Exam #1 Flashcards
A patient is sedated to relieve anxiety and pain. The patient is easily wakened by normal soft spoken verbal commands and is oriented and awake. The patient is able to respond normally to verbal commands, there is no change in vital signs. Pt is able to maintain pre-procedure mobility.
What level of sedation is the patient experiencing:
Minimal sedation.
What is the role of the RN during moderate sedation?
Relieve pain and anxiety, promote relaxation.
Monitor skin perfusion and skin turgor
Focus on this patient only, delegate other patients as appropriate.
Maintain venous access, monitor VS/LOC, cardiac rate/rhythm, have oxygen available, keep code cart at side
Administer medications and know potential complications.
Would it be appropriate for the RN to assist the physician with the procedure?
NO, RN is solely responsible with monitoring the well-being of the patient.
Would it be appropriate for the RN to get supplies during the procedure?
NO, the RN should stay with the patient and request someone else to gather supplies.
What qualifications should the RN have?
KNOW basic life support/ACLS/PALS
Have knowledge of A&P, IV therapy
KNOW reversal agents
KNOW sedation scoring card, cardiac measures and ventilation.
Should the RN document during the procedure?
YES- cover your ASSets
What are the advantages to using Propofol for moderate sedation?
Propofol is ultra-short acting hypnotic, sedative effect with no analgesic properties. Propofol has a rapid onset that enhances the GABA effects, post-op use and rapid distribution.
What are some of the disadvantages of using Propofol?
Long-term use of Propofol causes an increase in lipid levels, and decreases the patient’s BP.
Propofol also encourages bacterial growth–which is a potential source of infection.
Plasma levels decrease quickly when discontinued.
What are the effects of Ketamine on the nervous system?
The patient will turn BRIGHT RED
Will see disassociative anesthesia, analgesia, and hallucinations.
Stimulates the myocardium and Central Nervous System- increased BP, increased cardiac output, and tachycardia.
What are the most common complications of conscious sedation and what are appropriate interventions?
Complications- hypotension, neuroleptic toxicity, extra pyramidal S/Sx, buccolingual dysphasia, Parkinsonism, neuroleptic malignant syndrome, seizures, hypothermia, cardiac complications and respiratory depression.
Interventions- Apply oxygen, reposition to near flat position to promote tissue perfusion, PROTECT AIRWAY, and administer either Narcan or flumazonil.
Cyclobenzaprine (Flexiril) is prescribed for a client with muscle spasms of the lower back. Appropriate nursing interventions would include which of the following? Select all that apply.
A. Assess the heart rate for tachycardia
B. Assess the home environment for client safety concerns
C. Encourage frequent ambulatory
D. Provide oral auctioning for excess secretions
E. Provide assistance with ADLs such as reading
A. Assess the heart rate for tachycardia
B. Assess the home environment for client safety concerns
E. Provide assistance with ADLs such as reading
A client has been prescribed clonazepam (Klonopin) for muscle spasms and stiffness secondary to an automobile accident. While the client is taking the drug, what is the nurse’s primary concern?
A. Monitor hepatic lab work
B. Encourage fluid intake to prevent dehydration
C. Assess for drowsiness and implement safety measures
D. Provide social services referral for the client concerns about the cost of our the drug
C. Assess for drowsiness and implement safety measures
A female client is prescribed dantrolene sodium (Dantrium) for painful muscle spasms associated with MS. The nurse is writing discharge plans for the client and will include which of the following teaching points? Select all that apply:
A. If muscle spasms are severe, supplement the medication with hot baths or shower 3 times per day.
B. Inform the healthcare provider if she is taking any estrogen products
C. Sip water, ice, or hard candy to relieve dry mouth
D. Return periodically for lab work
E. Obtain at least 20 min. Of exposure per day to boost Vitamin D levels
B. Inform the healthcare provider if taking any estrogen products
C. Sip water, ice, or hard candy to relieve dry mouth
D. Return periodically for lab work
*** do NOT use if liver disease, notify of estrogen or cardiac med use, wear sunscreen, caution dizziness
A client who has been prescribed baclofen (Liorseal) returns to the health care provider after a week of drug therapy, complaining of continued muscle spasms of the lower back. What further assessment data will the nurse gather?
A. Whether the client has been taking the medication consistently or only when the pain is severe
B. Whether the client has increased consuming alcohol
C. Whether the client has increased the dosage without consulting the PCP
D. Whether the client’s log of symptoms indicates that the client is telling the truth
A. Whether the client has been taking the medication constantly or only when the pain is severe.
A 46 year old male quadriplegic patient has been experiencing severe spasticity in the lower extremities, making it difficult for him to maintain his position in his electric WC. Prior to the episode of spasticity, the patient was able to maintain a sitting posture. The risks and benefits of therapy with dantrolene (Dantrium) have been explained to him, and he has decided that the benefits outweigh the risks. What assessment should the nurse make to determine whether the treatment is beneficial?
Assess for liver damage, notifying if taking HEART mess, would see decreased spasticity, increased posture, use sunscreen when outdoors.
***Assess muscle firmness, pain, and alignment. Should see improvement in 1 week, if not seen in 45 days discontinue med.
A 32 year old farmer injured his lower back while unloading a truck at a farm coop. His healthcare provider started him on cyclobenzaprine (Flexiril) 10 mg TID for 7 days and referred him to an outpatient PT. after 4 days the patient reports back to the office nurse that he is constipated and having trouble emptying his bladder. Discuss the cause of these side effects.
Flexiril causes decreased muscle function- as cyclobenzaprines work on smooth muscles.
Anticholenergic properties slow bowel and bladder functions.
What assessment needs to be done for patient with an epidural who is difficult to arouse, but responds to simple commands, able to move her legs, and squeeze your fingers. Her vital signs have shifted from baseline, her BP is now 90/60, P 100, and RR 14. She is now moaning in pain and is unable to rate her pain. What further assessment needs made?
Check dressing site, assess skin for signs of bleeding, assess drugs given for over sedation, conduct EKG.
A patient with an epidural who is difficult to arouse, but responds to simple commands, able to move her legs, and squeeze your fingers. Her vital signs have shifted from baseline, her BP is now 90/60, P 100, and RR 14. She is now moaning in pain and is unable to rate her pain. What further actions should the nurse initiate?
Stop the epidural
Place the patient in FOWLERS position to increase tissue perfussion.
Have epidural placement assessed.
Place on cardiac monitor and oxygen; assess spinal Headache/labs/breath sounds/urine/DVT.
Assess neuros and mess given.
What are nursing diagnoses for a patient with epidural complications/ altered LOC/ and uncontrolled pain?
Altered tissue perfusion Ineffective airway Fluid volume deficit Acute pain Risk for confusion
What are nursing interventions for a patient with epidural complications/altered LOC/ and uncontrolled pain?
Assess VS q15mins for 2 hours. Activate RRT. Apply SCDs/TED hose Monitor AIRWAY, administer oxygen as needed Administer prescribed pain medications reposition patient to Fowler's position
What are safety concerns that need addressed for a patient with epidural complications/ altered LOC and uncontrolled pain?
Fall Risk
Over sedation- Monitor airway- hypoxia from sedation
Pain
Cardiac monitoring
Monitor Hemorrhage
Monitor Respiratory depression- prevent PNA
What patient teaching should occur for a patient with epidural complications/ altered LOC/ and uncontrolled pain?
Change position slowly TCDB and A, use IS q hour Monitor for bleeding Education on pain medications (S/Sx, adverse effects, sedation) S/Sx of infection Verbalized feelings Pain management- pain scale No lifting Complications of epidurals.
Which nursing intervention would be most appropriate for a client taking temazepam (restoril)?
A. Monitor for fever
B. Give drug intravenously only
C. Monitor daily weights
D. Tell the client to ask for help before standing
D. Tell the client to ask for help standing
Which of the following would indicate to the nurse that a client taking a sedative-hypnotic requires more teaching?
A. The client wants to listen to music on the radio
B. The client has saved her urine to be measured
C. The client says she has taken 1800mL of fluid today
D. The client requests a cup of kava kava tea to help her sleep faster.
D. The client requests kava-kava tea to help her sleep faster- kava-kava is an herb that may interact with CNS depressants.
Riker’s Score for sedation: score 7
Dangerous agitation- pulling tubes/catheters, climbing over bed rails, violence toward staff, trashing
Riker’s Score for sedation: score 6
Very agitated- doesn’t calm with frequent verbal cues, requires physical restraints, bites endotracheal tube
Riker’s Score for sedation: score 5
agitated- anxiety or mild-agitation, attempts to sit up, calms with verbal cues
Riker’s Score for sedation: score 4
Calm and co-operative: calm, awakes easily, follows commands
Riker’s Score for sedation: score 3
Sedated- weakens briefly to verbalized stimuli or gentle arousal, follows simple commands
Riker’s Score for sedation: score 2
Very sedated- arouses to physical stimuli, does not communicate or follows commands, moves spontaneously
Riker’s Score for sedation: score 1
Unarousable- no response to any stimuli
Nursing process: Assessment
Subjective or objective data
Gather information on current health Hx & mess, allergies, tobacco/nicotine/street drug use, readiness to learn, financial resources, limitations, symptoms, past medical Hx, language & communication, etc.
To enhance ADHERENCE: ask…
What things help you take you medicine?
What prevents you from taking your medications?
What would you do if you forgot/missed a dose?
Factors of non-adherence:
Forgetfulness Knowledge deficit Side effects Low self-esteem Lack of motivation Depression/anxiety Lack of trust Language barriers Cost Values/religion
Nursing Process: Nursing Diagnosis
Pain r/t hesitancy- fear of addiction
Acute Confusion r/t adverse reaction
Ineffective health maintenance- no preventative care
Deficit knowledge r/t effects of anticoagulants
Noncompliance r/t forgetfulness
Risk for Injury r/t side effects
Ineffective self-health management r/t lack of finances/insurance
Readiness for enhanced knowledge r/t meds
Nursing Process: Planning
Goal setting, develop nursing interventions
- patient centered
- SMART goals
- acceptable to patient and nurse
- shared with healthcare providers and family
- identify evaluation components
Nursing Process: Implementation
Complete interventions at this time
Provide education
Administer medications
***monitor drug administration and effectiveness
Nursing Process: Evaluation
Where goals obtained- if not revise
Follow-ups
Provide resources
Nursing role in Readiness to learn
Be sensitive to motivation to learn and attention span, level of frustration
Be an active listener and observer
Involve the family or caretakers
Patient Education to give:
Take meds as prescribed Monitor values as needed Psychomotor skills and abilities Give written instructions Advise foods to include or avoid Instruct to report unusual symptoms Give instructions to decrease side effects including changes in urine or stool, dizziness, etc. Be aware of cultural considerations
Cultural Sensitivity
Flexible in scheduling appointments
Language barriers- use interpreters, speak slow and clear
Provide education at a 4th grade level, avoid abbreviations
5 Rights of Medication Administration:
Right Patient Right Drug Right Dose Right Route Right Time **6th- Right Documentation
