final Flashcards
(159 cards)
1
Q
Fluid Volume Deficit
A
- Caused by loss of both water and solutes
from ECF
Hypovolemia
* Young children and older adults more at risk
Dehydration
Third-space fluid shift
* Distribution shift of body fluids into potential
body spaces
2
Q
SUBCUTANEOUS
INJECTION
A
- Volume usually less than 1 mL
- Size needle is 3/8 inch to 1 inch
- 25 to 30 gauge needle
- 45 to 90 degree angle
- Heparin: only in ABD. Avoid the area 2′′
around the umbilicus and the belt line.
3
Q
IM INJECTION*
A
- Volume: 1-5mL
- Needle size: 5/8- 1 ½ inch
- Gauge: 18-25 gauge
- 90-degree angle
- Z track may be used
4
Q
ICF
A
fluids within cells
5
Q
ECF
A
fluid between the cells
6
Q
Fluid volume excess
A
hypervolemia, overhydration, edema, excessive ECF accumulates in tissue spaces
7
Q
Pitting Edema scale
A
+1, slight indent (2mm), normal contour,
+2, deeper pit after pressing (4 mm),, fairly normal contour
+3, deep pit (6mm), remains several seconds after pressing, skin swelling obvious by general inspection
+4, deep pit (8mm), remains for a prolonged time after pressing, frank swelling.
Brawny edema: fluid can no longer be displaced secondary to excessive interstitial fluid accumulation, no pitting, tissue palpates as firm or hard
-skin surface shiny, moist, warm
8
Q
Hyponatremia
A
sodium less than 135
related to severe vomiting, diarrhea, excess sweating, drinking too much water, diuretics
Manifestations:
-confusion, hypotension, nausea, vomiting, muscle weakness, and cramps.
-less than 115 signs of CNS (lethargy, muscle twitch, hemiparesis, seizures, permanent neuro damage)
Treatment:
encourage foods with Na
Na replacement
monitor Na level and specific gravity
hypertonic IV fluids
water restriction
seizure precautions
9
Q
Hypernatremia
A
sodium > 145
related to sodium gain or water loss, lack of fluids, diarrhea, burns
Manifestations:
thirst, restlessness, weakness, disorientation, delusions, hallucinations, dry, swollen, sticky membranes, fever, tachycardia, postural hypotension
Treatment
-depends on cause + volume status
-IV fluids without sodium (D5W),
restrict sodium,
monitor Na+and specific gravity,
diuretics
10
Q
Potassium function
A
-major intracellular electrolyte
-primary function is to stimulate nerve cells and muscle function.
-cardiac conduction
-imbalances occur quickly
-telemetry monitoring with any K+ imbalances
11
Q
Hypokalemia
A
potassium less than 3.5
Manifestations:
muscle weakness, leg cramps, paresthesia (numbness, tingling), Dysrhythmias, irregular pulse, digitalis toxicity
Treatment
replace potassium, rich food like Banana
IV irritates veins, mixed by pharmacy, never give IV push up to 40 in 1L bag
12
Q
Hyperkalemia
A
potassium over 5.0
Manifestations: cardiac dysrhythmias, muscle weakness, paralysis
Treatment: Mild (< 6 mEq/L): Stopping K intake or K-
sparing medications
- Severe: IV & medications: Na+ bicarb, insulin,
hypertonic dextrose, sodium polystyrene
sulfonate (Kayexalate) oral or enema, dialysis
last resort
13
Q
Hypocalcemia
A
calcium less than 8.6
Manifestations: Chvostek & Trousseau’s sign, numbness and tingling fingers, mouth, feet, muscle cramps, seizures, pathological
fractures
- Chvostek’s sign: twitching of facial muscles in response to tapping over the area of the facial nerve.
-Trousseau’s sign is carpopedal spasm that results from ischemia (arm getting inflated by BP cuff)
Treatment:
Calcium,
seizure precautions if severe,
educate about nicotine and alcohol
14
Q
Hypercalcemia
A
calcium > 10.2
Manifestations:
n/v, constipation, excessive urination, thirst, confusion, lethargy, slurred speech, bone pain
* Severe (>17) = cardiac arrest
Treatment: fluids, diuretics, restrict intake of calcium
15
Q
Hypomagnesemia
A
mg less than 1.5
Manifestations:
Muscular weakness & tremors, tetany, seizures, hyperactive, Deep Tendon Reflexes (DTRs), mental status changes, cardiac dysrhythmias, respiratory paralysis
- Treatment:
Replacement of mg (dark leafy
greens, nuts, seeds, fish, beans, whole grains, avocados, yogurt, bananas, dried fruit, dark chocolate)
seizure precautions,
airway support
16
Q
Hypermagnesemia
A
mg over 2.5
Manifestations:
Early signs include flushing, sense of skin warmth, N/V, loss of DTRs, respiratory depression, lethargy progressing to coma, cardiac arrest
- Treatment:
Calcium gluconate,
furosemide.
hemodialysis in severe cases
17
Q
Hypovolemia
A
GI losses, burns or hemorrhage, fever, diuretics, decreased oral intake
*Manifestations:
Poor skin turgor, dry mucous membranes, Postural hypotension, tachycardia, weak pulse, Oliguria, Increased hematocrit
18
Q
Hypervolemia
A
CHF, renal failure, excessive Na+ intake, cirrhosis
Manifestations:
Rapid weight gain, edema, Crackles in lungs, neck vein distention, Polyuria, increased BP, bounding
pulse, decreased hematocrit
19
Q
Health history example questions
A
usual patterns of fluid intake, fluid elimination, pt evaluation of their fluid status, history of disease process, medication/nutrition history
20
Q
Nursing process for fluid + electrolyte imbalances
A
Weight- any changes, need for daily weight, same time each day
Fluid intake? Look at I& O balance over 24-hour period CBC, increased HCT
- BUN & creatinine, can be elevated with
dehydration and kidney disease - Close assessment of electrolyte lab
values
21
Q
Complication: IV Infiltration
A
- Swelling, pallor, coolness, pain
*Discontinue site, raise extremity, wrap in
moist towel, Insert new site
22
Q
Complication: IV Phlebitis
A
Redness, acute tenderness, warmth over vein
Discontinue infusion, remove IV, and insert in
new vein
Apply warm, moist, heat compress
Peripheral IV sites should be changed every
72-96 hours (CDC recommendations)
23
Q
Administering Blood + Blood Products
A
Steps for Safety
- Review site/facility policy
- Second RN to verify order
- Confirm informed consent
- Assess vital signs (before, during, and
after) - Blood Typing and Cross Matching
- Blood types
- Cross matching
- Rh factors
- Donors
24
Q
Transfusion Order
A
Prescriber order (confirmed by second RN):
Type of blood
Date and rate
Patient
Type and Cross: persons blood type and the
compatibility of blood specimens
Packed Red Blood Cells (PRBCs) usual transfusion
is over 2 hrs (per unit)
May be lengthened to 4 hrs (> 4 hours risk of
contamination)
IV push Furosemide (a diuretic, which gets rid of
extra fluid through kidneys) may be prescribed before or between PRBCs to prevent fluid overload
25
Types of transfusion reactions
Allergic: Itching, hives, anaphylaxis
*Febrile: Fevers, chills, headache
Hemolytic (incompatibility): Fevers, chills, headache,
low back pain, shock
Overload: Dyspnea, dry cough
26
Transfusion reaction interventions
* Stop transfusion
* Keep IV line open with 0.9% NS
* Notify physician
* Remain with client & take vital signs
every 5 mins
* Urine, blood will be obtained and sent
to lab
* Incident report
27
Examples of Classification of Surgical
Procedures
* Elective: Delay of surgery has no ill effects; can be scheduled in advance based on patient’s choice
* Urgent: Usually done within 24–48 hours
* Emergency/Emergent: Done immediately
* Diagnostic: To make or confirm a diagnosis
* Ablative: To remove a diseased body part
* Palliative: To relieve or reduce intensity of an illness; is not curative
* Reconstructive: To restore function to traumatized or malfunctioning tissue may also improve self-concept
28
Examples of Preoperative Teaching
Exercises and Physical Activities
* Deep-breathing exercises
* Coughing
* Incentive spirometry
* Turning
* Leg exercises
* Early mobility
Pain Management
* Meaning of PRN orders for
medications
* Multimodal pain medication options
* Timing for best effect of medications
* Splinting incision
* Nonpharmacologic pain management
options
29
Examples of Postoperative Teaching
Postanesthesia Care Unit
* Frequent vital signs, assessments (e.g.,
orientation, movement of extremities,
strength of grasp)
* Dressings/drains/tubes/catheters
* Intravenous lines
* Pain medications/comfort measures
* Family notification
* Sensations
* Airway/oxygen therapy/pulse oximetry
Transfer to Unit
* Frequent vital signs
* Sensations
* Pain medications/nonpharmacologic
strategies
* NPO, diet progression
* Exercises
* Early ambulation
30
Examples of Postoperative Complications
Cardiovascular Complications:
* Hemorrhage
* Shock
* Thrombophlebitis and
thromboembolism
* Pulmonary embolus
Respiratory Complications:
* Pulmonary embolism
* Atelectasis
* Pneumonia
31
Effective Coughing
* Place the patient in a semi-Fowler’s position, leaning forward.
* Provide a pillow or folded bath blanket to use in splinting the incision.
* Ask the patient to: Inhale and exhale deeply and slowly through the nose three times.
* Take a deep breath and hold it for 3 seconds.
* “Hack” out for three short breaths.
* With mouth open, take a quick breath.
* Cough deeply once or twice.
* Take another deep breath.
* Repeat the exercise every 2 hours while awake.
32
Advance Care Planning (ACP)
ACP is a process of planning for future care in the event a person becomes unable to make their own decisions.
* Advance directives: allow individuals to state in advance what their choices would be for health care should certain circumstances develop.
Living Will:
provide specific instructions about the kinds of health care that should be provided or foregone in particular situations.
Durable Power of Attorney for Health Care:
appoints an agent the person trusts to
make decisions in the event of subsequent incapacity.
33
Types of anesthesia
General anesthesia
* Moderate sedation/analgesia
* Regional anesthesia
* Local anesthesia
* Topical anesthesia
34
Informed Consent
* Obtaining informed consent is the responsibility of the person who will perform the diagnostic or treatment procedure or research study.
Your role as a nurse is to:
* Confirm that a signed consent form is present in
the patient’s chart and to answer any patient
questions about the consent.
* As a nurse you sign the consent form as a
witness to the patient signing the form (not as
having obtained the consent, yourself)
* Unless you are obtaining consent for a nurse-
prescribed and nurse-initiated intervention.
35
Types of Loss
* Actual Loss - a loss that is real and can be confirmed by others.
* Perceived Loss - a loss that is personally felt but not observed by others.
* Maturational Loss - a normal part of growing up or life changes
* Situational Loss - a sudden, unexpected loss due to a specific situation or event
* Anticipatory Loss - a loss that is expected and felt before it occurs
36
Kuber Ross Model for Grief
Stage 1: Denial - this isn't happening
Stage 2: Anger - how can this happen to me? this isn't fair.
Stage 3: Bargaining - take me instead, pls dont do this
Stage 4: Depression - why even bother to have hope now, what's the point,
Stage 5: Acceptance - everything happens for a reason, i cant change the past
37
Types of Grief
Dysfunctional grief - prolonged, intense, or interferes with daily life. It goes beyond normal grief reactions and may require professional help.
Unresolved grief - Grief that is not processed or expressed fully. The person stays "stuck" in grief, often for years
Inhibited grief - Grief that is held back or not shown outwardly. The person avoids feeling or expressing emotions related to the loss.
38
Dying & Death: Select Terms
* Do-not-resuscitate (DNR) Order,
or No Code
* Allow natural death (AND) Order
* Hospice Care
* Palliative Care
* POLST (Physician Order for
Life-Sustaining Treatment) Form
* MOLST (Medical Orders for Life-
Sustaining Treatment) Form
* Postmortem Care
39
Localization/Location of Pain
Cutaneous pain: pain in skin or subcutaneous tissue
Somatic pain: pain in muscles, bones, joints, ligaments
Visceral pain: pain in internal organs
Referred pain: pain felt in a location that is different than the actual source of pain
40
Etiology of pain
* Nociceptive pain - tissue damage or inflammation
* Neuropathic pain - nerve damage or dysfunction
* Nociplastic pain - abnormal pain processing in the nervous system, without clear tissue or nerve damage.
41
Duration of Pain
Acute pain: short term, sudden
Chronic pain: long term,
Remission: pain goes away or decreases for a period of time
Exacerbation: pain suddenly gets worse after a period of relief
42
Intractable Pain
severe and constant pain, hard to manage or relieve.
43
Phantom pain
pain felt in a body part that is no longer there
44
Forms of communication
* Verbal (language)
* Non-verbal (body language)
* Touch, eye contact, facial expressions
* Tone of voice
* Posture, gait, gestures, movement
* General physical appearance
* Mode of dress, grooming
* Sounds, silence
45
Intrapersonal communication
self-talk; communication within a person
46
Interpersonal communication
communication between 2 or more people w/ a goal to exchange messages
47
Group communication
small group, organizational communication, group dynamics
48
SBAR
S - situation
B- background
A- assessment
R - recommendations
49
Interviewing Techniques
Open-ended questions: Tell me how you take
your medication at home?
Closed questions: Do you take aspirin daily?
Validating questions: What I heard you saying
was...
Clarifying questions: Could you explain what
you mean by ...
Reflective questions: Repeating back, I heard
you say that you are worried about the
surgery. Is this correct?
Sequencing questions: When did this occur?
Directing questions (when you need to obtain
more information): You mentioned earlier...
50
Blocks to Communication
* Failure to listen
* Nontherapeutic comments and
questions
* Belittling clients’ concerns
* (“don’t worry”)
* Using closed questions
* Using “why” and “how”
* Probing for information
* Using judgmental comments
* Changing the subject
* Giving false assurance
51
Oxygenation Assessment Includes:
Usual pattern of respirations or recent
changes
Respiratory Infection; cough, sputum, fever
Medications
Dyspnea
Smoking
Fatigue
Pain Allergies
52
Physical assessment for oxygenation
Inspection: appearance + work effort
Auscultation: Adventitious sounds
* Crackles: soft high-pitched, heard on inspiration (fluid)
* Coarse: low pitched, secretions can clear
with coughing
Wheezes: Musical sounds heard on inspiration and/or expiration
53
Capnography
Measures ventilation and indirectly blood flow through the lungs.
54
Thoracentesis
* Puncture the chest wall toremove pleural fluid from pleural space
* Signed informed consent needed
* Diagnostic or therapeutic
* Post-procedure:
1. Assess for changes in respirations
2. Hemoptysis or severe
cough report immediately
3. Chest Xray performed afterwards
55
Deep breathing
Semi-Fowlers position
* Ask patient to:
* Exhale completely
* Inhale through the nose
* Hold 3-5 seconds
* Exhale thru pursed lips
* Repeat
* Done every 1-2 hours
56
Effective coughing
Semi-Fowlers position & a splint
pillow
* Ask patient to:
* Inhale & exhale deeply
slowly thru nose
* Take deep breath & hold
3 secs.
* Cough deeply 1-2 times
* Done every 2 hours while awake
57
Expectorants; cough meds
* Facilitate removal of secretions by thinning
secretions
* Guaifenesin (Robitussin)
* Humidified air &
Adequate fluid intake
58
Suppressants; cough meds
Used for dry, non-productive cough
* Depresses cough reflex
* Codeine, prescription
required
* Usually at bedtime
59
Administering inhaled Medication
Bronchodilators: open narrowed airways
* Nebulizers: disperse fine particles of liquid medication into the deeper passages of the respiratory tract
* Meter-dose inhalers: deliver a controlled dose of medication with each compression of the canister
* Dry powder inhalers: breath-activated delivery of medications
60
Metered Dose Inhalers: Common
Mistakes Patients Make
* Failing to shake the canister
* Inhaling through the nose rather than mouth
* Inhaling too quickly
* Stopping inhalation when feeling the drug
* Failing to hold breath afterwards
* Inhaling two sprays with one breath
61
Sterile technique for suctioning
* To prevent hypoxia
* Hyper-oxygenate
* Limit time to 10-15 seconds (prevent hypoxia)
* Do NOT suction during insertion of catheter
* Apply intermittent suction while withdrawing
catheter
* To prevent atelectasis
* Use appropriate pressure, 80-150 mmHg
62
Physiological changes of aging
decreased elasticity (sagging, wrinkles)
dry, thin hair,
fragile skin, nails yellow and thick
edema on low extremities,
fatty plaque deposits, less efficient clearing of secretions
-increased RR
malnutrition, anemia, constipation (decreased peristalsis), dry mouth
decreased muscle mass + strength, stiff joints, less mobile, less subcutaneous tissue, bone demineralization
-slow reflex, less sensations in extremities, issues w/balance, sleep disturbance
-decreased accommodation, yellowing lens difficulty adjusting to light, decreased frequency tones, wax build up
decreased taste buds, decreased smell
63
Sundowning Syndrome
confusion & agitation after dark
64
Dementia
progressive and usually develops gradually. It
involves a group of symptoms that affects mental cognitive tasks such as memory and reasoning
65
Types of Dementia
Alzheimer’s: most common
Vascular: second most common, due to infarcts/strokes
Mixed dementia
Age is the greatest risk factor
Mild Cognitive Impairment
There is evidence of memory loss, but it does not disrupt daily life
Does not always progress to Alzheimer's dementia
66
Treatment & Prevention
Active management improves quality of life
Use of treatment, supportive services, coordination of care, use of adult day services, management of other health conditions
Prevention: no specific interventions
Management of cardiovascular, diabetes and other health conditions may help avoid or delay Alzheimer's
67
Cascade of Iatrogenesis
The serial development of multiple medical
complications that can be set in motion by a seemingly harmless first event, such as a
fall
68
SPICES
S – Sleep disorders
P – Problems with eating or feeding
I – Incontinence
C – Confusion
E – Evidence of falls
S – Skin breakdown
69
Delirium
reversible condition, it is temporary state of
confusion
causes: medication, infection, or dehydration
70
Delirium Risk Factors
1. Cognitive Impairment
2. Sleep deprivation
3. Immobility
4. Visual Impairment
5. Hearing Impairment
6. Dehydration
71
Torts
NTENTIONAL
Assault (threat)
Battery (actual contact)
Defamation of character
Invasion of privacy
False imprisonment
Fraud
UNINTENTIONAL
Negligence:
Below the standard of care, "reasonably prudent person”
Malpractice
Failure to carry out duty caused injury
72
Four Elements of Liability: Malpractice
1. Duty: You have an obligation to use due care. This is what a reasonable and prudent nurse would have done in the same circumstances. Defined by standard of care.
2. Breach of Duty: Failure to meet the standard of care
3. Causation: Need to prove that failure to meet the standard of care (breach of duty) caused harm or the injury.
4. Damages: The actual harm or injury that occurred to the patient
73
Incident report
document harm to a client, employee, or visitor
74
Minimizing Chance of Liability
Practice within legal boundaries of practice
Promptly and accurately document all assessments and care
Perform procedures correctly and appropriately
Administer the right medication, in the right dose, via the right routes, at the right time, to the
right client
Following institutional procedures and policies
Delegate appropriately
Protect clients from injury
Report all incidents
Always check any order that is
questioned
Know own strengths and
weaknesses
Maintain clinical competence
Refusing to accept responsibilities for
which you are unprepared
75
HIPAA
Breaches:
Discussing information in public areas
Interacting with the patient’s family in ways not
authorized by the patient
Using tape recorders, dictating machines,
computers without taking precautions to
ensure the patients confidentiality
Improperly accessing information
Preparing school assignments about patients
without concealing their identity
Social networks / posting
76
Elements of Informed Consent
Disclosure
Comprehension
Competence
Voluntariness
77
Purposes of Patient Records
communication,
Diagnostic and therapeutic orders
Care planning
Quality process and performance improvement
Research; decision analysis
Education
Credentialing, regulation, and legislation
Reimbursement
Legal and historical documentation
78
Documentation Guidelines
* Sign your first initial, last name, and title to each entry. Do not sign notes describing interventions not
performed by you that you have no way of verifying
.
* Do not use dittos, erasures, or correcting fluids. Draw a single line through an incorrect entry and write the words “mistaken entry” or “error in charting” above or beside the entry and sign. Then rewrite the entry correctly.
* Identify each page of the record with the patient’s
name and identification number.
* Recognize that the patient record is permanent.
Follow facility policy pertaining to the color of ink and the type of pen or ink to be used. Ensure that the patient record is complete before sending it to medical records.
79
Informatics
a field that combines nursing with information and computer science. It helps nurses and healthcare teams use data and technology to make better decisions and improve patient care. This involves organizing, managing, and sharing information in ways that support all areas of nursing and healthcare.
80
Variables Influencing Bowel Elimination
Developmental considerations (i.e., older adult)
Daily patterns
Food and fluid
Activity and muscle tone
Lifestyle
Psychological variables
Pathologic conditions
Medications
Diagnostic studies
Surgery and anesthesia
Medications
81
Bowel assessment
PHYSICAL ASSESSMENT
Sequence: inspection, auscultation,
percussion, palpation
Document as hypoactive, hyperactive, or
inaudible
82
Promoting Regular Bowel Habits
Timing
Positioning
Privacy
Nutrition
Exercise
83
Prevent diarrhea
Follow CDC food safety guidelines
Avoid certain foods (i.e., raw
seafood, uncooked eggs)
Hand washing
Travel precautions
84
Treat diarrhea
Treat cause of diarrhea
Oral rehydration/ may need IV fluids
Skin care
Monitor electrolytes
Medications
Loperamide (Immodium)
Bismuth(Pepto-bismol) antimicrobial
85
Types of Enemas
Cleansing Enemas
Tap water
Soap suds
Fleets most common
Retention Enemas
Oil
Medicated
Large volume is most cleansing
Small volume: fleets and retention
86
Enema administration
1. Sterile technique is unnecessary.
2. Wear gloves.
3. Lubricate tip
4. Explain the procedure, positioning (left side-
lying) and length of time necessary to retain the solution before defecation.
87
Stoma
Opening into the abdominal wall
for fecal elimination
Consider:
Color
Expectations for stool production after
surgery
88
Temporary or permanent bowel diversions
Ileostomy: liquid fecal content from the ileum of small intestine
Colostomy: formed feces from the colon
89
TEACH
T: Tune into the patient
* E: Edit patient information
* A: Act on every teaching moment
* C: Clarify often
* H: Honor the patient as a partner in the
education process
90
Who is at greatest risk for health literacy concerns?
Adults over age 65
* Patients with limited education or low
incomes
* Non-native speakers of English
* Racial or ethnic groups
* Recent refugees and immigrants
* Adults with any type of disability, difficulty or illness
Most adults will struggle with limited
health literacy at some point in their lives
91
Ask me 3 campaign
a patient education program designed to promote communication between health care providers and patients in order to improve health outcomes
This tool encourages patients to ask three simple questions each time they talk to a care team member:
1. What is my main problem?
2. What do I need to do?
3. Why is it important for me to do this?
92
Steps of the Teaching-Learning
Process
Assess Learning Needs and Learning Readiness
* Identify the Patient’s Learning Needs
* Develop Learning Outcomes
* Develop a Teaching Plan
* Implement Teaching Plan and Strategies
* Evaluate Learning
93
Culturally Considerate Patient
Teaching
* Develop an understanding of the patient’s culture
* Work with a multicultural team in developing educational programs
* Be aware of personal assumptions, biases, and prejudices
* Understand the core cultural values of the patient or group
* Listen to the patient and family/caregivers; explore customs or taboos
* Understand the patient’s religious practices and determine how their beliefs influence perceptions of health and health care
* Develop written materials in the patient’s preferred language
94
Holistic cures for pain
* Using distraction
* Employing humor
* Listening to music
* Using imagery
* Mindfulness practice
* Cutaneous stimulation
* Hypnosis
* Biofeedback
* Therapeutic touch
* Animal-assisted intervention
95
Pain scales
* 0–10 Numeric Rating Scale
* Adults and children (>9 years old) in all patient
care settings who are able to use numbers to rate
the intensity of their pain
* Pain Assessment in Advanced Dementia Scale (PAINAD)
* Patients whose dementia is so advanced that they
cannot verbally communicate
* Wong–Baker FACES Pain Rating Scale
* Adults and children (>3 years old) in all patients
care settings
* Critical-Care Pain Observation Tool (CPOT)
* Adults who are sedated and nonresponsive
* Adult Nonverbal Pain Scale (NVPS)
* Adults who are sedated and nonresponsive
* Behavioral Pain Scale (BPS)
* Useful with intubated, critically ill patients; measurement of bodily indicators of pain; and tolerance of intubation
* CRIES Instrument
* Neonates (ages 0–6 months)
* Faces Pain Scale—Revised (FPS-R)
* Children (4–16)
patients choose the depiction of a facial expression that best corresponds with their pain
96
Administering Analgesics
* An analgesic drug is a pharmaceutical agent that relieves pain. Analgesics function to reduce the person’s perception of pain and to alter the person’s responses to discomfort.
There are three general classes of drugs used for pain relief:
* Opioid analgesics (all controlled substances, e.g., morphine, codeine, oxycodone, meperidine, hydromorphone, methadone)
* Nonopioid analgesics (acetaminophen and nonsteroidal anti-inflammatory drugs
[NSAIDs])
* Adjuvant analgesics (anticonvulsants, antidepressants, multipurpose drugs)
97
Sensory overload
excessive stimuli over which a person feels little control; the brain is unable to meaningfully respond to or ignore stimuli.
Nursing Interventions
* Provide a consistent, predictable pattern of stimulation to help the patient develop a sense of control over the environment.
* Offer simple explanations before procedures, tests, and examinations.
* Establish a schedule with the patient for routine care such as eating, bathing, turning, positioning, coughing, and exercising.
* Speak calmly with the patient and move slowly; communicate confidence.
* Explore with the patient what stimuli are most distressing and develop a plan to reduce or eliminate them
(e.g., incoming phone calls, visitors); earplugs or pain medication may be indicated.
Noise-reducing headphones may be helpful.
* Be careful not to cause sensory deprivation.
* Identify and, wherever possible, eliminate culturally inappropriate stimuli.
98
Sensory deprivation
insufficient quantity or quality of stimuli; may result from decreased sensory input or monotonous, un-patterned, and unmeaningful input.
Nursing Interventions
* Maintain sufficient level of arousal by increasing sensory stimuli from all sensory
modalities:
* Instruct the patient in self-stimulation methods: counting, singing, reading, reciting
poetry.
* Structure meaningful tangible stimuli into the patient’s external environment; include a
variety of people, ideas, sensations; a pet may provide excellent stimulation.
99
Factors affecting safety
Developmental considerations (i.e., children and
adolescents, older adults)
Lifestyle (i.e., occupation, risk takers)
Environment (i.e., high crime areas)
Mobility
Sensory perception alterations
Knowledge (i.e., awareness of safety)
Ability to communicate
Physical health state
Psychosocial state (i.e., stress, depression)
100
Falls
Leading cause of injury, fatalities for older adults, results in hip or other fractures & head trauma
Risk Factors
Lower body weakness
Poor vision
Gait / balance issues
Problems with feet/shoes
Use of psychoactive
medications
Postural dizziness/
orthostatic hypotension
Hazards in the home (and
community)
History of confusion
History of falls
101
Clinical facilities way to prevent falls
Hourly Patient Rounding
Complete a risk assessment and communicate if patient at risk (door and chart)
Keep bed in low position & locked
Call bell and needed items within reach
Eliminate physical obstacles
Non-skid footwear
Cognitive assessment: report any changes
-most successful is bed alarms
102
Physical restraint use
Prevent patient from harm, however, restraints
should NOT:
Interfere with physiologic function
Limit physical activity to the point of
immobilization
Interfere with respiratory function
Federal guidelines for use
Primary factor guiding nurse clinical judgment:
* Patient’s safety and well being
103
Restraint policies
Least restrictive should be the first option
Never applied for staff convenience
Long-term care: must involve family before
applying them
Requires a written order from physician or
licensed independent practitioner and includes:
* Type of restraint
* Justification
* Criteria for removal
* Never a PRN
104
Fire action nurse
R - Rescue and remove all patients from
danger
A- Activate the alarm
C - Confine the fire by closing doors, turn off oxygen & equipment
E - Extinguish the fire with appropriate
extinguisher
105
Incidence report
Must be completed after any accident or incident in a health care facility that compromises safety
Describes the circumstances of the accident or the
incident
Thoroughly describe the facts
Details the patient’s response to the examination and treatment of the patient after the incident
Completed by the nurse immediately after the accident
Primary concern is the patient’s well being
Disclosure to patient: check agency policy
Not a part of the medical record
106
Oral drugs
Capsule: Powder or gel form in a gelatinous container
* Tablet: Small, solid dose of medication, may be any color, size, or shape
* Enteric-coated tablets are coated with a coating that is insoluble in gastric acids to reduce gastric irritation by the drug
* Extended Release: Allows for slow and continuous release over a predetermined period
* Elixir: Medication in a clear liquid containing water, alcohol, sweeteners, and flavor
* Suspension: Finely divided, undissolved particles in a liquid
medium; should be shaken before use
107
Routes med admin
oral: mouth
enteral: tube that goes through stomach or intestine
sublingual: under the tongue
buccal: between gum and cheek
parenteral: injection
topical: applied to skin or mucous membranes
108
Drug dose levels
* Therapeutic Range: concentration in the
blood stream that produces desired effect,
such as digoxin, anticoagulants, anticonvulsants, or hypoglycemic medications
* Peak levels: highest plasma level
* Trough levels: lowest concentration.
-crawn 30 minutes before next dose.
109
Med order parts needed
1. Patient’s name
2. Date and time order is written
3. Name of drug to be administered
4. Dosage of drug
5. Route by which drug is to be administered
6. Frequency of administration of the drug
7. Signature of person writing the order
Example: Morphine 2mg IV every 4 hours prn for
pain
110
Controlled substances
Kept in a locked location
*Federal mandate to track all controlled
substances
*Reconciliation (an actual count) of controlled
substances performed on regular schedule per
policy of agency
*Any narcotic not administered must be discarded
with another nurse who witnesses the waste &
signs for it
111
6 rights of med admin
1. Right medication
2. Right patient
3. Right dosage
4. Right route
5. Right time
6. Right reason
112
How to identify pt before giving meds
* The nurse must check that the client is the correct
patient before giving any medications
* Use 2 identifiers (Joint Commission requirement)
* 1. Patient name
* 2. Identification bracelet with medical record
number and or birthdate
113
TYPE OF MEDICATION ERRORS
Inappropriate prescribing of the drug
* Extra, omitted, or wrong doses
* Administration of drug to wrong patient
* Administration of drug by wrong route or rate
* Failure to give medication within prescribed time
* Incorrect preparation of drug
* Improper technique when administering drug
* Giving drug that has deteriorated or is past the expiration date
114
Strategies to Reduce Med Errors
Three checks
Correct patient identification steps
Pharmacists on clinical units
Medication reconciliation
115
Maslow Hierarchy Needs (most to least)
Physiological – Basic survival needs (air, food, water, rest).
Safety – Protection, stability, security.
Love/Belonging – Relationships, affection, connection.
Esteem – Respect, confidence, recognition.
Self-actualization – Achieving full potential, personal growth.
116
Nursing Diagnosis Statements
* Problem: the Nursing Diagnosis
* Etiology: The cause of the problem
* Defining Characteristics/Signs and Symptoms: subjective and objective data supporting
problem
117
Nursing process
Assessment – Gather patient data (subjective & objective).
Diagnosis – Analyze data to identify nursing problems.
Planning – Set goals and desired outcomes; plan interventions.
Implementation – Carry out the plan of care.
Evaluation – Assess if goals were met and revise as needed.
118
Health equity
When everyone has the opportunity to attain their full health potential, and no one is
disadvantaged from achieving this potential because of their social position or other socially determined
circumstances.
119
Cultural Competence:
Identified as essential component of nursing education and practice to improve
cross-cultural encounters, address health disparities, and foster health equity.
120
Health Inequities:
Differences in the types of health care received and health outcomes achieved among
diverse populations
121
Cultural competency nursing
Awareness/examination of one’s own cultural values, beliefs, and behaviors
Awareness and acceptance of cultural differences
Recognition that people of different cultures have different ways of communicating, behaving, interpreting, and problem-solving
Recognition that cultural beliefs impact patients’ health beliefs, help seeking behavior, interactions with health professionals, health care practices, and
health outcomes
An ability and willingness to adapt the way one works to fit the patient’s cultural
preferences to provide optimal care for that individual
122
LEARN for cross cultural communication
L: Listen actively to what patients say with empathy and understanding, without imposing your
own values and beliefs.
E: Explain your perception of the problem and express your understanding that perceptions of
illness vary by culture.
A: Acknowledge and discuss the differences and similarities in perspectives. Be careful not to
devalue the pt’s perspective and privilege yours.
R: Recommend nursing care that respects pt preference and integrate aspects of cultural
health beliefs (herbal med, traditional healers, cultural rituals)
N: Negotiate agreement as authentic partners (not as superior authority figure) in developing,
implementing, and evaluating the plan of care.
123
Risk Factors for Skin Alteration
* Impaired circulation/oxygenation
* Immobility (i.e., in a long surgery)
* Impaired immune function
* Diabetes
* Inadequate nutrition
* Obesity
* Exposure to Moisture
* Smoking
* Age
124
Prevent pressure injuries
* Assess skin-focus on bony prominence
* Keep skin clean from incontinence. Mild cleansing, avoid hot water, apply barrier cream
* Do not massage reddened areas or over bony prominences
* Avoid friction and shearing-lifting, transfer devices
* Support surfaces: e.g., placing an air mattress on the bed
* Nutritional support
* Use pillows foam wedges, pressure reducing boots
* Turn and reposition every 2 hours
125
Staging pressure injuries
Stage 1: Skin is intact that is non-blanchable redness
Stage 2: Partial thickness skin loss involving epidermis and/or dermis. Open and shallow
tage 3: Full-thickness skin loss
Subcutaneous fat may be visible
Stage 4: Full thickness skin & tissue loss
with exposed bone, tendon, or muscle
126
What to do based on the color of wound?
Red = Protect
* Yellow = Cleanse
* Black = Debride
127
Cleaning Wounds
* Normal saline (0.9% sodium chloride)
* Technique Clean to dirty or inside-out (so not to
transfer any microorganisms) for open wound
* Clean from top to bottom for approximated wound;
un-approximated clean from the center working
outward
* Sterile equipment used for irrigation
128
Effects of Heat
* Reduces muscle tension
* Relieve muscle spasm and joint
stiffness.
* Used to treat infection, arthritis, joint and muscle pain, dysmenorrhea, chronic pain
129
Effects of cold
* Reduces muscle spasms
* Promotes comfort (reduces
release of pain-producing
substances)
* Reduces edema and
inflammation
* Direct trauma, muscle spasms,
sprains and some chronic pain
130
Factors affecting nutrition
Developmental
Considerations Biological Sex State of Health
Alcohol Abuse Medications
Megadoses of Nutrient
Supplements
Economic
Factors Religion Meaning of
Food
Culture
131
Diet types
House: regular diet with no restrictions
Clear Liquid: Broth, clear juices, coffee, tea
(without milk), popsicles
Full Liquid: Cereal gruels, milk, puddings, custards,
pasteurized eggs
Pureed diet “Mushy” blender
Mechanically altered diet: regular diet with
modifications for texture. Foods are ground
mashed or soft.
*NPO
132
Feeding a Client with
Dysphagia
* Rest
* High Fowlers
* Chin down position
* Pace feeding &
placing food
* Viscosity
* Liquid types: thin, nectar-like, honey- like and spoon-thick
133
Enteral Nutrition-Short
Term Nutritional
Support
Oral feeding is preferred
* Delivers formula to the
GI tract
* Nasogastric Tube- short term (less than 4 weeks)
* Need to confirm NG placement after insertion and before using for feeding or giving medications
* Radiographic Exam (x-ray) after initial placement
* Aspirate PH-check PH
134
Complications Related
to Use of Central
Venous Access Devices
Pneumothorax
Thrombo-embolism, Air Embolism
Infection and sepsis
◦ Tubing change: use sterile
technique
◦ Sterile dressing change
Blood glucose, fluid, & electrolyte
imbalances
135
QSEN COMPETENCIES
Patient-centered care
Teamwork and collaboration
Evidence-based practice
Quality improvement
Safety
Informatics
136
Nursing aims
PROMOTE HEALTH
PREVENT ILLNESS
RESTORE HEALTH
FACILITATE COPING WITH DISABILITY OR
DEATH
137
When to do hand hygiene
* Moment 1 – Before touching a
patient
* Moment 2 – Before a clean or
aseptic procedure
* Moment 3 – After a body fluid
exposure risk
* Moment 4 – After touching a
patient
* Moment 5 – After touching
patient surroundings
138
Causes of contamination sterile field
Clean object touching a sterile object
* Opening a sterile package towards you
* Moisture
* Objects below your waist or your out of sight
* Outside of the 1 inch of sterile field
* If in doubt, obtain new supply/equipment
139
Types of HAI
* Catheter-associated urinary tract infection
(CAUTI)
* Surgical site infection (SSI)
* Central-line associated bloodstream infection
(CLABSI)
* Ventilator-associated pneumonia (VAP)
140
Infection stages
Incubation Period – Time between pathogen entry and symptom onset. No symptoms yet.
Prodromal Stage – Early, mild symptoms (fatigue, malaise). Pathogen multiplying.
Full Stage (Acute) – Full-blown symptoms appear; disease is at peak.
Convalescent Stage – Recovery begins; symptoms decline and health is restored.
141
Airborne precautions
TB, chicken pox, measles
private room w/negative air pressure
door closed, n95, transport only when needed
142
Droplet
Flu, rubella, mumps
private room, door may be open
PPE, visitors 3 feet away
transport only if needed
143
Contact
drug resistant organisms, diarrhea
private room, door can be open
-gloves and gown
-limit movement out of room
144
Normal vitals
Oral temperature—98.6°F
Pulse rate—60 to 100 (80 average)
Respirations—12 to 20 breaths/min
Blood pressure—120/80
145
RRS
Tachypnea: increased respiratory rate; may occur in response to an increased metabolic rate
* Bradypnea: decreased respiratory rate
* Apnea: periods when no breathing occurs
* Dyspnea: difficult or labored breathing
* Orthopnea: changes in breathing when sitting or standing
146
Tachycardia causes
* Decreased blood pressure
* Elevated temperature
* Inadequate oxygenation
* Exercise
* Prolonged application of heat
* Pain
* Strong emotions
* Some medications
147
Hypertension
* Based on at least 2 readings – taken on 2 different occasions
* Correct position
Seated for at least 5 minutes
Back supported
Feet on floor
Arm supported – horizontal
BP cuff at heart level
This is very important! It takes
several readings before someone is
diagnosed with hypertension
148
FACTORS INFLUENCING HYGIENE
Culture Health State
Socioeconomic status
Personal Preferences
Spiritual Practices
Developmental stage
Physical condition
149
CONSIDERATIONS: FEET
Avoid soaking feet
Rinse and dry
Apply moisturizer
Nail care Teaching:
Not to go barefoot
Wear cotton socks
Proper fitting shoes
150
AM CARE
After breakfast, nurse completes
morning care:
* Toileting
* Oral care
* Bathing
* Back massage
* Special skin measures
* Hair care, cosmetics
* Dressing
* Positioning for comfort
* Refreshing or changing bed linens
* Tidying up bedside
151
Urine assessment
-color, odor, turbidity (clear, but cloudy if left), pH
-measure urine output on flat surface
-call DR if less than 30 mL
152
Specimen collection
* Routine analysis: Clean
* Clean catch/voided or mid stream
(culture and sensitivity): Sterile cup &
midstream
* Sterile (culture and sensitivity):
indwelling catheter, use sterile cup
* 24-hour collections-post sign in room
with time, may need ice or refrigeration.
153
24hr specimen rules
* To start collection first void of the morning is flushed/ discarded.
Next void you start saving.
* To end collection patient to void at the end of the 24 hours. Add specimen to container & send to lab
* If someone flushes a specimen... you will need to start over.
* Communication is essential
Patient and family teaching
Post sign in the bathroom
Include it in shift report and working with nursing assistants
154
Urinary retention
Inability to fully empty the bladder
* Manifestations:
Feeling of bladder pressure
Overflow develops, releasing small amounts of urine
Void small amounts frequently.
* Assess for distention
Bladder can hold up to 2-3 liters!
Post-void residuals (PVR)
Amount of urine in bladder after
voiding. Bladder scan or catheterization.
Normal PVR < 50 mL PVR >than
150 mL may need to catheterize
155
UTIS
Causes & Risk Factors:
Catheterization
Poor hygiene
Female anatomy & sexually active women
Urinary retention, stasis
Older adults
Diabetes
* E.coli =most likely cause
156
Ileal conduit:
ureters are diverted to ileum of small intestine...stoma is made where urine is excreted.
* External appliance to collect urine
* Skin care
* Change in body image & teaching
157
Reasons for RN back injury
* Uncoordinated lifts
* Manual lifting (without devices)
* Fatigue
* Repetitive movements
* Standing for long time
* Uncooperative patients
158
Safe pt handling
Determine patient’s abilities
Use proper assistive devices
Work in teams
Reduce friction
Body mechanics
Patient assessment of:
Ability to assist
Ability to comprehend instructions
Use proper assistive device such as:
Gait belts
Lateral assistive devices (e.g., to reduce
friction, this is a slide board)
Mechanical assistive devices: Powered full
body sling lifts, powered stand-assist lifts
159
Proper use of equipment
Walkers:
◦Should be lifted, but some use walkers with wheels athome
Canes:
◦Widens a person’s base of support
◦Hold cane on stronger side and the cane is then
advanced
◦Weaker leg moves to the cane (thereby sharing the
load)
◦Quad cane is more supportive
Crutches:
◦Proper fit
◦Support of body weight on hands and arms not axilla
◦Non-weight bearing, toe touching of partial weight-
bearing
