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113 Cards in this Set
- Front
- Back
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WHEN OBTAINING A 24 HOUR URINE SAMPLE, WHAT DO YOU DO?
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FIRST COLLECT COLLECTION CONTAINER FROM THE LAB ANC CHECK W/LAB ON HOW COLLECTION IS TO BE STORED (ICED, PRESERVATIVE)
POST A SIGN IN THE PT. ROOM TO ALERT EVERYONE TO SAVE URINE TO START: ASK PT TO VOID AND EMPTY AND DISGARD THAT SPECIMINE COLLECT ALL URINE FOR 24 HOURS THEREAFTER EMPTY INTO SPECIAL RECEPTICLE ALL URINE FOR THE NEXT 24 HRS. WILL BE COLLECTED IF YOU MISS ONE URINE, START ALL OVER. |
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IF TAKING A STERILE SPECIMEN FROM A FOLEY, WHAT DO YOU DO?
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CLAMP TUBING TO ASSURE URINE AT THE PORT
CLEAN PORT WITH ALCOHOL AND USE A NEEDLE TO ASPIRATE URINE FROM THE TUBING PLACE SPECIMEN IN STERILE CONTAINER, LABEL, SEND TO LAB DON'T FORGET TO UNCLAMP TUBING OR YOU WILL BE CAUSING PT. TO HAVE URINARY RETENTION. **SPECIMEN CAN ALSO BE TAKEN BY INSERTING STRAIGHT CATH INTO PT. |
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HOW IS A CLEAN CATCH SPECIMINE COLLECTED?
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CLEAN GENITAL AREA WITH ANTIMICROBIAL TOWELETTES (MEN CLEAN MEATUS IN CIRCULAR MOTION USING 3 TOWELETTES, FEMALE FRONT TO BACK 3 TIMES USING ONLY 1 TOWELETT AT A TIME)
INSTRUCT PT. TO START VOIDING AND COLLECT SPECIMEN FROM MID-STREAM CAP, LABEL, SEND WITHIN 1 HOUR. |
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TYPES OF INCONTINENCE
**URINARY INCONT. IS NOT A FORMAL SEQUENCE OF AGING |
STRESS - RESULTS FROM INTRABDOMINAL PRESSURE FROM COUGH,SNEEZE,LAUGH
URGE-INVOL. PASSAGE OF URINE AFTER A STRONG SENSE OR URGENCY TO VOID. PT CAN'T STOP THE FLOW ONCE IT STARTS (COMMON IN OLDER BUT NOT CAUSED BY AGING) OVERFLOW-INVOL. PASSAGE OF SM. FREQ. AMT. OF U R/T OVERFILLING OF BLADD. OR A BLADD. W/DECREASED VOL. FUNCTIONAL - INVOL, UNPREDICTABLE PASSAGE OF U. MAY BE DUE TO MEDS. OR MED. PROBLEMS TOTAL-PT. EXPERIENCES A CONTINUOUS AND UNPRED. LOSS OF U. FROM A NON-DISTENDED BLADD. **MOST COMMON - STRESS & URGE ***SOME INCONT. IS A MIXTURE OF ALL THESE |
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EXPECTED CHARACTERISTICS OF URINE
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SHOULD BE TRANSPARENT OR CLEAR
COLOR-PALE STRAW TO AMBER NORMAL HAS AMONIA ODOR SG 1.010-1.030 (HIGH SG = DRY) NO BLOOD, GLUCOSE, MICRO ORG, ACETONE SHOULD BE PRESENT. **STRONG ODOR USU. ASSOC. W/ CONCENTRATED URINE SWEET SMELLLING URINE USU. INDICATES HIGH GLUCOSE CONTENT FETID OR FOUL SMELL USU. INDICATES INFECTION |
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WHAT AFFECTS URINARY ELIMINATION
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AGE-INFANTS ARE NOT ABLE TO CONCENTRATE AND REABSORB WATER. THEY MAY URINATE 20TIMES/DAY.
PERSONAL HABITS-SOME PEOPLE CAN ONLY URINATE IN PRIVATE AND MAY BE UNABLE TO VOID, WHICH CAUSES VOL. U. RETENTION. GOOD MUSCLE TONE IS NEEDED FOR CONTRACTION OF DELTRUSOR MUSCLES AND BLADDER STRETCH. DISEASE OF KIDNEY SUCH AS RENAL FAILURE OTHER DISEASES SUCH AS HEART, CIRCULATORY AND VOMITING, HEMMORAGE CAN DECREASE BLOOD FLOW TO KIDNEYS AND DECREASE GLOMERULAR FILTRATION KIDNEY STONES ENLARGED PRSTATE EFFECTS OF SURGERY ANTICHOLINERGIC DRUGS CAN CAUSE U RETENTION BLOOD LOSS DURING SURGERY DIURETICS INCREASE URINARY OUTPUT |
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ANTICHOLINERGIC DRUGS - WHAT DO THEY DO AND WHAT ARE THE SIDE EFFECTS
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USED TO TREAT INCONTINENCE
S/E: CAN'T PEE- CAUSES U RETENTION CAN'T SEE- BLURRED VISION CAN'T SPIT -DRY MOUTH CAN'T SHIT- CONSTIPATION |
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CHOLERGENIC DRUGS - WHAT DO THEY DO AND WHAT ARE THE S/E
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USED TO TREAT URINARY RETENTION
S/E: S - INCREASED SALIVATION L - INCREASED LACRIMATION U - INCREASED URINATION D - DIARRHEA G - INCREASED GASTRIC MOTILITY/CRAMPS E - EMESIS |
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WHAT IS A KEY INDICATOR OF URINARY OUTPUT?
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I&O TO MONITOR FLUID AND ELECTROLYTE BALANCE.
**IN MOST HOSPITALS IF A PATIENT IS ON IV THERAPY, THEY WILL BE ON I&O. THIS CAN ALSO BE INSTITUTED AS A NURSING MEASURE IF THE NURSE FEELS IT IS NECESSARY FOR THE PT. |
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HOW IS I&O MONITORED
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KEPT THROUGHTOUT THE DAY AND TOTALED AT THE END OF SHIFT
IF I&O FALLS BELOW 30ML/HR ASSESS FOR OTHER SIGNS OF SHOCK SUCH AS VITAL SIGN CHANGES OR BLEEDING TO BE ACCURATE, ALWAYS USE A GRADUATED CONTAINER, URINE HAT, OR UROMETER TO MEASURE. |
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OLIGURIA
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URINE OUTPUT LESS THAN 30ML/HR OR LESS THAN 500ML IN 24 HOURS
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ANURIA
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LESS THAN 100ML IN 24 HRS.
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WHAT TYPES OF DRUGS EFFECT URINARY OUTPUT
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OPIODS
ANTIHISTIMENES ANTIDEPRESSANTS ALL DECREASE U/O |
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NURSING INTERVENTIONS TO PROMOTE URINARY ELIMINATION
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INCREASE FLUID INTAKE TO 2000-3000ML/DAY (INTAKE OF 1500ML/DAY IS ADEQUATE FOR NORMAL ADULT)
ENCOURAGE PT.TO MAINTAIN NORMAL HABITS PROVIDE PRIVACY WHEN TOILETING PLACE PT ON TOILETING SCHEDULE AND MAKE SURE CALL BELL IS IN REACH DISCOURAGE EVERYONE FROM SUPPRESSING THE URGE BE SURE PT. IS IN PROPER POSITION TO URINATE TEACH PROPER HYGEINE KEGELS EXERCISES WARM WATER CREDE'S MANEUVER (MANUAL PRESSURE TO BLADDER) LOWER SALT INTAKE WEAR LOSE CLOTHING (DARK, MOIST PLACES = MICRO ORG) |
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WHAT HAPPENS WHEN A PT. AVOIDS THE URGE TO DEFICATE?
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CHANGE IN BOWEL HABITS OCCURS LEADING TO CONSTIPATION OR POTENTIAL IMPACTION
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ENEMA POSITION
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LEFT, SIDE-LYING
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TYPES OF ENEMAS
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HYPOTONIC:
TAP WATER - DO NOT REPEAT (WATER TOXICITY COULD OCCUR) ISOTONIC: NORMAL SALINE SOAP SOL.(USES CASTILLE SOAP)- IRRITATES INTESTINAL MUCOSA HYPERTONIC SALINE: FLEET'S SODIUM PHOSPHATE - DRAWS WATER INTO BOWEL OIL RETENTION (FLEET'S MINERAL OIL): LUBES RECTUM AND COLON CARMINATIVE (MGW): PROVIDES RELIEF FROM GAS RETURN FLOW ENEMA (HARRIS FLUSH): USED TO EXPEL GAS *POSTION-LEFT SIDE-LYING |
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OSTOMY CARE
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NORMAL STOMA IS PINK/RED AND MOIST (BLUE/PURPLE COULD INDICATE ISCHEMIC CHANGE TO TISSUES).
ESCORIATION OR SKIN BREAKDOWN ON PERIWOUND CAN OCCUR IF STOMA IS NOT KEPT CLEAN/DRY. TREAT LIKE A BABY'S BUTT (CLEAN WITH GENTLE SOAP/WATER)IT'S NOT STERILE, BUT NEED TO PROTECT PERIWOUND. |
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COMMON BOWEL DISORDERS
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CONSTIPATION
IMPACTION DIARRHEA FECAL INCONTINENCE FLATULENCE HEMMROIDS BOWEL DIVERSIONS |
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FACTORS INFLUENCING BOWEL ELIMINATION
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POSITION -SITTING OR SQUATTING IS PROPER POSITION (BEDPANS CAN BE DIFFICULT)
FIBER AND FLUIDS ALCOHOL PAIN MEDS (OPIODS INCREASE CONSTIPATION) SUPRESSING THE URGE CAN LEAD TO CONST. PRIVACY-GIVE PT. PRIVACY |
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LOCATION OF OSTOMY DETERMINES STOOL CONSISTANCY.
NAME OSTOMY TYPES AND STOOL TYPE. |
SIGMOID OSTOMY - NEAR NORMAL FORMED STOOL
ILEOSTOMY - SEMI-SOLID OR LIQID STOOL LOOP COLOSTOMY - PROXIMAL LOOP DRAINS STOOL, DISTAL STOMA DRAINS MUCUS DOUBLE-BARREL COLOSTOMY- PROXIMAL IS FUNCTIONING AND DISTAL IS NON-FUNCTIONING |
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COLASE IS A?
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STOOL SOFTENER
TAKES 12-24 HOURS TO WORK |
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DULCOLAX
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LAXITIVE THAT IS AN IRRITANT TO LINING THAT CAN CAUSE BM
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TYPES OF PAIN
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CUTANEOUS -SKIN OR SUBQ TISSUE (PAPER CUT)
DEEP SOMATIC-LIGAMENTS, BONE,TENDONS,NERVES (ANKLE SPRAIN) VISCERAL-ORGANS (BOWEL OBSTRUCTION) RADIATING-EXTENDS TO TISSUE (CHEST PAIN THAT RADIATES TO NECK AND SHOULDERS) REFERRED-PAIN FELT IN BODY SOMEWHERE OTHER THAN THE SITE OF THE STIMULI CAUSING PAIN. NEUROPATHETIC-SHOOTING OR STABBING PAIN DUE TO DISTURBANCE OF NERVOUS SYSTEM DUE TO INFECTION OR DISEASE PHANTOM PAIN-SENSATION PERCIEVED IN A BODY PART NO LONGER THERE PHANTOM SENSATION-FEELING THAT A MISSING BODY PART IS STILL THERE INTRACTIBLE-SEVERE PAIN THAT DOESN'T GO AWAY (CANCER PAIN) |
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PCA
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PATIENT CONTROLLED ANESTHESIA
NO ONE CAN USE BUT PT. |
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MEASURING PAIN
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PAIN SCALE (SUBJECTIVE)
NUMERICAL FACIAL GRIMACING,ROCKING,CRYING |
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WHEN A PT IS IN PAIN, WHAT ARE SOME PHYSICAL CHARACTERISTICS?
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RESTLESS
DIAPHORESIS INCREASED BP, PULSE, RESP. PALLOR DILATED PUPILS MUSCLE TENSION N&V GRIMACING,ROCKING,CRYING CAN'T CONCENTRATE |
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S/E OF OPIATES
NURSING RESPONSIBILITIES |
RESPIRATORY DEPRESSION
SEDATION CHECK RESP RATE Q1 HR FOR 24 HR TO ENSURE PROPER BREATHING CHECK SEDATION LEVEL **IF PT HAS LESS THAN 10-12 BREATHS PER MINUTE, THE PT NEEDS TO BE VENTILATED BETTER AND DR.CALLED |
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SLEEP DISORDERS
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SLEEP APNEA-CESSATION OF BREATH LASTING 10 SEC OR MORE
INSOMNIA- MOST COMMON. DIFFICULTY FALLING OR STAYING ASLEEP SLEEP DEPRIVATION - DECREASE IN QUALITY AND QUANTITY OF SLEEP HYPERSOMNIA -EXCESSIVE SLEEP (ESP.DAYTIME)R/T DEPRESSION,ILLNESS,ANXIETY NARCOLEPSY-SUDDEN WAVE OF SLEEPNESS THAT OCCURS DURING THE DAY PARASOMNIAS -BRUXISM,SLEEPWALKING,SLEEP TALKING, NIGHT TERRORS, ENURESIS, RESTLESS LEG SYND. |
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HYPNOTIC MEDS: EXAMPLES, HOW LONG SHOULD THEY BE USED, WHAT SHOULD PT. KNOW BEFORE TAKING, WHAT S/E
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BENZODIAZIPINES
USE TEMPORARILY NO ALCOHOL,DRIVING GIVES YOU A HANGOVER FEELING INTERFERES WITH REM CYCLE |
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THE BEST MEASURE OF SLEEP IS
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FEELING RESTED
EVERYONE IS DIFFERENT OLDER ADULTS ONLY NEED 6 HR YOUNGER ADULTS NEED 8 HR CHILDERN NEED 10-12 HR |
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RESTRAINTS- WHAT NEEDS TO BE DONE BEFORE APPLYING THEM?
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ASSESS PT.FIRST TO TRY ALTERNATIVE MEASURES TO RESTRAINTS
HAVE A SITTER SIT W/PT. MOVE PT. TO HALLWAY WHERE THEY CAN BE WATCHED BY EVERYONE HAVE FAMILY SIT W/PT BED ALARM |
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WHAT MUST YOU HAVE BEFORE APPLYING RESTRAINTS
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DR ORDER
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NURSING RESPONSIBILITYS REGARDING RESTRAINTS
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REMOVE Q2 HR
ROM EXERCISES AFTER REMOVED 2 FINGER CHECK FOR TIGHTNESS CHECK Q 15 MINS AFTER APPLYING THEM |
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IF A PT IS AMBULATING AND BECOMES DIZZY, WHAT SHOULD YOU DO?
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GET THEM IN A SAFE POSITION
MAY NEED TO LOWER THEM TO THE FLOOR IF THERE IS NO WHERE TO SIT |
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WHAT ARE SOME NURSING INTERVENTIONS FOR A PT. WHO HAS POOR VISION R/T PT. SAFETY
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GIVE GOOD LIGHTING
REMOVE OBSTRUCTIONS GOOD COMMUNICATION SKILLS IF BLIND - PUT FOOD IN A CLOCK-WISE POSITION |
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IF A PT HAS DECREASED TACTILE SENSATION IN FEET WHAT SHOULD YOU DO TO ENSURE SAFETY?
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NON-SKID SOCKS
PROTECT HEELS WITH BOOTIES |
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#1 CAUSE OF ACCIDENTS WITH TODDLERS
SCHOOL AGE CHILDREN HIGH SCHOOL CHILDREN OLDER ADULTS |
TODDLER -POISONING
SCHOOL AGE - HEAD INJURY HIGH SCHOOL - MVA'S,DRUG/ALCOHOL,MRSA OLDER ADULT- FALLS R/T DIZZINESS,SENSORY OVERLOAD,HYPOTENSION |
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WHEN HELPING A PT.AMBULATE, STAND ON WHICH SIDE?
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PT. WEAK SIDE
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A PT SHOULD AMBULATE WITH THE CANE ON WHICH SIDE OF BODY
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STRONG SIDE
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PATIENT MOST SUCCEPTBALE TO F/E IMBALANCE?
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INFANTS - 80% OF TBW IS FLUID. MORE FEVERS,BODY SURFACE AREA IS LARGER, AND HIGHER METABOLISM
OLDER ADULT-50% OF TBW IS FLUID AND THEY HAVE DECREASED SENSITIVITY TO THIRST,SMALL LOSSES OF WATER HAVE GREAT IMPACT,PANCREATIC AND KIDNEY FUNCT IS DECREASED **ALSO AT RISK FOR F/E IMBAL. BURN VICTIMS AND POST OP PT. |
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PEOPLE LOSE ACID THROUGH WHAT?
BASE? |
ACID - LOST THROUGH VOMIT
BASE - LOST THROUGH DIARRHEA POTASSIUM IS LOST IN BOTH CASES. |
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POST OP PT IS AT RISK FOR F/E IMBALANCE. WHAT NURSING INTERVENTION IS ESSENTIAL TO MAINTAIN PROPER F/E BAL.
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TURN Q2 HRS POST-OP WILL STIMULATE THE KIDNEY
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WHAT TYPE OF DRUG IS LASIX AND IF A PT IS TAKING LASIX, WHAT NEEDS TO BE MONITORED?
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LASIX IS A DIURETIC (INCREASES URINE SECRETION,DECREASES EDEMA, USED FOR PT WITH HTN)
MONITOR POTASSIUM LEVEL HYPOKALEMIA (POTASSIUM LOSS) |
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IF POTASSIUM SUPPLEMENT IS ORDERED, WHAT SHOULD THE NURSE DO BEFORE GIVING IT?
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LOOK AT LABS TO SEE WHAT POTASSIUM LEVEL IS
MONITOR FOR ARRYTHMIAS MAKE SURE THEY HAVE GOOD KIDNEY/RENAL FUNCTIONING (PT WITH IMPAIRED RENAL FUNCT SHOULD NOT GET POTASSIUM) REMIND PT TO EAT YELLOW FRUITS/VEGGIES |
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5 SIGNS AND SYMPTOMS OF FVE
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EDEMA
JVD MOIST CRACKLES CONGESTED COUGH SOB TACHYCARDIA HIGH BP DECREASED BUN (HIGH IS DRY) |
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WHEN MONITORING FVE, WHAT INTERVENTIONS SHOULD NURSE TAKE
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DAILY WEIGHT
2.2 LBS = 1 LITER OF FLUID NURSING DIAGNOSIS R/T FVE: ALT IN FV R/T DISEASE PROCESS AEB S/S OF FVE |
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RESPIRATORY ACIDOSIS. WHAT IS IT AND WHAT KIND OF PT IS AT RISK FOR IT?
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INCREASED CO2 IN LUNGS DUE TO HYPOVENTILATION. CAN LEAD TO A COMA
PT. WITH BRADYPNEA IS AT RISK FOR IT PT. WITH CHRONIC LUNG DISEASE OR INFECTION WHO IS PRONE TO AN ACIDOTIC STATE. |
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TX FOR RESPIRATORY ACIDOSIS
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VENTILATE, VENTILATE, VENTILATE
DEEP BREATHS AMBU BAG |
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RESPIRATORY ALKALOSIS
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LOSS OF CO2 DUE TO HYPERVENTILATION
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S/S OF RESPIRATORY ALKALOSIS
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ANXIETY
NUMBNESS,TINGLIING |
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TX FOR RESPIRATORY ALKALOSIS
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SLOW BREATHING AND RE-BREATH CO2, PURSE LIP BREATHING
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WHAT LAB TEST WILL INDICATE F/E IMBALANCE
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CHEM 7
BASIC METABOLIC PANEL H&H ABG SERUM OSMOLALITY URINE SG BUN |
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WHAT IS THE NORMAL LEVEL FOR SERUM OSMOLALITY
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280-295
INCREASED=DEHYDRATION DECREASED=OVERHYDRATION |
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HOW MUCH FLUID/DAY SHOULD WE CONSUME?
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2500ML/DAY IS ADEQUATE
DOESN'T HAVE TO BE ALL WATER. CAN BE JUICE ALSO |
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TPN FEEDINGS - WHAT ARE THEY
WHAT CONDITIONS WARRENT THEM |
HYPERTONIC SOLUTIONS INJECTED INTO VEINS WHERE THEY ARE DILUTED BY THE BLOOD.
USED FOR PEOPLE WHO HAVE A NEGATIVE NITROGEN BAL EX-MALNOURISHED,BURN VICTIMS,BOWEL DISEASE, ETC. |
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TPN FEEDINGS ARE HYPERTONIC AND HIGH IN GLUCOSE, SO INFUSIONS ARE STARTED SLOW TO PREVENT HYPERGLYCEMIA. WHAT SHOULD BE MONITORED?
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BLOOD GLUCOSE Q6HRS.(SLIDING SCALE)
FVE (WATER FOLLOWS SALT) BP PULSE |
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S/S FVD
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PULSE: INCREASED,WEAK,RAPID,TACHYCARDIA
JVD:ABSENT BP:DECREASED LUNGS:CLEAR SKIN:WARM,DRY,SLUGGISH TURGOR WT./EDEMA:WT.LOSS,NO EDEMA U/O:DECREASED,MONITOR LESS THAN 30ML/HR NEURO:DISORIENTED,LETHARGIC LABS:BUN,HCT,URINE SG -ALL INCREASED |
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WHEN A PERSON IS ON TUBE FEEDING, WHAT SHOULD BE MONITORED?
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INFECTION. MICRO-ORGANISMS LIKE SUGAR.
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WHY SHOULD YOU DISCONTINUE TUBE FEEDINGS SLOWLY?
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TO PREVENT HYPERINSULINEMIA AND HYPOGLYCEMIA.
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DEMENTIA VS DELERIUM
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DEMENTIA: L/T, SLOW ONSET, CHRONIC, IRREVERSIBLE
DELERIUM: TEMPORARY, USUALLY RAPID ONSET, CAN OCCUR WITH DRUG TOXICITY |
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PRESBYOPIA
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LOSS OF THE ABILITY TO SEE CLOSE OBJECTS AS A RESULT OF AGING
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NURSING INTERVENTIONS R/T PRESBYOPIA
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NIGHTLIGHT
LARGE PRINT EYE GLASSES MAG. GLASSES NO PM DRIVING PHONE W/LARGE #'S |
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PRESBYCUSIS
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LOSS OF HEARING D/T AGING
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NURSING INTERVENTIONS R/T PRESBYCUSIS
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GET AT THEIR EYE LEVEL SO THEY CAN READ LIPS
DON'T YELL LOW-PITCHED VOICE |
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PHYSIOLOGICAL CHANGES WITH OLDER ADULT
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LOSE HAIR
WRINKLIING DECREASED GI MOTILITY DECREASED ACID PRODUCTION POOR DENTITION DECREASED LUNG EXPANSION NONPRODUCTIVE COUGH FOR MUCOUS REMOVAL |
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HEALTH PROMOTION FOR OLDER ADULT
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FLU VACCINE ANNUALLY
PNEUMOCOCCAL VACCINE SCREENINGS SUCH AS: COLONOSCOPY DIGITAL RECTAL PROSTATE MAMMO PAP LIPID PANEL,GLUCOSE HEARING/VISION DEPRESSION SCREENING |
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FACTORS THAT EFFECT SKIN INTEGRITY FOR THE OLDER ADULT
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DEHYDRATION
PROFUSION - VASCULAR INSUFFICIENCY INABILITY TO TURN THEMSELVES IMMOBILITY EMACIATION (NO BODY CUSHION) |
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ERICSONS STAGES
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INFANCY (BIRTH-18MOS): TRUST VS MISTRUST
TODDLER (18MOS-3YRS): AUTONOMY VS SHAME AND DOUBT EARLY CHILDHOOD (3-5 YRS): INITATIVE VS GUILT EARLY SCHOOL (6-12YRS): INDUSTRY VS INFERIORITY ADOLESCENCE (12-20YRS): IDENTITY VS ROLE CONFUSION EARLY ADULTHOOD (18-25YRS): INTIMACY VS ISOLATION MIDDLE-AGED ADULTS(25-65YRS): GENERATIVITY VS STAGNATION OLDER ADULTS(65-DEATH):INTEGRITY VS DESPAIR |
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POLYPHARMACY IS WHEN A PT. TAKES A LOT OF DRUGS.WHAT MAKES THE OLER ADULT SUCCEPTIBLE TO PROBLEMS R/T THIS?
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RISK FOR DRUG INTERACTIONS
OLDER A. HAVE DECREASED GLOM.FILTRATION AND IMPAIRED LIVER METABOLISM |
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MALPRACTICE CLAIM MUST HAVE WHAT 4 ELEMENTS TO AHVE A VALID CLAIM
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DUTY OWED
DUTY BREACHED DAMAGES TO PLAINTIFF DIRECT CAUSE |
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TO AVOID BEING SUED, WHAT ARE SOME THINGS THE NURSE SHOULD DO?
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DOCUMENT
ALWAYS FOLLOW STD OF CARE BE NICE TO PT.FAMILY |
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IF A NURSE FLOATS TO ANOTHER UNIT, WHAT ARE SOME THINGS SHE CAN DO TO PREVENT A POTENTIAL LIABILITY D/T LACK OF EXPERIENCE ON THAT UNIT?
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ASK FOR ORIENTATION
WORK TOGETHER AS A TEAM ASK TO BE ASSIGNED TO AN EXPERIENCED PERSON **IF YOU WALK OUT THAT IS ABANDONMENT |
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WHEN TAKING A PHONE ORDER FROM AN MD, WHAT SHOULD YOU DO TO AVOID THE RISK OF A MISTAKE
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ALWAYS REPEAT ORDER BACK
ALL ORDERS WRITTEN,DATED,TIMED VERBAL PHONE ORDER -MD 24 HRS TO SIGN CLARIFY ORDERS-IF IN QUESTION, NOTIFY SUPERVISOR AND CALL DR. IF IT'S THE MIDDLE OF THE NIGHT, HAVE 2ND NURSE ON THE LINE TO VERIFY |
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INFORMED CONSENT CRITERIA
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NO ABBREVIATIONS
18 YRS OLD EMANCIPATED MINOR OR PREG MINOR IF PT. SEDATED-CANT SIGN IF LEGALLY INCOMPETENT, A LEGAL GUARDIAN OR POA MAY SIGN IF PT DEAF, GET INTERPRETER IF EMERGENCY-PROCEEDURE IS DONE W/O CONSENT TO SAVE A LIFE. MD MUST ANSWER Q'S |
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TYPES OF PROBLEM ORIENTED RECORDING
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SOAP
PIE FOCUS |
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SOAP DOCUMENTATION
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SOAP:
SUBJECTIVE-WHAT PT STATES OBJECTIVE-MEASURED AND OBSERVED ASSESSMENT-DX.BASED ON DATA PLAN-WHAT NURSE PLANS TO DO I AND E FOR INTERV. AND EVAL |
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PIE DOCUMENTATION
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LIKE SOAP BUT PIE HAS A NURSING ORIGIN
P-PROBLEM OR NURSING DX I-INTERVENTION OR ACTION TAKEN E-EVALUATION-EACH PROB. IS EVAL. AT LEAST ONCE Q8 HOURS |
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FOCUS DOCUMENTATION
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USES A FOCUS COLUMN TO INCL. TOPICS THAT INVOLVE ASPECTS OF A PT. AND CARE
D-DATA A-ACTIONS R-RESPONSE ALLOWS FOR DOC IN ANY SITUATION |
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CBE OR CHARTING BY EXCEPTION
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NORMAL FINDINGS AND STANDARDS OF PRACTICE ARE NORMS.
ONLY ITEMS OUTSIDE THE NORM IS CHARTED IN NARRATIVE FORM DECREASES CHARTING TIME BUT PREVENTATIVE AND WELLNESS FACTORS ARE NOT DOC. LENGTHY PREP AND TRAINING TIME REQ. |
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GUIDELINES FOR PROPER RECORDING
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BE LEGIBLE
DON'T MAKE SPELLING MISTAKES CHART FOR YOURSELF AVOID ABBREVIATIONS YOU DON'T KNOW DON'T GENERALIZE AVOID PERSONAL OPINONS |
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WHEN INTERVEWING PT. WHAT KIND OF QUESTIONS SHOULD YOU ASK TO GET A STATEMENT OTHER THAN YES OR NO
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OPEN ENDED
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3 MOST COMMON TYPES OF DRAINS AND BRIEF DESCRIPTION
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JACKSON PRATT: CLOSED DRAINAGE SYSTE, BULB DEVICE FOR COLLECTION, BULB IS SQUEEZED THEN SEALED AND DRAIN IS SUTURED ONTO SKIN
HEMOVAC: CLOSED DRAINAGE SYSTEM, SPRING LOADED CONTAINER FOR COLLECTION, SUTURED ONTO SKIN, LARGER THAN JP PENROSE: USES GRAVITY, NO COLLECTION DEVICE (DRESSING IS COLLECTION DEVICE), LATEX DEVICE PLACED INTO WOUND |
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DEBRIDEMENT
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REMOVAL OF DEAD,NECROTIC TISSUE FROM A WOUND
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WHAT ARE METHODS OF DEBRIDEMENT?
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MECHANICAL
BIOCHEMICAL SHARP AUTOLYTIC |
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MECHANICAL DEBRIDEMENT
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IRRIGATION TO FLUSH AND CLEANSE WOUND TO REMOVE DEAD DEBRIS
WHIRLPOOL BATH CAN BE USED FOR LARGER WOUNDS WET TO DRY DRESSING IS APPLIED WHEN DAMP AND REMOVED WHEN DRY |
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IF A NEW PT WITH AN EXISTING WOUND COMES IN, WHAT SHOULD BE DONE AND WHY
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DOCUMENT. IT SERVES AS A BASELINE
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WHY WOULD YOU APPLY HEAT TO A WOUND?
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HEAT ENCOURAGES VASODIALATION (CAUSES BLOOD TO GO TO THE SITE WHICH IINCREASES CAP. PERM)
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THE USE OF AN INCENTIVE SPIROMETER DOES WHAT
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INCREASES ENDOTHORAIC NEGATIVE PRESSURE
EXPANDS AIRWAY |
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DIAPHRAGMATIC BREATHING
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CONSCIOUS EFFORT BREATHING
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WHAT IS MONITORED WHEN ADMINISTERING HEPARIN
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PTT-PARTIAL THROMBOPLASTIN TIME.
NORMAL IS 30-45 SEC.(IT'S THE TIME NEEDED TO FORM A CLOT) WHEN A PT. IS ON HEPARIN THIS TIME IS EXTENDED TO 50-70 SEC |
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WHAT IS MONITORED WHEN ADMINISTERING COUMADIN
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PT-PROTHROMBIN TIME
NORMAL IS 9-11 SEC WITH COUMADIN, THE RANGE IS 1-1/2 - 2 TIMES THAT |
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NEEDLE GUAGES FOR IM,SUBQ
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IM - 21-23 GUAGE
SUB Q - 25 |
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IM INJECTION -WHAT ANGLE
SUB Q? |
IM:
90 DEGREE SPREAD SKIN FLAT SUBQ: 45-90 DEGREE PINCH SKIN |
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WHAT ARE THE SITES FOR IM INJECTIONS
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DELTOID
DORSOGLUTEAL VASTUS LATERALIS RECTUS FEMORIS |
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WHAT ARE THE SITES FOR SUBQ INJECTIONS
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ABDOMEN
ARMS ANT THIGH UPPER BACK DORSOGLUTEAL |
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LOCAL COMPLICATIONS OF IV THERAPY CAN CONSIST OF WHAT?
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INFLILTRATION-SEEPAGE OF FLUID INTO SURROUNDING TISSUE
PHLEBITIS-INFLAMATION OF VEIN HEMATOMA-SWELLING W/BLOOD VENOSPASM-SPASM OF VEIN,SHARP PAIN |
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SEPTICEMIA
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SYSTEMIC INFECTION THAT CAN BE RELATED TO POOR IV CARE
S/S: FEVER,SWEATING,N/V,ADB.PAIN,HYPOTENSION,TACHYCARDIA,ALT. MENTAL STATUS. INTERVENTIONS: START NEW IV AND NOTIFY MD, OBT. BLOOD CULTURES, ADMIN. MEDS AS ORDRED. |
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TYPES OF SYSTEMIC INFECTIONS R/T IV THERAPY
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AIR EMBOLISM -LG AMT OF AIR ENTERED IV SYSTEM
SPEED SHOCK -REACTION TO MEDS. S/S: IRREG PULSE,HYPOTENSION,CHEST PAIN,DIZZINESS,SHOCK PROGRESSES (MED EMERGENCY) CIRCULATORY OVERLOAD: FVE RT TOO MUCH FLUID GIVEN IN A SHORT PERIOD OF TIME INTERV: DECREASE IV RATE, PLACE PT IN HIGH FOWLERS PULM EDEMS: LUNGS FILLED W/ FLUID, PT CANT BREATHE S/S: SOB,LABORED BREATH.,FROTHY PINK SPUTUM INTERV: O2 THERAPY, GIVE MEDS CATH EMBOLISM: CATH BREAKS AND TRAVELS INTO VEIN S/S: SHARP SUDDEN PAIN AT SITE, CHEST PAIN,TACHYCARDIA,SOB INTERV: TOURNIQUET ABOVE ELBOW,CONTACT DR.,VENOGRAM AT RADIOLOGY |
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NURSING RESPONSIBILITIES WHEN MONITORING IV SITE
HOW OFTEN SHOULD TUBE, SOLUTION,AND BAG BE CHANGED |
SITE ASSESSMENT-SHOULD BE CLEAN AND DRY
CHANGE IV SOLUTION Q24 HR CHANGE TUBE Q72 HR CHANGE IV BAG Q 24 HR ALWAYS USE STERILE DRY DRESSING OVER SITE |
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ISOTONIC SOLUTIONS WHAT DO THEY DO AND WHAT ARE THEY?
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NO MOVEMENT OF FLUID
.9% SODIUM CHLORIDE (NORMAL SALINE) LACTATED RINGERS SOL 5% DEXTROSE IN WATER .2% DEXTROSE IN WATER |
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HYPOTONIC SOLUTIONS WHAT DO THEY DO AND WHAT ARE THEY?
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FLUID SHIFTS FROM THE VASCULAR COMPARTMENT INTO THE CELL
.45% SODIUM CHLORIDE (HALF NORMAL SALINE) .33% SODIUM CHLORIDE |
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HYPERTONIC SOLUTIONS WHAT DO THEY DO AND WHAT ARE THEY?
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FLUID SHIFTS OUT OF THE CELL AND INTO VASCULAR COMPARTMENT.
5% DEXTROSE AND .45% SODIUM CHLORIDE 5% DESTROSE AND 9% SODIUM CHLORIDE 10% DEXTROSE AND .9% SODIUM CHLORIDE 3% SODIUM CHLORIDE 5% DEXTROSE IN LACTATED RINGERS |
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REGULAR INSULIN
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ONSET IS 1/2 HOUR
PEAKS 2-4 HOURS PT NEEDS TO HAVE FOOD IN THEIR SYSTEM WITHIN 30 MINS AFTER RECIEVING INSULIN AND AROUND THE TIME THE INSULIN IS PEAKING SO IF A PT. IS GIVEN INSULIN AT 8 AM, GIVE A SNACK AROUND 10 AM |
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NPH INSULIN
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ONSET 2-4 HOURS
PEAK 6-12 HOURS LASTS 18-20 HOURS IT'S IMPORTANT FOR PT TO HAVE LUNCH IN AROUND NOON AND ALSO A MID AFTERNOON SNACK. |
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HYPOGLYCEMIA
S/S HYPOGLYCEMIA TX tx |
BLOOD SUGAR LESS THAN 60
CONFUSION IRRATIBILITY SHOCK DIAPHORESIS RAPID PUULSE NERVOUSNESS TX: OJ, 15G. CARB AND REPEAT IN 15 MINS IF THEY CAN'T SWALLOW, D50 IS GIVEN IV OR GLUCAGON 1MG IS GIVEN IM |
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HYPERGLYCEMIA
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BLOOD SUGAR OVER 110
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5 RIGHTS OF MED ADMIN
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RIGHT:
DRUG DOSE PATIENT SITE TIME |
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NARCAN. S/S THEY NEED IT
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ANTIDOTE FOR OPIATES
S/S RESPIRATORY DEPRESSION |
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ANTIDOTE FOR COUMADIN
IF A PT. IS ON COUMADIN, WHAT FOODS SHOULD THEY AVOID |
VITAMIN K
MONITOR PROTHROMBIN TIME AND INR IF ON COUMADIN: NO GREEN LEAFY VEGGIES, FISH,LIVER,CHEDDAR,EGG YOLK *THESE FOODS CONTAIN VIT K AND WILL INTERFERE WITH COUMADIN THERAPY. PT SHOULD EITHER AVOID OR EAT IN MODERATION |
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HEPARIN ANTIDOTE
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PROTAMINE SULFATE
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HYPOVOLEMIA
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FVD
LOSS OF WATER AND ELECTROLYETS R/T: VOMITING DIARRHEA EXCESSIVE SWEATING POLYURIA FEVER NASOGASTRIC SUCTION ABNORMAL WOUND DRAINAGE |
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HYPERVOLEMIA
S/S |
FVE
S/S: WEIGHT GAIN FLUID INTAKE GREATER THAN OUTPUT FULL,BOUNDING PULSE MOIST CRACKLES, DYSPNEA SOB MENTAL CONFUSION |
