Final Exam Flashcards
(210 cards)
1
Q
Administering fluids, medications, or nutrition directly into a vein
A
Reason for IV
2
Q
Maintain or prevent fluid and electrolyte imbalances
Administer medications
Replenish blood volume
Assist in pain management
Correct or maintain nutritional status
A
Goals of IV Therapy
3
Q
Rapid Onset – good in an emergency
Can’t tolerate PO, can’t swallow, NPO
Large molecule drugs - chemo Rapid hydration
Precision to establish constant therapeutic blood levels
Meds that are irritating to muscle and SC (alkaline) – given IV and tolerated better
A
IV Advantages
4
Q
No room for error (no ability to remove from body like PO)
High risk (infection, injury)
Incorrect application (i.e: pushing too fast) has serious implications
Challenges to stay in place, insert
Time-consuming (lots of equipment to handle, many meds require 2 nurse check)
A
IV Disadvantages
5
Q
is short term treatment (days)
Peripherally inserted
Superficial veins
A
PVAD
6
Q
Therapy > 7 days (weeks to months)
Catheter inserted into a large or peripheral vein of the chest or groin with the tip advanced to a central position, either the superior or inferior vena cava
Can have multiple lumens
Decreased trauma and physical anxiety for client
Pt vascular characteristics/age/comorbidities (poor venous access for example)
pH and osmolality
Large volumes
A
CVAD
7
Q
Duration of treatment, type of solution Patient characteristics (vessel health, comorbidities)
A
Type of VAD depends on
8
Q
Types:
Long PIVC
- Midline Catheter
- CVADs
- PICC
- Implanted Port
- Non Tunneled CVAD
- Tunneled, Cuffed Catheter
A
Types of VAD
9
Q
Peripheral IV </= ___ days
A
5
10
Q
Ultrasound guided PIV _____ days
A
6-14
11
Q
Non Tunneled / Acute CVS _____ days
A
6-14
12
Q
_______ preferred to PICC if proposed duration is </=14 days
A
Midline catheter
13
Q
_______ preferred to midline if proposed duration >/=15 days
A
PICC
14
Q
_______ preferred to tunneled catheter and ports for infusion 14-30 days
A
PICC
15
Q
Tunneled & Port >/= ____ days
A
31
16
Q
During IV insertion, dressing change, medication administration
A
Breaking sterility / contamination
17
Q
Asepsis during insertion
Use site above previous insertion if failed
A
Reducing contamination
18
Q
Our role:
Aid with placement
Care and maintain device
Administer solutions or medications
Assess site for s/s complications
A
CVAD
19
Q
Notify of any complications.
Document catheter information.
Skin integrity, complications, external catheter length, mid-arm circumference (PICC)
Type of equipment, type of securement device
Dressing integrity – D&I
Document exit or port insertion site.
Document catheter removal.
Document blood draw.
Document unexpected outcomes, health care provider notification, interventions, and patient response.
Special equipment
Palpate
Edema, Pain And Tenderness
Inspect For
redness, swelling, discharge
kinks in tubing
presence of a securement device
ensure dressing is completely intact (change 5-7 days)
blanching of skin around insertion site or along vein path with infusions
assess chest and neck for engorged veins or difficulty with movement
Measure external length of CVAD
Flush and assess patency according to policy
Assess for signs of systemic infection (fever, chills, hypotension)
A
CVAD Nursing Responsibilities
20
Q
Safety Guidelines:
1. Clinician competence is required for the use, placement, and management of VADs.
a. Knowledge + skills
b. Recognizing s/s of VAD-related complications
2. Know the indications for prescribed therapy prior to initiating IV therapy.
a. High risk = know your meds, know your calcs
b. Understand Flow Rate and Concentration
3. Prior to initiating IV therapy, assess the patency and functioning of the VAD.
a. Aspiration of blood return
b. Absence of resistance
c. Patient c/o pain when flushing
4. Reduce risk for administration set misconnections.
a. Trace path between IV connection and patient
b. Label admin sets (tubing)
c. Route different tubing in different directions
5. Maintain sterility of a patent IV system using Infusion Nurses Society (INS) standards.
6. Know standard precautions for infection control for bloodborne pathogens exposure.
A
safety guidelines for VAD
21
Q
No blood return, can’t flush
A
Signs line is not patent
22
Q
Scored 1-6
A
Phelbitis
23
Q
Scored 0-4
A
Infiltration
24
Q
Intravenous (IV) site appears healthy
A
Phelbitis Score 1
25
All of the following signs are evident and extensive:
Pain along path of cannula
Erythema
Induration
Palpable venous cord
Pyrexia
Phelbitis Score 6
26
Two of the following are evident:
Pain at the IV site
Erythema
Swelling
Phelbitis Score 3
27
No symptoms
Infiltration Score 0
28
Skin blanched, translucent
Skin tight, leaking
Skin discolored, bruised, swollen
Gross edema >15.2 cm (6 in) in any direction
Deep pitting tissue edema
Circulatory impairment
Moderate-to-severe pain
Infiltration of any amount of blood product, irritant, or vesicant
Infiltration Score 4
29
Select the most appropriate vein and location by visual inspection and palpation. Veins should feel soft and bouncy and be adequate size to accommodate selected gauge.
Use the most distal site above the wrist in forearm
Do not use areas of flexion
Avoid veins located in hands for short term use
Do not use a site below a failed insertion attempt unless completely healed
Skin must be intact/free of infection
Criteria: anticipated duration of tx, type of solution, pt characteristics (age, comorbidities, vessel health)
Select least invasive and smallest device allowed. Incollab with patient, for vessel health and preservation.
PVAD Site Selection
30
BEVEL UP!
Applying Tourniquet to dilate vein
Caution in older pts
Avoid arm hair (place over gown)
Vein Selection
Inspection + Palpation
No gloves necessary while selecting
Pt can clench and unclench fist to build pressure
Veins should be soft and bouncy
Big enough to accommodate chosen gauge
No areas of flexion (AC, wrist), avoid hands
Site most distal above the wrist
Do not use site below failed insertion attempt
Skin assessment
3 finger widths above wrist
Can use heat to vasodilate
Contraindications: fistula, extremity affected by CVA, lymphedema or lymph node removal
Remove the tourniquet after insertion - not longer than 60 seconds on arm
VAD Insertion
31
A single clinician should not make more than __ attempts at initiating a PIVC and should limit total attempts to no more than four.
2
32
Trauma, surgery, rapid blood transfusions, and rapid fluid replacement
Gauge 14, 16, 18
33
Continuous or intermittent infusions in adults; administration of blood transfusions in adults
Gauge 20
34
Continuous or intermittent blood products in adults, children, newborns, and older persons
Gauge 22
35
Continuous or intermittent infusions in adults, children, newborns and older persons; administration of blood or blood products in adults, children, newborns, or older persons
Gauge 24
36
_________ Infusion (IV you inserted is now connecting to a line and a bag)
Connect to primed tubing
Release clamp
Start pump
Continuous
37
_________ Infusion (We insert the IV and “lock” the short amount of tubing, saving it for later when meds will be given)
Preservative-free 0.9% NS to fill the extension set
Used to use Heparin to prevent clotting, now only for special situations (dialysis access, CVADs, certain types of equipment)
Attach syringe with NS to extension set and flush/lock with recommended amount
Intermittent
38
Maintenance:
Assessment
Monitoring site for complications
Monitoring for patency
Monitoring Dressing
Scheduled Tasks & Assessments
Assess site how often?
Change the needleless connector?
Change the entire system and insert a new VAD?
Change tubing per employer policy
~ every 72-96 hours
Daily if TPN (Total Parenteral Nutrition)
Assess patency qShift
Flush with 1-2 mL, gently aspirate for blood return
After confirmed blood return, push/pause flush (1 mL bolus)
Volume of flush tbd by VAD type and agency
IV Site Maintenance
39
Maintaining the System:
Keeping system sterile
Should you disconnect an IV line to change a patient gown? NO
Changing solutions, dressings Assisting patient with ADLs without disrupting system
Walking IV-poles
Tubing should never be disconnected because it becomes tangled
Extension tubing is possible but not recommended
Needle-free connector (purple leur-lock things) are better than caps
IV Site Maintenance
40
Check orders for discontinuation, understand the rationale
Pt education: keep extremity still; report bruising/edema/pain that develops after removal
Wear gloves
Close clamps on line
Remove tape first
Slide catheter out, holding gauze over insertion site with hub parallel to skin
Apply pressure for 30 seconds longer if on blood thinners (5-10 mins)
Inspect catheter to make sure it is intact
IV Removal
41
Assessment of site and VAD
Decision/rationale for removal
Care after removal (dressing)
Documenting Removal of IV
42
________ for Intermittent:
Can be given through saline lock
Some IVs have a “saline lock” which keeps the IV patent without having to maintain a constant drip
Locks save time by eliminating constant monitoring of IV line
Better mobility, safety, and comfort for patients (don’t need to be hooked up to a bag all the time)
After you administer bolus through IV, flush with saline to keep it patent
Flushes vary 1-5 mL
Saline Lock
43
Before:
Assess site
Assess patency + placement Flush if “saline locked” with 2-5 mL NS and pull back for blood return (patency)
IV Assessment
44
After:
Flush
Normal Saline for Peripheral Catheters 2-5 mL if “saline lock”; 10 mL if primary is not compatible with med
“Heparin lock” – only specific situations (dialysis)
Fluids and volumes you flushed with are documented
Usually small volumes of flushing fluid are in larger syringes (decrease pressure, decrease catheter damage)
Med Delivery:
Always assess compatibility
IV Assessment
45
Concentrated dose directly into systemic circulation
IV Push Bolus
46
Advantages:
No fluid overload risk (couple of mLs)
Fast onset in emergency
Doses of short-acting meds can be titrated by pt response
More accurate (no med left in IV bag/line)
Back in the day: some med hanging in a large bag (1 L) – not so common anymore; management of admin would carry from shift to shift – multiple people
No need to program pumps, no need to label bags
IV Push
47
Disadvantages:
Most dangerous, no time to correct or stop, med peaks quickly
Not all meds can be pushed
Requires precise calculation and timing
Could irritate BV lining (concentrated) – infiltration, phlebitis risk
IV Push
48
Use hourly rate to calculate minute flow rate (gtt/mL). Know calibration (drop factor), in drops per milliliter (gtt/mL), of infusion set used by employer
Infusion via gravity
49
Dextrose 5% in water (D5W)
Dextrose 10% in water (D10W)
Dextrose in Water Solutions
50
0.225% sodium chloride (quarter normal saline; ¼ NS; 0.225% NaCl)
0.45 sodium chloride (half normal saline; ½ NS; 0.45% NaCl)
0.9% sodium chloride (normal saline; NS; 0.9% NaCl)
Saline Solutions
51
Dextrose 5% in 0.45% NaCl sodium chloride (D5 ½ NS; D50.45% NaCl)
Dextrose 5% in 0.9% sodium chloride (D5NS; D50.9% NaCl)
Dextrose in Saline Solutions
52
Lactated Ringer’s (LR)
Dextrose 5% in lactated Ringer’s (D5LR)
Balanced Electrolyte Solutions
53
Isotonic
Isotonic when first enters vein; dextrose enters cells rapidly, leaving free water, which dilutes ECF; most of water then enters cells by osmosis.
Dextrose 5% in water (D5W)
54
Hypertonic
Hypertonic when first enters vein, dextrose enters cells rapidly, leaving free water, which dilutes ECF; most of water then enters cells by osmosis.
Dextrose 10% in water (D10W)
55
Hypotonic
Saline is sodium chloride in water.
Expands ECV (vascular and interstitial) and rehydrates cells.
0.225% sodium chloride (quarter normal saline; ¼ NS; 0.225% NaCl)
56
Hypotonic
Expands ECV (vascular and interstitial) and rehydrates cell
0.45 sodium chloride (half normal saline; ½ NS; 0.45% NaCl)
57
Hypertonic
Draws water from cells into ECF by osmosis
0.9% sodium chloride (normal saline; NS; 0.9% NaCl)
58
Hypertonic
Dextrose enters cells rapidly, leaving 0.45% sodium chloride
Dextrose 5% in 0.45% NaCl sodium chloride (D5 ½ NS; D50.45% NaCl)
59
Hypertonic
Dextrose enters cells rapidly, leaving 0.9% sodium chloride
Dextrose 5% in 0.9% sodium chloride (D5NS; D50.9% NaCl)
60
Isotonic
Contains Na+, K+, Ca2+, Cl − , and lactate, which liver metabolizes to HCO3 –. Expands ECV (vascular and interstitial); does not enter cells.
Lactated Ringer’s (LR)
61
Hypertonic
Dextrose enters cells rapidly, leaving lactated Ringer’s.
Dextrose 5% in lactated Ringer’s (D5LR)
62
In general, _____ fluids are used most commonly for extracellular volume replacement (e.g., FVD after prolonged vomiting).
isotonic
63
The decision to use a hypotonic or hypertonic solution is based on the specific fluid and ________
electrolyte imbalances
64
The patient with a hypertonic fluid imbalance will in general receive a ________ intravenous solution to dilute the ECF and rehydrate the cells.
hypotonic
65
All intravenous fluids should be given carefully, especially ________ solutions, because these pull fluid into the vascular space by osmosis, resulting in an increased vascular volume that can lead to pulmonary edema, particularly in patients with heart or renal failure.
hypertonic
66
insertion site is jugular vein and subclavian veins (best inshort term needs in acute care setting. About 1-2 weeks.
Nontunnelled cvad
67
catheters are tunnelled from the entry site, subcut, to the preferred vein, where the cath is inserted and advanced into the SVC. synthetic cuff anchors catheter for decrease risk of infection. Surgeon places tunnelled cath. For pts requiring blood, dialysis (long term needs)
Tunnelled cuffed
68
2.5mm 10mL/min
Digital/metacarpal
69
6mm 45mL/min
Cephalic
70
16mm 300mL/min
Axillary
70
8mm 80mL/min
Basilic
71
19mm 800mL/min
Subclavian
72
20mm 2000mL & Turbid
Superior Vena Cava
73
Employer policy re: fever (e.g: present to emergency department for fever over 38); s/s fever
Should have a list of providers #s
Written instructions for dressing changes, flushing, tubing changes if discharging; also written list of suppliers of equipment
Kelly clamp (no teeth)
Patient and caregiver education: flushing, dressing changes, site care
How to dispose soiled dressings
CVAD Discharge
74
Protocols give the nurse more autonomy to determine the rate/amt of drug to administer
Similar to insulin SC sliding scale, nurse will titrate
Amount of Heparin given is based on latest aPTT
Amount of Insulin is based on blood glucose
IV Infusion Protocol
75
Fluid Balance:
Ins and Outs
Ins: PO liquids (drinks, soup, gelatin, ice); IV fluids (+ flushes), blood components, fluids provided with meds (including tube flush, etc)
Outs: urine, diarrhea, emesis, gastric suction, tube and wound drainage
Daily intake should equal output plus 500 mL
I&O Purpose
76
Disruption in the 1:20 ratio of _____ to ______
acid; base
77
a chemical system that prevents a radical change in fluid pH by dampening the change in hydrogen ion concentrations in the case of excess acid or base. Most commonly, the substance that absorbs the ions is either a weak acid, which takes up hydroxyl ions, or a weak base, which takes up hydrogen ions.
A buffer
78
Lungs adapt rapidly to an acid–base imbalance (Minutes)
Slower than the chemical buffers (seconds) but still rapid
Powerful regulator
Increased levels of hydrogen ions and carbon dioxide provide the stimulus for respiration.
Respiratory center (medulla)
Respiratory buffer
79
Kidneys
Longer - few hours to several days to regulate acid–base imbalance
Excreting Acids:
Excrete small amounts of free H+ (uses phosphate), weak acids Combine H+ with ammonia to form ammonium for excretion
Urine is acidic – body depends on excretion of some acid through urine (pH = 6)
Can speed up or slow down H+ excretion (pH 4 – 6) as part of compensation
Reabsorption of bicarb
Production of new bicarb
Kidney disease/injury will impact the ability to regulate
Metabolic buffer
80
_______: Respiration rate and depth ↑ to get rid of CO2
Hyperventilation
Acidosis Respiratory
81
________: Respiration rate and depth ↓ to preserve CO2
Hypoventilation
Lung disease/disorder = impairment of this system
Alkalosis Respiratory
82
Carbonic acid concentrations (comes from CO2)
Respiratory
83
H2CO3 (carbonic acid) → H+ (hydrogen ion) and HCO3- (bicarbonate which is a base)
The major source is _______ acid
carbonic
84
Patient blood pH ↓ 7.35 = “_____”
acidosis
85
Patient blood pH ↑ 7.45 = “______”
alkalosis
86
________ is characterized by an increase in the hydrogen ion concentration in the systemic circulation that results in an abnormally low serum bicarbonate level. Signifies an underlying disorder that needs to be corrected to minimize morbidity and mortality.
Metabolic acidosis
87
defined as a disease state where the body's pH is elevated to greater than 7.45 secondary to some metabolic process
Metabolic alkalosis
88
7.35-7.45
Normal pH
89
35-45 mmHg
Normal PaCO2
90
23-28* mmol/L
Bicarbonate (HCO3-) Level
91
80-100 mmHg
PaO2
92
95-100%
O2 saturation
93
a pH less than 7 is
acidic
94
a pH greater than 7 is
basic
95
Acidosis = pH < 7.35, PaCO2 > 45
Respiratory
96
Alkalosis:
↑ pH, ↓ PaCO2
Decreased carbonic acid caused by hyperventilation
Alkalosis = pH > 7.45, PaCO2 < 35 mmHg
Respiratory
97
Acidosis:
↓ pH, ↓ HCO3-
Excessive metabolic acids
Acidosis = pH < 7.35, HCO3- < 23
Metabolic
98
Alkalosis:
↑ pH, ↑ HCO3-
Decreased metabolic acids
Alkalosis = pH > 7.45, HCO3- > 29
Metabolic
99
Antigenic factor
Pos or Neg
This is where we get “O negative” or “O positive”
Unlike ABO, no natural antibodies Rh negative exposed to
Rh positive blood -> immune response after repeated exposure
Rh Factor (Rhesus Factor)
100
Group A: has _ antigen
A
101
Group B: has _ antigen
B
102
Group AB: has _ antigens
A and B
103
Group O: has _ antigens
no
104
O- is the
Universal Donor
105
AB+ is the
Universal recipient
106
Collection of patient’s own blood for transfusion
Hip replacement, knee replacement, hysterectomy
Rare blood types, plasma protein deficiencies Drawn one week apart, for four weeks leading up to surgery
Min Hgb: 110 g/L; Min hct 33%
Autologous transfusion
107
Manitoba: competent person > age 16
Prescriber obtains written consent
Nurse confirms consent
Right to refuse, confirm person understands reason and risk
Prescribers can defer consent in emergencies patient lacks decision making ability, substitute decision maker not available
Life, limb, organ under threat
Informed Consent
108
2 nurse check at the bedside with the patient, the blood, and the type & Screen results from the lab
Patient identity (First name, Last name, PHIN)
ABO Group, Rh Group, antigen presence Blood
Unit Donation Number Donor ABO group + Rh
Blood Bags have an identifier tag
Federal regulation -> cannot remove until transfusion is over
Then shred in confidential waste
Special Checks blood transfusion
109
Timing is important
Begin within 30 minutes 4 hour infusion maximum
Blood is living tissue; is stored in special conditions – preservatives + anticoagulants
RBC breakdown = K+ release
Handling Blood Products
110
Requesting and retrieving donor blood:
Request sent to blood bank
Nurse attends in person, with written documentation (no verbal orders)
Brings back to unit cannot leave unattended
Administration to begin within 60 minutes (some facilities 30 minutes)
If not used, return to blood bank within 60 minutes
Handling Blood Products
111
Donor number
ISBT 128 Blood Group Code
Collection Date & Time
ABO/Rh Blood Group
ISBT 128 Product Code
Expiration Date & TIme
Component Description
Special Testing: >Red cell phenotype
Blood product bag tag information
112
Equipment:
18 – 22 gauge catheter
16 – 18 gauge for rapid infusion
Special tubing (administration set) with filter
Change after 4 consecutive units
More than 30 minutes between units
Occlusion
Hang time > 4 hours
Normal saline prevents hemolysis (cannot run with dextrose) – Y site
Blood Bag: check for discolouration, clots, tears, expiry date
catheter sizes for blood transfusions
113
16 – 18 gauge for
Rapid infusion
114
Infectious Risk
Non-Infectious Risk
Transfusion Associated Risks
115
Low but not guaranteed
Infectious Risk
116
Transfusion Associated Circulatory Overload (TACO)
Transfusion Associated Dyspnea (TAD)
Transfusion Related Acute Lung Injury (TRALI)
Hemolytic Reaction
Incompatible Transfusion
Hypotensive reaction
Aseptic Meningitis
Non-Infectious Risk
117
when incompatible (mis-matched) blood is transfused, the recipient’s antibodies Trigger Red Blood Cell destruction
Response: Mild -> Severe
Mild: hives, rash diphenhydramine
Transfusion Reaction
118
1 in 300 chance; fever during transfusion or up to 4 hours-post -> acetaminophen
Febrile Non-Hemolytic Reaction
119
when wrong ABO is infused
Fever, chills, hemoglobinuria (most common)
Pain, hypotension, dyspnea, renal failure, DIC (less common)
Acute Hemolytic Transfusion Reaction
120
within 1 to 45 minutes of transfusion starting
Rash, upper/lower airway obstruction, hypotension
STOP transfusion
Anaphylactic Reaction
121
Can be delayed by 6 hours
Hypoxemia, fever, hypotension, dyspnea in absence of evidence of circulatory overload
Supportive care (critical interventions – mechanical ventilation PRN)
Rare, not well understood, thought to be immune-mediated response
Transfusion Associated Acute Lung Injury (TRALI)
122
Assess for signs of FVE, who is at risk
1 unit blood = 200 mL
Dyspnea, cyanosis, increased BP, crackles
Administer O2 as needed, send for CXR
Transfusion Associated Circulatory Overload (TACO)
123
1 in 10,000
Fever, tachycardia, hypotension, N/V, DIC, Rigors, sweats/chills
Bacterial Contamination
124
What the drug does to the body to create a response
Relates to the MOA of a drug
Pharmacodynamics
125
degree to which a drug attaches and binds to a receptor
Drug with the best “fit” or strongest will elicit the greatest response
Affinity
126
ability of drug produce biological response
Intrinsic activity
127
Cellular molecule to which a medication binds to produce its effects
Found inside cells and on their surface
Receptors
128
Mimics the action of endogenous substances; response may be greater than endogenous activity.
Agonists
129
“Block” a receptor
Compete for the receptor with either an endogenous ligand or the agonist (drug)
Attaches to the receptor but doesn’t activate it (doesn’t have intrinsic activity)
Antagonists
130
Produces weaker responses than endogenous substances
Partial agonist
131
substance that catalyzes biochemical reaction in a cell
Inhibition is more common
Enzyme
132
Dividing the median toxic dose by the median effective dose gives us a therapeutic index
The higher the value, the safer the medication
Low TI: difference between therapeutic dose and toxic dose is small
E.g.: Warfarin, Digoxin
High TI: big difference between therapeutic and toxic
E.g.: Amoxicillin
Therapeutic index
133
difference between therapeutic dose and toxic dose is small
E.g.: Warfarin, Digoxin
Low TI
134
big difference between therapeutic and toxic
E.g.: Amoxicillin
High TI
135
amount of drug required to produce a particular intensity of response
The drug that requires the lowest dose is most potent
Potency
136
maximum intensity of response produced by a particular dose of drug
Drug with the highest intensity of response has highest efficacy
Note! Do not assume the drug with the lower dose gives fewer adverse effects
Efficacy
137
Response to a dose is distributed among a population
Some people require more drug, some people require less -> to achieve a therapeutic response Most require a dose somewhere in the middle
Median Effective Dose: the average dose of drug that will provide a therapeutic response in 50% of people
Median Effective Dose is represented as ED50
Referred to as “normal frequency distribution”
ED50
138
refers to median lethal dose
Dose at which 50% of test subjects are killed by drug
LD50
139
refers to median toxic dose
Dose at which 50% of test subjects exhibit a response indicative of toxicity
TD50
140
__ = TD50 / ED50
We want the therapeutic index to be a high number; > 10
TI
141
nurse gathers info. Bio, sociocultural, environmental, spiritual, psychological data
Assessment
142
nurses perspective on the appropriate focus for the patient
Diagnosis
143
nurses would prioritize issues raised during assessment in relation to diagnosis. Identify which areas could be assisted by nursing intervention. Create a plan of care.
Planning
144
plan of care is carried out.
Intervention
145
the plan's success or failure would be judged both against the plan itself and the patient's overall health status. Has the intended outcome been achieved?
Evaluation
146
Subjective : clients verbal description of condition
Objective: observations of clinical measurements or assessments
Cue
Inference
Types of data
147
to form a nursing judgement, nurses critically assess, validate data, interpret info gathered, and look for diagnostic cues that lead to identification of pts problems.
NANDA - common language that enables members or the team to understand pts needs.
NG focuses on clients actual or potential response to health problems rather than on the physiological event, complication, or disease Ex: client knowledge regarding post operative routines.
Provides basis for selecting intervention
Provides precise definition of clients needs
Nursing diagnosis
148
Two part format: diagnostic label and related factor
Definition
Risk factors
Support of the diagnostic statement - ex: acute pain related to surgical procedure as evidence by facial grimace, guardian behavior and verbal report of 9/10 pain felt in the lower abdominal region
Nursing diagnosis
149
The ________ or related factors identifies probable cause of the health problem, and or the conditions involved in the development of the problem. Directs nursing interventions. If wrong, the nursing care would be inappropriate to the client.
etiology
150
The __________ is the name nanda has given the problem. It is chosen based on the presence of defining characteristics.
Suggests goals for the client
diagnostic label
151
Criteria should meet smart goals
Goals should be client centered : reflects the highest level of wellness and independence for patient or client
Short or long term depending on situation
Good goal of care
152
independent nursing interventions, does not require orders from other health care providers
Nurse-initiated interventions
153
dependant, requires orders from physicians or NP
Physician initiated interventions
154
interdependent, established in interdisciplinary health care team conference
Collaborative interventions
155
ADLS, IADLS, physical care techniques, controlling for adverse reactions, life saving measures, counseling, teaching, preventative measures
Direct care
156
communicating nursing interventions; written or oral, delegating, supervising, and evaluating the work of other staff members
Indirect care
157
Well lit, well-ventilated room, appropriate furniture, comfortable temperature. Quiet setting with little distractions. Provide privacy. An ideal environment is not always achievable, nurses can adapt environment as much as possible.
Ideal teaching enviroment
158
Cognitive
Affective
Psychomotor
Domains of learning
159
all intellectual behaviors and requires thinking . remembering, understanding, applying, analyzing, evaluating, creating.
Cognitive
160
expression of feelings and acceptance of attitudes, opinions, or values. Receiving, responding, valuing, organizing, characterizing.
Affective
161
involves acquiring skills that require integration of mental and muscular activities. Perception, set, guided response, mechanism, complex overt response, adaption, origination.
Psychomotor
162
Social motives: reflect a need for connection, social approval. ex : going to help groups because you want to meet people
Task mastery motives: ones driven by desire of achievement, want to leave the hospital, have to learn to do the dressing
Physical motives: desire to maintain and improve health
Motivation and social learning theory: self-efficacy, social learning theory concept, persons perceived ability to successfully complete a task. When people believe that they can execute a particular behavior, they are more likely to do it.
Client centered approach: standard of care that positions the patient as the focus of care delivery and as a partner in the delivery of care. Listen, establish, adopt, reinforce, name, strengthen.
Motivations to learn
163
Developing teaching plan - work with patient to select teaching method
Sets goals and expected outcomes
Develop learning objectives
Set priorities
Timing
Organizing teaching material
Maintaining attention and participation - active participation is important
Building on existing knowledge
Selecting resources
Writing teaching plans
Planning stage - Pt education
164
any undesirable occurrence involving medications: preventable or unpreventable, med error, equipment malfunction, WD
Adverse Event
165
unintended, often predictable, secondary effect that a medication causes. Can be harmless. Or cause injury.
Side effect
166
causes injury, lethality. - intolerable to patient causing severe disruption to life affecting adherence to the drug
Adverse effect
167
adverse effects, do not require change in therapy or dose; no interventions
Mild ADR
168
change to drug regimen, can be severely/permanently disabling, life-threatening, or fatal, cause organ damage etc.
Severe Adverse Drug Reaction (ADR)
169
extension of drugs normal effects on the body. Ex: antihypertensives, blood thinners, insulin. Predictable frequency and intensity. Occurrence is the result of the dose. The dose makes the poison.
Pharmacologic reactions
170
change in dose, d/c drug therapy
hypersensitivity - requires a previous exposure to allergen. Severity not proportional to dose of a drug. The allergy symptoms are non-specific to drug. Drugs with highest incidence of allergic reactions: beta-lactam antibiotics = penicillins. Antibiotics containing sulfa drugs. NSAIDS. Cancer chemo. Preservatives
Resolution
171
Abnormal reactivity to a chemical that is peculiar to a given individual. AE’s that are unusual or unexpected responses to drug that are unrelated to action of drug. Rare. not an allergy. Unrelated to dose. Ex: dress syndrome. Steven johnsons. TEN.
Idiosyncratic reaction
172
drugs that promote birth defects during pregnancy. Only used when benefit clearly outweighs risk of fetus. Concern related to pregnancy, may have benefits to other populations.
Teratogenic drugs
173
drugs known for producing cancer risks. Only used when benefit outweighs risk. Effects may not be seen for years. Ex: antineoplastics, immunosuppressants, hormone and hormone antagonists.
Carcinogenic drugs
174
defined as occurring when the presence of a substance increases or decreases the action of a drug. Admin of one drug alters the effects of another. May or may not be harmful. Drug-drug. Food-drug. Affects pharmacokinetic and pharmacodynamics.
Drug interactions
175
Brain very sensitive to toxic substances
Difference between therapeutic and toxic doses can be very small
Important for nurse to recognize CNS toxicity
Behavioural changes - depression or mania
Sedation
Hallucinations
Seizures
Ototoxicity - inner ear damage to CN VIII - mycin - antibiotics have high risk. Vancomycin, clindamycin.
s/s of CNS toxicity
176
non pitting edema. Subcut and sometimes mucosal layers. Face. lips. Neck. extremities. Oral cavity. Larynx. Gut.
swelling in the deep layers of the skin and other tissues. can have itchy, raised rash. Swelling around eyes. Swelling of the lips.
Swelling of tissue can impair breathing
Angioedema s/s
177
AE skeletal muscle and tendon. Drug induced skeletal myopathy.
Rare
Muscle breakdown and cell components released into bloodstream
Kidneys cant keep up with excreting extra components (myoglobin, CK, phosphate)
Can develop complications from electrolyte imbalances (hyperkalemia)
Rhabdomyolysis s/s
178
response is equal to sum of its parts. Tylenol and caffeine.
Additive effect
179
response is greater than sum of its parts. Alcohol and CNS depressants. Opiods and NSAIDS.
Synergist effect
180
(used for depression) - can induce some hepatic enzymes, altering activity of antidepressants, benzos, warfarin.
St. johns wort
181
(used to improve mem and circulation) - antangonizes anti-seizure drugs, enhances activity of anti-clotting drugs.
Ginkgo biloba
182
Constitution of canada
Civil law (quebec) and common law (rest of canada)
Precedent
Private (civil) law
Disputes between individuals, contracts, property
Torts
Public law
Criminal → public good
Common law: written/unwritten rules and principles which come from a court judgment
Sources of law
183
law enacted by parliament or provincial legislature Ex: health care directives act, child and family services
Statutory law
184
civil wrong committed against a person or property. Intentional or unintentional
Tort
185
Nurses have a _______ relationship with patients. Nurses are accountable and responsible for practice that is demonstrated and informed by evidence and demonstrates competence.
fiduciary
186
is accountable to the public for ensuring safe, competent, and ethical nursing care. exist for RPNS.
Regulatory body
187
Nursing practice is ____, define scope of practice
legislative
188
define scope more specifically
Regulatory bodies
189
Nursing practice act aka health professions act
Regulatory bodies
Professional and specialty nursing organizations
Standards of psychiatric nursing practice: 1. Therapeutic relationships 2. Competent, evidence informed practice 3. Professional responsibility and accountability 4. Leadership and collaboration in quality psychiatric nursing practice 5. Professional ethical practice. Recognize the standards, promote the standards, uphold the ethical standards of the profession.
Nursing standards come from
190
negligence: failure to take the care that a reasonable and prudent nurse in a similar situation would take. Conduct falls below desirable standard. Most common reason nurses get sued.
Unintentional torts
191
willful act that violates a persons rights. Assault, battery, invasion of privacy, false imprisonment.
Intentional torts
192
Communication and documentation
Chart is legal. Do it properly.
Follow standards, continuing education
Insist on proper orientation and adequate staffing
Negligence prevention strategies
193
Nurse must witness the following be verified:
Person must have the legal and mental capacity to make treatment decision
The consent must be given voluntarily without coercion
Person must understand the risks and benefits of the procedure or treatment, the risks of not undergoing the procedure or treatment, and any available alternatives.
Nurses role - Informed Consent
194
a mechanism enabling a mentally competent person to pla for a time when mental capacity is lost - living will, instructional directive, proxy directive, psychiatric advance directive
Advance directive
195
The person you appoint to make your medical decisions when you can't make your own.
Healthcare Proxy
196
A person can be admitted to a psych unit involuntarily or voluntary(form 4). If voluntarily, they have the right to refuse treatment and the right to discharge themselves.
If the pt may cause harm to self or others, provincial/territorial mental health legislation permits police to bring person for examination and treatment without persons consent (form 3)
Consent under Mental Health Act
197
Nurse has legal responsibility to follow the laws enacted to protect the public health: reporting suspected abuse and neglect, reporting communicable diseases, reporting other health-related to protect the publics health
Reporting Requirements
198
1. Ask the clinical question
2. Collect the best evidence
3. Research literacy: critique the evidence
4. Integrate the evidence
5. Evaluate the practice decision or change
Five steps of researching evidence
199
Patient population of interest
Intervention of interest
Comparison of interest
Outcome
PICO (Forming Clinical Question)
200
Comprehension and committing tp drug tx regimen
Communicate instructions in a manner that older patient fully understands
Work with pharmacist to ensure meds are dispensed easily
Clear labels with instructions on drugs
Simplify regimen to reduce number of drugs taken a day
Daily/weekly pill counter
Check off calendar for documentation
Engage family members or friends
Schedule periodic tests to determine plasma drug levels
Follow-up calls to high risk patients
Med Adherence - Older Adults
201
little vasculature so drugs in maternal circulation have little effect
Preimplantation
202
most rapid development. Teratogens can have most impact during this period
Embryonic
203
fetal placenta barrier becomes more permeable. Greater sharing between mom and baby
Maternal liver and kidney disease can have big impact on drug levels in fetus
Fetal period
204
teach parents admin of drugs and assessing for AEs. water to body fat, immature liver, underdeveloped BBB, thin skin.
Infancy
205
1-3. Dosing is usually by body weight. AE manifest same way as they do in adults. Keep meds out of reach.
Todderhood
206
3-12. From 6-12, rapid growth. Common problems are GI and respiratory.
School age
207
12-18: rapid growth and physiological development. Risk of recreational drug use. Parents should be aware of common side effects of rec drugs. Performance enhancing drugs. Common needs for pharmaco: skin probs, headaches, menstrual, sex-related, eating disorders, alcohol/tobacco, sports-related.
Adolescence
208
18-40: generally healthiest period, require few prescriptions, compliance is good. 18-24 risk for substance abuse.
Young adulthood
209
stress is more common leading to variety of chronic health issues. Cardio, obesity, arthritis, cancer.
Middle adulthood
