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103 Cards in this Set
- Front
- Back
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If you are the first nurse to locate a patient what do you do after calling code blue?
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begin CPR
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Once the code blue team arrives what should the bedside nurse do?
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-stop CPR
-state history -gather patients information -provide relevant data |
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One of the most important roles of bedside nurse during code blue it what?
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-what is admitting diagnosis
-s/s before arrest -meds given -acute/chronic conditions -recent lab results -call family |
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Who places a chest tube?
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surgeon
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What is the chest tube placed into?
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pleural cavity
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Why do you need to be very careful not to knock chest tube container over?
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it will then provide an inaccurate reading if suctioning fluid. then you will have to throw it away and start over.
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What are we monitoring with the graduated air leak monitor?
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if there are any air leaks. we will see bubbles. you will want to call MD for this since it is supposed to be a closed system with negative pressure.
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Where are chest tubes normally placed?
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mid-axillary line (pleural cavity obviously)
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What is special about the dressing placed over a chest tube?
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it will be sutured to the skin and be air tight.
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What is a hemothorax?
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blood in pleural space
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How can we re-inflate a lung from a pneumothorax?
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chest tube to re-establish pressure
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What is empyema?
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pus or infected fluid around the lung
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What does the water seal on the chest tube device do?
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allows drainage and air to drain into the collection chamber wo air entering.
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What do we ask our pt to do when we are assessing the chest tube for airleaks?
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cough and watch for bubbles in water seal. bubbles indicate an air leak and we may need to call MD.
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What are the purpose of chest tube?
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-to facilitate reinflation of lung
-to facilitate removal of fluid |
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What do you want to ensure are on your orders with a chest tube?
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-continuous or intermittent suction
-amount of suction -presence of airleak -DC of suction -clamping of CT |
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What position is optimal for a pt with a CT do give optimal lung expansion?
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semi-fowlers
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How do we assess the insertion site of the CT?
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-note any drainage
-ausculation -thoracic expansion -palpate for krepitis (air under skin |
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What do we want to document about fluid being removed from a CT?
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-color fluid
-character of fluid -amount of fluid -with sharpie mark the amount & time on CT chamber -viscosity of fluid |
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What can we encourage a pt to do nonpharmacologic to help drain fluid with CT?
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-deep breathing exercises
-incentive spirometer |
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What are some things typically seen on documentation with a pt with a CT?
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-chest tube drainage
-chest tube patency -presence of an airleak -amount of suction -pain level -dressing status -respiratory status |
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What are the three smaller compartments of the ECF?
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-intravascular
-interstitial -transcellular |
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What regulates ECF?
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-baroreceptors
-RAA |
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What are the functions for water in the body?
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-medium for transporting nutrients to cells, wastes from cells
-facilitate cellular metabolism -solvent for electrolytes** -maintains body temperature -tissue lubricant |
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When should we take daily weight?
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6am before pt has breakfast
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In general, 1 liter of fluid equals what in weight?
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1kg (2.2lbs)
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If intake is greater than output what do we call that?
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fluid excess
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If intake is less than output what do we call that?
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fluid deficit
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What does a basic metabolic panel test?
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-sodium
-potassium -calcium -chloride -carbon dioxide -glucose -BUN -creatinine |
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What are the five electrolytes that are very important in everyday practice?
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-sodium
-potassium -calcium -magnesium -phosphate |
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What are the normal limits for sodium?
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135-145 mEq/L
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What plays a major role in ECF volume & concentration, generation and transmission of nerve impluses?
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sodium
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What are the causes of hyponatremia?
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-fluid overload
-GI loss -sweating -diuretics |
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If we have s/s of:
-MS changes -hypotension -tachycardia -N/V/D -convulsions what may this lead us to? |
hyponatremia
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What are the causes of hypernatremia?
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-water deprivation
-increased sensible & insensible water loss |
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If I notice a large change in weight, where may I see that fluid?
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-edema
-DVT -lung sounds |
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If we have the s/S of:
-MS changes -thirst -dry, flushed skin -dry mucus membranes what may these lead us to? |
hypernatremia
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What are the normal limits of potassium?
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3.5-5.0 mEq/L
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What is necessary for transmission and conduction of nerve impluses, maintenance of normal cardiac rhythms, and skeletal mm contractions?
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potassium
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What is the amount we do not want to exceed when administering K+ through IV infusion?
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10-20 mEq/hr
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What are the causes of hypokalemia?
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-V/D
-polyuria -extreme sweating -excess insulin |
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What are the causes of hyperkalemia?
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-renal failure
-cell damage -use of potassium-sparing diuretics -rapid blood transfusion |
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If we have s/s of:
-PVC, VT, VF -weakness fatigue -decreased mm tone what may these lead us to? |
hypokalemia
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True or False:
You may ALWAYS use a pump to administer potassium? |
true
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If we have the s/s of:
-dysrhythmias -anxiety -weakness -abdominal cramps what may this lead us to? |
hyperkalemia
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What are the normal limits of calcium?
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8.9-10.1 mg/dL
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What electrolyte has the function of transmission of nerve impluses, myocardial contractions, blood clotting, mm contractions?
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calcium
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What are the normal limits of magnesium?
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1.5-1.9 mEq/L
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What electrolyte is important for normal cardia and neuromuscular function?
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magnesium
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What are the causes of hypomagnesemia?
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-inadequate intake
-inadequate absorption |
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When we see the s/s:
-tremors -hyperreflexia -confusion -dysrhythmias what may we think? |
hypomagnesemia
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What are the causes of hypermagnesemia?
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-renal failure
-excess intake |
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If we see the s/s
-hypoactive reflexes -hypotension -flushing what may we think? |
hypermagnesemia
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What are the normal limits of phosphate?
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1.7-2.6 mEq/L
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What electrolyte is essential to function of mm, RBCs, & NS?
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phosphate
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How is a Trousseau's Sign indicated?
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apply blood pressure cuff over systolic pressure. wait 3 mins. watch for carpal spasm. adduction of thumb/fingers
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If Trousseau's Sign is positive what may that conclude about a pt?
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hypocalcemia
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What is it when osmotic concentration is equal to that of the body fluids & there is no change in cells?
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isotonic
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What is it when there is a lower concentration than in the body fluids; fluid enters cells causing cells to swell?
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hypotonic
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What is it when greater concentration that body fluids; water leaves cells causing cells to shrink?
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hypertonic
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Where does isotonic solution remain when it is administered?
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in vascular circulation
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If we have a pt with cellular dehydration what would we administer?
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hypotonic solution
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What type of solution is 0.9%NaCl (NS), Lactated Ringers (LR), 5% Dextrose in water (D5W)?
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isotonic solution
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What type of solution will you not administer to pt who is at risk for increased ICF or third space fluid shifts?
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hypotonic solutions
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What type of solutions are 0.45%NaCl & 0.33%NaCl?
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hypotonic solution
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What solutions will draw out of the ICF & interstitial compartments into the vascular space (expanding vascular space)?
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hypertonic solution
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What solution do we NOT administer to pt w/kidney or heart disease who are dehydrated?
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hypertonic solutions
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What type of solutions are 5% dextrose in NS (D5NS), 5% dextrose in 0.45%NaCl (D5 1/2 NS)?
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hypertonic solution
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What is pressure exerted by colloids (proteins) in solution?
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oncotic pressure
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What holds fluid in vascular compartment by pulling water from the interstitial space back into circulation?
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oncotic pressure
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Regarding I & O's what is a very important piece of information to gather from surgeon?
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EBL (estimated blood loss)
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What are the s/s of fluid volume deficit?
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-weight loss
-thirst -orthostatic/postural changes -BP -UO |
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What do we want to include in our assessment of fluid & electrolyte balance?
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-fluid I & O
-weight -physical assessment (edema, DVT, VS) -Lab (CBC, serum electrolytes, urine pH, SG, ABG) |
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What is the normal limits for SG of urine?
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1.010-1.020
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If there is less than 3.5 on the serium albumin what may we think?
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nutritional deficits
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What infusions may be give that are considered colloid infesions?
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-blood products
TPN |
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What blood type is the universal donor?
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AB
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What blood type is the universal recipient?
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O
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What is the most common type of blood products administered?
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packed cells or red cells (PRBC)
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When may be administer cyroprecipitate?
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hemophilia pt (it contains Factor VIII)
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What can we administer to increase colloidal osmotic pressure in the blood?
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albumen
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What can we administer that will provide clotting factors, proteins, & fluid volume?
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fresh frozen plasma (FFP)
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What saline should you ALWAYS use when administering PRBC?
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NS
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What must you do before administering blood products?
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double check with another nurse
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Blood typing is only carried on what?
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RBC
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What do you need to verify on the blood bag label?
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-pt ID name & #
-blood unit # and unit # in record -blood group & Rh type on unit -type of blood product & expiration date |
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What gauge is typically used when administering blood products?
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18G
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How do we assess VS before and during administering blood products?
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-baseline VS
-monitor VS every 5 minutes for 15 mins |
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What do we do if we ever sense an allergic reaction when administering blood products?
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stop IV immediately
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What is the most serious reaction when administering blood products?
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hemolytic reaction
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What will you see s/s with hemolytic reaction?
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-facial flushing
-fever -chills -HA -low back pain -increased HR -decreased BP |
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From the moment the blood product leaves the blood bank and is completely administered how long do you have?
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4 hours
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Why do we see transfusion related acute lung injury (TRALI)?
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damage caused to lungs from components in blood products (Ab to Leukocytes)
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What are the A,B, C, D's of respiratory interventions?
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-airway
-breathing -circulation -diagnostic data |
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When we hear crackles what should you think?
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fluid
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When we hear rhonchi what should we think?
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sputum
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When we hear wheezes what should you think?
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narrowed airway
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What does pink frothy mucus indicate?
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pulmonary edema
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What is the FIO2 of RA?
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21%
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What is the FIO2 for 1L?
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23-24%
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What is the FIO2 for 2L?
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28%
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What is the FIO2 for 15L with the rebreather mask?
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100%
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What is the self use oral suction called?
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yankauer (tonsil tip)
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