse
  2. carotid pulse
  3. apical pulse
  4. brachial pulse
  5. radial pulse
  6. femoral pulse
  7. popliteal pulse
  8. posterior tibial pulse
  9. pedal pulse
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15
Q

How to locate the apical pulse

A

5th intercostal space, left mid-clavicular line

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16
Q

Mean Arterial Pressure (MAP)

A

the average blood pressure throughout the cardiac cycle.
NOT the average of the diastolic and systolic pressures as diastole exceeds systole.
MAP = (2xDBP + SBP) / 3
MAP needs to be greater than 60mmHg to perfuse tissue

17
Q

What is the AVPU scale?

A 
Rapid/simplified assessment of level of consciousness
A = alert
V = responds to voice
P = responds to pain
U = unresponsive
18
Q

What is acute compartment syndrome?

A

pressure increases within any confined space in the body, resulting in a reduction of blood flow to the tissues contained within that compartment space; resulting in muscle, nerve and tissue ischaemia.

19
Q

What are the early findings for neurovascular deficit?

A

Pain (and related oedema/swelling) - with passive stretch, out of proportion to the injury, unrelieved by narcotics
Paraesthesia (pins and needles) - diminishing sensation
Palpation - tense compartment with a tight, firm feeling

20
Q

What are the late findings of neurovascular deficit?

A

paralysis - decrease or loss of movement
pallor - pale skin is a sign of decreased blood flow. May also become cyanosis or mottled
pulses - reduced or absent peripheral pulses
temperature

21
Q

Colour descriptions during neurovascular obs

A
  • natural
  • pale
  • mottled
  • cyanotic
22
Q

Assessing neurovascular obs

A
  • Pain - is it relieved by opioids?
  • colour
  • temperature
  • capillary refill (should be <2 secs)
  • pulses (pedal pulse unpalpable in ~ 10%)
  • sensation (was there a nerve block?)
  • movement
23
Q

Assessment tools for neurological obs

A
  • vital signs
  • glasgow coma scale
  • neurological signs:
    • pupil size and reaction to light
    • upper limb motor function
    • lower limb motor function
24
Q

What are the three sections of the glasgow coma scale

A
  • eyes open
  • best verbal response
  • best motor response
25
Q

GCS - eyes open scores

A

4 - spontaneously
3 - to speech
2 - to pain
1 - none

26
Q

GCS - best verbal response

A 
5 - oriented
4 - confused
3 - inappropriate words
2 - incomprehensible sounds
1 - none
27
Q

GCS - best motor response

A 
6 - obeys commands
5 - localise
4 - withdraw
3 - abnormal flexion
2 - extension
1 - none
28
Q

order of vital signs during a neurological assessment?

A

1 - respiration
2 - temperature
3 - blood pressure and pulse

29
Q

Abnormal breathing patterns assessable on neurological assessment?

A

Ataxic - completely irregular, random deep and shallow resps, irregular pauses
Biot’s - irregular rate and depth, alternating patterns of deep gasping and apnoea
Cheyne-Stokes - regular pattern of alternating deep breathing and apnoea
Central neurogenic hyperventilation
Apneustic breathing - prolonged inspiration, pause at full inspiration

Acute Care Nursing 1 (1 decks)

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