Fundamentals Final(YOU GOT THIS!) Flashcards
1
Q
How to care for orthostatic hypotension?
A
- move patient slowly
- dangle feet at side of bed
2
Q
First task on shift?
A
Get report(SBAR)
- updates - VS - family issues
3
Q
What to do after shift report?
A
review labs and medications
4
Q
2 Delegation points of not delegating
A
- Dont delegate assessment
2. Dont delegate out of scope
5
Q
What asessment is taken at beginning of shift?
What assessment is taken in middle of shift?
A
Head to toe assessment
Focused assessment
6
Q
Who obtains VS when patient is out of ICU or surgery?
A
The Nurse
7
Q
Prioritization
A
Stable vs unstable
ABCSPI (life threatening labs/VS after circulation)
How Old? When admitted? When was/is surgery? How many body systems involved?
8
Q
What is a fever?
A
above 100.4 degrees
9
Q
Infection indicators
prevention?
A
fever, increase WBC and RR, drainage, odor
hand hygiene, antibiotics/antibacterials
10
Q
Putting PPE on order
Putting PPE off order
A
gown, mask, goggles, gloves
gloves, goggles, gown, mask
11
Q
What does decreased bowel sounds indicate?
A
Ileus
12
Q
TPN musts
A
- 2RNS must check TPN
- 10% dextrose if TPN runs out
- check BG q6h
- check placement of tubes by CXR and gurgling
13
Q
Sleep interventions
Benzodiazapine?
A
teach to get to bed quickly, start low if elderly, environment is safe, BE CAUTIOUS of benzodiazapines in elderly, promote health habits
14
Q
What to do if patient has skin wound?
A
turn patient
Eschar MUST be debrided
collect drainage for culture
15
Q
How many L/min for face mask?
A
at least 5 L/min, 6-12 L/min
35-50%
easy to use and short term
16
Q
How many L/ min for nonrebreather?
A
10-15 L/min
60-90%(high concentration)
reservoir bag must be inflated
17
Q
How many L/min for nasal cannula?
A
1-6 L/min
24-44%
flow rates over 4/L min need humidification
easy, can talk and eat, comfortable
18
Q
what is a vapotherm?
A
High flow nasal cannula, O2 is warm and humidified
19
Q
What are venturi masks used for?
A
low concentration, specific amount
24-60%
20
Q
What is a face tent used for?
A
Claustrophobic patients
21
Q
Early S/S of hypoxia? Late?
A
Early: Fear,Anxiety,Tachycardia,not concentrated,dizzy,dyspnea,pale
Late: Decreased LOC, Fatigued, Cyanosis, Hypotension,
22
Q
Inhaler Patient Teaching
A
Rinse mouth after using MDI Shake 5-6 times administer during inspiration hold breath for 10 seconds don't smoke clean equipment
23
Q
How often are eye exams?
How often are ear exams?
A
q 2 years, or yearly if eye problems
yearly if in noisy environment
24
Q
Cheyne-Stokes= Kussmaul= Eupnea= Tachypnea= Bradypnea- Apnea= Hypernnea- Orthopnea-
A
Cheyne-Stokes= alternate between apnea and deep. respiratory center problem Kussmaul=compensate for metabolic acidosis , deep and fast Eupnea= effortess Tachypnea= >20 Bradypnea= <12 Apnea= no breathing Hypernnea- abnormally deep Orthopnea- sitting up to breath
25
Different aphasias
```
Expressive= understand but cant communicate, use pictures to communicate
Receptive= cannot understand
Global= both expressive and receptive
```
26
Cognitive patient teaching
Affective patient teaching
Psychomotor patient teaching
```
Cognitive= knowledge
Affective= communication, care
Psychomotor= demonstration
```
27
Who gets consent for surgery?
Who is a witness and advocate of patient?
The Surgeon
The Nurse
28
How often to check 2 point and 4 point restraints?
2 point- q2h
| 4 point- every 15 minutes
29
Malpractice standards
Nurse had a duty
Duty was breached
Breach resulted in injury
30
UTI S/S, tests, interventions
```
Dysuria
Hematuria
Pain
Frequency and urgency
Small Volumes
Increased RBC and WBC
fever
N/V
```
management: urinalysis, C&S
complications: pyelonephritis, drug tolerance, renal abcess
Interventions: assess VS, UA, C/S
administer antibiotics(trimethoprim/sulfamethoxazole), bladder analgesic(phenazopyridine/pyridium), atnispasmsic( Hycosamine), anticholinergicdrink fluids, cranberry juice
Teach to report S/S
prevention:
- wipe front to back
- drink fluids and cranberry juice
- urinate before and after sex
31
CAUTI S/S, tests, interventions
```
poor appetite
sudden incontinence
nocturia
dysuria
hematuria
confusion
Urosepsis (UTI found too late)
Pulse Rises, BP drops, shock, death
```
Meds: antibiotics (Sulfonamides, Fluoroquinolones, Penicillin, Cephalosporin)
bladder analgesics: phenazopyridine (pyridium)
Macrobid/Macrodine
Antispasmodic: Hyoscyamine
Anticholinergic
32
Urolithiasis (Kidneys stones) S/S, tests, interventions
Ca levels are high
pain
pallor(skin color)/diaphoresis(sweating)
N/V hematuria
Narcotics, NSAIDS, antiemetics(ondansetron), and Alpha adrenergic blockers(tamsulosin)
straining
Management: noncontrast CT, KUB, and ultrasound
Surgery: lithotripsy, ureteroscopy, stent or nephro tube)
Pre care: NPO, bowel prep, IV for sedation
Post care: hydrate, first urine is bloody, strain, possible bruising
33
Bladder Cancer expectation
risk factors
intervention
Painless Hematuria, increase in frequency and urgency, nocturia
Smoking
Create diversion to bypass bladder
34
Types of incontinence
```
Stress: stretched/relaxed muscle (pregnancy)
Urge: irritants (caffeine, nicotine)
Overflow: enlarged bladder, diabetes
Functional: unable to reach bathroom
Reflex: spine or brain injuries
```
35
normal WBC value
5,000-10,000
```
Neutrophil:55-70%
Bands:3-5%
Eosinophils:1-4%
Basophils: .5-1%
Lymphocytes:20-40%
Monocytes: 2-8%
```
36
What to avoid if neutropenic/leukocytopenia?
NO fresh flowers, fruits, and veggies
37
function of HGB and hematocrit
Transport Iron
38
Low HCT indicates what?
Iron deficiency anemia
39
normal platelet value
150,000-400,000
40
normal RBC value
4. 2-6.1 MILLION
| 4. 2-5.4 women) (4.7-6.1 for men
41
normal HGB balue
12-18
Men:14-18
Women:12-16
42
normal HCT value
37-52%
Men:42-52%
Women: 37-47%
43
rule of three
RGB X3 = HGB
| HGB X3 =HCT
44
what dos thrombocytopenia indicate
bleeding, brusing
45
where do patients lose potassium?
In stool
46
Dilute Potassium? Give IV PUSH?
Yes, Dilute
| NEVER give IV PUSH
47
What to watch for in EKG in hyperkalemia? In hypokalemia?
Peak T waves
U waves
48
What conditions shows Chvostek(face react) and trousseaus signs (hand react)?
Hypocalcemia and Hypomagnesemia
49
What does high BUN indicate?
Dehydration
50
Normal BUN value
10-20
51
Normal Creatinine Value
.5-1.1
52
Normal BG value
70-110
53
What to give patient if Blood glucose is low?
Insulin and D50
54
Normal HGB A1C value and function
4-5.9%
Control Diabetes
55
What med is regulated with PT? antidote? what to look at?
Coumadin/Warfarin
Vitamin K
look at INR
56
What med is regulated with PTT? antidote?
Heparin
Protamine Sulfate
57
What does acidosis indicate? alkalosis?
Acidosis indicates hyperkalemia
| Alkalosis indicates hypokalemia
58
Normal pH
7.35-7.45
59
Normal paCO2
35-45
60
Normal HCO3
22-26
61
IVP knowledge/interventions
Know allergies to shellfish and iodine dye
NEED consent
Check BUN & Creatinine
HOLD metformin/glucophage when giving dye
NPO before and after
62
Renal arteriogram knowledge/interventions
Know allergies to shellfish and iodine dye
NEED consent
Check BUN & Creatinine
HOLD metformin/glucophage when giving dye
PT and INR
Check for bleeding at site
63
CXR knowledge/interventions
diagnose pneumonia, check line placement
pregnant?
NO consent
64
CT scan knowledge/interventions
Know allergies to shellfish and iodine dye
NPO
Claustrophobic?
Pregnant?
65
MRI knowledge/interventions
NO metal
| Sedation if nervous
66
KUB knowledge/interventions
abdominal, look for NG tube placement
| NO consent
67
Thoracentesis knowledge/interventions
NEED consent
| sit up, arms out
68
Paracentesis knowledge/interventions
NEED consent
| lay on back
69
PO route knowledge/interventions
do NOT crush enteric coated meds
| first pass effect
70
IM route knowledge/interventions
1 mL into Deltoid because only small amount
up to 2 mL in vastus lateralis(mid thigh)
up to 3 mL in ventrogluteal (hip)
shorter needle for deltoid
71
what does PR stand for ?
Per rectum
72
SubQ knowledge/interventions
Rotate sites, give .5-1 mL in shots
73
SL (sublingual) knowledge/interventions
need moist mouth
NO food or drink after/during
Under tongue
74
Buccal knowledge/interventions
No food or drink
75
Order of meds for inhaler
Bronchodilator(albuterol) then Steroid
76
Topical knowledge
rotate sites
wear gloves
bypass first pass effect
77
Optic meds. knowledge/interventions
Pull down lower lid
hold pressure
wait between drops
78
Otic meds knowledge/interventions
Adults: Pull up and back
| Children under two: Pull down and back
79
Intradermal degress
5-15 degrees
80
Laxatives knowledge/interventions
AVOID long term use
81
Different types of laxatives
metamucil- bulkforming
dulcolax(bisacodyl)- irritant
colace(sodium docusate)- emoliant(lubricant), stool softener
82
```
PPI suffix
function
interventions
```
-prazole
inhibit gastric acid secretion
give in morning for prophylaxis(fight disease)
83
```
H2 Blocker Suffix
function
interventions
```
-dine
inhibit gastric acid secretion
Give at bedtime
avoid smoking and eating B12 foods
84
```
Benzodiazapines suffix
function
interventions
What is antidote?
```
-zepam and -zolam
Suppress CNS activity, Treat Anxiety
Check LOC and RR
Do NOT mix with alcohol
Do NOT stop abruptly
Antidote: Romazacom
85
Narcotics/Opiates function
interventions
side effect
antidote
Treat Pain
```
check BP(BP typically drops), RR
side effect: constipation, urine retention, GI distress, Respiratory down
```
Antidote: narcan
86
NSAID interventions
| examples
watch for Ototoxicity and GI distress
aspirin
ibuprofen
87
```
Antiemetic
function
interventions
```
Prevent vomiting
No alcohol with phenergan
Monitor Hydration, I&O
Mouth Care
88
```
Antihistamine suffix
function
intervention
```
-ine
Prevent allergies
Cause drowsiness
89
```
Ace Inhibitor suffix
function
interventions
```
-pril
Relax veins to drop BP
Check BP prior to giving, do NOT give if too low
side effects:
-coughing
-fluid status altered
-promotes aldosterone
-potassium is retained (WATCH K Levels!)
90
Beta Blockers suffix
function
interventions
-lol
Decrease BP by decreasing HR
Check HR & BP( if below 60 HOLD beta blocker)
91
Loop Diuretics suffix
| interventions
(-nide and -mide)
used for hypertensions
check fluid/electrolyte, I&O, and daily weight
(-lactone is K sparing)= spironolactone
92
```
Cardiac Glycoside suffix
function
interventions
```
-xin (Digoxin)
Decreases HR and increases contractions(output)
Monitor HR and dont give below 60
93
Antianginal (Nitroglycerine) function
dilate blood vessels, men should not be on viagra
94
Antibiotics interventions
```
check allergies
fluids
should not be exposed to sun
DO NOT STOP EARLY
TAKE FULL COURSE
```
95
What is kayexelate?
Treat hyperkalemia, poops K out
96
What is metformin?
Impacts kidney, hold on diagnostic tests
97
Purpose of Half-life
Determine dosing
98
Danger of protein binding
Increase risk of ototoxicity
| more free drug
99
Schedule II drugs:
Need prescription
NO call for refill
not a controlled substance
100
Peak vs. trough
Peak is checked 60 minutes AFTER med is given
| Trough is checked 30 minutes BEFORE Meds is given
101
Needle size SubQ vs. IM
SubQ=25-27 (shorter gauge)
| IM=21 (larger gauge)
102
What labs are important to know kidney function?
BUN and creatinine
103
What does High BUN indicate?
Dehydration
104
What to do if Glucose is low? High?
Give D50
| Give Insulin and D50
105
What is HGB A1C?
test 3 month period(120 days) of RBC life
| Treats diabetes
106
How to catch Urinalysis?
Catch sterile technique, NOT by cup
107
What diagnostic tests need consent?
IVP and Renal arteriogram
108
Interventions for invasive diagnostic tests that use dye?
- Check allergies to dye and shellfish
- Check PT & INR (renal arteriogram)
- Check BUN & Creatinine
- Hold metformin if allergic
109
Cataract deficit
Cloudy, opaque lens that distorts passage of light
110
Glaucoma
Pressure against optic nerve, Halos seen
111
Diabetic Retinopathy
Spotted Vision from edema
112
Macular Degeneration
Decrease in central vision
113
Altered attention
Short Attention Span
114
Memory impairment
Head Trauma, meds
115
Disorganized thinking
Delirium: Fast onset
Dementia: Slow onset
Sundowners
116
How often are eye exams?
Every 2 years
| Every year if eye problem
117
How often are ear exams?
Yearly
118
Acute Care checks
Orientation to environment
Safety measures
Controlling sensory stimuli
119
Restorative Care checks
Promoting self-care safely
| Socialization
120
Kubler Ross Classical Behavioral stages
```
Denial
Anger
Bargaining
Depression
Acceptance
```
121
Grief Task Model
Acceptance of reality loss
Work through pan of grief
Adjust to environment
Relocate emotionally/move on
122
Factors that Influence Grief
```
Human Development
Personal Relationships
Nature of Loss
Coping Strategies
Socioeconomic Status
Culture & Ethnicity
Spiritual/Religious Beliefs
Hope
```
123
Difference between Living Will and Durable POA/Health Care Proxy
Living Will: Written instructions about treatments on how you want to be kept alive, or medical treatments
Durable POA: Name a person to make decisions when you are unable to do so
124
Difference between Palliative and Hospice care
Palliative Care: Prevent, relief, reduce symptoms throughout entire course of illness
-Support Patient
```
Hospice is a multidisciplinary team that focuses on quality of life
-focus on quality of life
Hospice patients must be:
1. Terminally ill
2. Insurance Covered
3. 6 months or less to live
```
125
Different types of death
Death= Heart and lungs fail to function
Clinical Death= Heart, Lungs stop, no brain function
- brief time before organs die to perform CPR, not that effective
Brain death= Absence of brainstem reflexes(apnea, coma) heart & respirations stop
-can be on life support: ventilator and vasopressor to maintain heart and lung function
126
```
Strategies of Psychosocial Care
Grief and Mourning
Promote Spirituality
Communication
Provide Referrals
```
Grief and Mourning:
offer physical and emotional support. Provide presence
be realistic, accept situation
encourage reminiscence
Provide Spirituality:
find meaning in suffering without explaining loss
deal with it
look at hope
Communication:
remind family patient may still hear them
Provide Referrals:
Bereavement counseling
127
Steps of postmortem care
Pronouncement of death by APN or MD
Prepare patient for family visit
Allow family to see patient in private, customs( Call Chaplain)
Family chooses funeral home; nurse notifies to pick up body
Offer family to pack belongings
Prepare for transfer. Funeral home will bring stretcher. If to hospital morgue, wrap in shroud and ID
128
Core Elements of Framework
Caring, Connecting, and Empowering
129
Professional Standards of Nursing
```
Patient- Centered
Health Promotion
Teamwork/Collaboration
Informatics/Innovation
Evidence-based practice
Professionalism
Cultural competence
Quality & Safety
```
130
Elements of human, impact on environment of each
```
Physiological
Psychological
Sociocultural
Spiritual
Environment
```
131
Distressing symptoms at end of life
Assess patient
Educate Family & Patient
Assurance
132
Antibacterial Interventions
Check allergy prior to administration
Obtain sample for culture prior to administration
Monitor labs (liver enzymes, kidney function, peak and trough)
Administer in relation to meals
Increase fluids
Monitor for S/S of allergies, toxicities, superinfection
Teach to take entire course as scheduled
133
What antibacterials to check peaks and troughs?
Glycopeptides (vancomycin) and Aminoglycosides
134
What diagnostic tests need consent?
IVP
Renal Arteriogram
CT scan
135
What diagnostic tests do nurses check BUN & Creatinine?
IVP and CT
136
What diagnostic test do nurses check PT & INR?
Renal Arteriogram, go into vessel
137
If medication error, what steps do nurses take?
```
Assess
Call
Report
Compute
(ACRC)
```
138
Coumadin time
| Heparin Time
11-12.5 seconds
| 30-40 seconds
139
INR definition, values
time it takes blood to clot
- Healthy: .8-1.1
- Anticoagulants: 2-3
- Atrial Fibrilation/Heart Valve: 3-4
140
Circulatory Overload findings & interventions
Findings:
crackles
SOB
edema
```
Interventions:
elevate HOB
Reduce IV rate
Monitor VS & labs
Contact HCP
```
141
Infiltration findings & interventions
Findings:
cool and taught(tight) skin
Interventions:
Stop, discontinue, start new IV
Apply warm/cold compress
elevate extremity
142
Phlebitis findings & interventions
Findings:
redness, tenderness, pain, warm veins
```
Interventions:
Do NOT massage
apply warm compress
Stop, Discontinue, Start new IV
Contact HCP if needed
```
143
Local Infection findings & interventions
Findings:
heat, redness, swelling, drainage
Interventions:
Culture drainage
Stop, discontinue, Start new IV
Notify HCP
144
Bleeding findings & interventions
Findings:
fresh blood and pooling
Interventions:
Assess IV intact
Apply Pressure
Start new line if needed
145
Isotonic Fluids
9%NS (dehydration)
D5W
LR
146
Hypotonic Fluids
.45% NaCl (1/2 NS)
| .2% NaCl (1/4 NS)
147
Hypertonic fluids
D5NS
D10W
D5LR
3%NaCl (for hypernatremia)
148
What is Intractable Pain?
Idiopathic pain?
Referred pain?
No treatment found
No cause found, hard to find
Shows up in different place
149
What is Atelactasis?
Collapse of Alveoli
150
S1 and S2?
S1: Mitral and Tricuspid close
S2: Aortic and Pulmonic close
151
Urinary Acute Care meds
Antimuscarinics- treat overactive bladder
Antibacterials- treat UTI
Urinary analgesics- treat pain
152
Urinary restorative Care
```
lifestyles changes (diet- avoid caffeine, citrus, artificial sweeteners, spicy food)
Kegel exercises
bladder retraining
toilet schedule
intermittent catherization
```
153
Diarrhea Care
MAINTAIN FLUIDS
| bland diet
154
Anti Diarrhea Meds
Opiates (Paragoric, Lomotil, Imodium(loperamide)
Adsorbents (Peptobismol, Kaopectate, Charcoal)
Normal flora (lactobacillus acidophilus, Kefir)
155
Care for stoma
Odor Control
| Body Image
156
What does -scopy indicate?
Direct Visualization
157
Ace Inhibitors
-pril
Capoten
Vasotec
Zestril
158
Beta Blockers
-lol
Lopressor
Inderal
Coreg
159
Antianginal
Nitrostat-SL
Nitrobid-ointment
Transderm nitro-patch
Nitroglycerin drip tidal-IV
160
Cardiac Glycoside
-xin
| Lanoxin/Digoxin
161
Loop Diurectics
-mide & -nide
Lasix
Bumex
162
Thiazide
-thiazide
HCTZ
Diuril
163
K Sparing
-actone
| Spirinolactone/aldactone
164
H2 blocker
-dine
Axid
Pepcid
Tagamet
165
PPI
-prazole
Nexium
Prilosec
Protonix
166
Benzodiazapine
-zepam, -zolam
Ativan
Valium
Xanax
167
Antiemetics
Phenergan(promethazine)
Zofran(Ondanstron)
Dramamine(Dimenhydrinate)
168
Chest tube care
```
Assess patient
Keep system upright and below insertion level
Assess tubes for kinks and loops
Monitor Drainage
Connections secure
KEEP PATIENT MOVING
```
169
Antibacterial interventions
```
Check allergies
Obtain sample for culture
Monitor Lab
Administer in relation to meals
Monitor for S/S of allergic reaction, toxicity, superinfection
Teach to take entire course
Increase Fluid intake
```
170
Medications to check for peaks and trough
Glycopeptides (Vancomycin) & Aminoglycosides
