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89 Cards in this Set
- Front
- Back
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What are the tests that are typically performed in preparation for surgery? |
* ABGs, Pulse oximetry * Blood glucose * BUN, creatinine * Chest X-ray * CBC (RBCs, Hgb, Hct, WBCs, WBC diff) * Electrocardiogram * Electrolytes * hCG (pregnancy for women) * Liver Function tests (AST, ALT) * PT, PTT, INR, platelet count * Pulmonary function studies * Serum Albumin * Type and crossmatch * Urinalysis |
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What are the normal values for ABGs? |
pH: 7.35 - 7.45 PaCO2: 35 - 45 mm Hg PaO2: 80 - 100 mm Hg HCO3: 22- 26 mEq/L O2 Sat: 95 - 100% |
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What is the normal Blood Glucose value? |
Fasting: 70 - 100 Normal: Below 125 |
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What is normal BUN and creatinine? |
BUN: 7 - 20 mEq/L Creatinine: W .6 - 1.1 M .7 - 1.3 |
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What are the normal CBC values? |
RBCs: W 3.9 - 5.2 M 4.4 - 5.8 WBCs: 3.8 - 10.8 Hgb: W 12 - 15.6 M 13.8 - 17.2 Hct: W 35 - 46% M 41 - 50% Platelets: 150 - 450 |
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What are the normal electrolytes values? |
Sodium: 136 - 145 Potassium: 3.5 - 5 chloride: 97 - 107 Calcium: 8.5 - 10.3 Magnesium: 1.5 - 2.4 |
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What are the Liver function tests and what are the normal values for those? |
AST: W 0 - 31 M 0 - 37 ALT: W 0 - 20 M 0 - 35 |
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What are the normal PT, PTT, INR and platelet count values? |
PT: 10 - 12 seconds PTT: 30 - 45 seconds INR: 1 - 2 |
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What is the normal serum albumin level? |
3.5 - 5 g/dL |
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What is post-op care for an NG tube and peristalsis? |
A patient is typically placed in the lateral recovery position in the PACU in case of nausea and vomiting. Patient normally remains NPO until peristalsis returns in the form of bowel sounds or or passed gas. An NG tube may be used to prevent N/V and abdominal distention. If oral intake is well tolerated, the IV infusion may be discontinued. |
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How is an adequate post-op respiratory assessment made? |
* evaluate airway patency * evaluate chest symmetry (may be seen as slowed breathing - must be checked) * evaluate the depth, rate & character of respirations * monitor O2 sat * assess for use of accessory muscles * auscultate breath sounds * note color of sputum (normally clear from trachea & throat, thick and yellowish from lungs and bronchi - if other, could be infection) |
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What are the manifestations of hypoxia? |
* tachypnea * gasping * anxiety * restlessness * confusion * rapid, thready pulse |
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What are the common causes of respiratory problems for post-op patients? |
* Atelectasis * Pneumonia |
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Why are respiratory problems common after surgery, particularly abdominal or thoracic surgery? |
The postoperative development of mucous plugs and decreased surfactant production is directly related to hypoventilation, immobility and bed rest, ineffective coughing, and history of smoking. smoking. Increased bronchial secretions occur when the respiratory passages have been irritated by the drying of mucous membranes that occurs with intubation, inhalation anesthesia, and dehydration. |
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What is the nursing assessment for a post-op patient's urine? |
* Color * Amount * Odor * Assess indwelling catheters for patency |
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What should urine output be for a post-op patient when they being urinating again? How long before the patient is urinating again? |
* .5mL/kg/hr
* 6 - 8 hours after surgery (if not, scan bladder for fullness) |
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How can a nurse aid a patient to void after a sufficient amount of time has passed after surgery? |
* Normal positioning (sitting for women, standing for men) * Reassurance * Privacy * Running water * Pouring warm water over perineum |
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If it's been 6 - 8 hours and the physician gives an order to catheterize, what should a nurse do? |
1. Validate the bladder is actually full 2. Palpate or scan bladder 3. Try to aid the patient in voiding 4. Try to straight-cath patient instead of an indwelling because of risk of CAUTI |
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What are the different acute transfusion reactions that can occur? |
* Acute hemolytic Reaction * Febrile, nonhemolytic reaction * Mild allergic reaction * Anaphylactic and severe allergic reaction * Circulatory Overload reaction * Sepsis Reaction |
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What are the manifestations of an acute hemolytic reaction to a blood transfusion? |
In first 15 minutes * chills & fever* low back pain * flushing * tachycardia * hypotension * vascular collapse * hemoglobinuria * acute jaundice * dark urine & acute kidney injury * bleeding * shock * cardiac arrest * DIC * death |
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What is the management of an acute hemolytic reaction to a blood transfusion? |
* Treat shock & DIC if present * draw blood slowly for testing * send urine to lab * Maintain BP w/IV colloid solutions * Give diuretics to maintain urine flow * Insert indwelling catheter to measure urine * Do not transfuse until blood bank has given newly crossmatched units |
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What are the manifestations of a febrile nonhemolytic reaction to a blood transfusion? |
* sudden chills * rigors * fever * headache * flushing * anxiety * vomiting * muscle pain |
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What is a febrile, nonhemolytic reaction to a blood transfusion? |
A sensitization to donor WBCs, platelets or plasma proteins. |
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What is the management of an a febrile, nonhemolytic reaction to a blood transfusion? |
* Give antipyretics as prescribed (avoid acetaminophen in thrombocytopenic patients) * Do not restart transfusion unless physician orders |
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What is a mild reaction to a blood transfusion? |
A sensitivity to foreign plasma proteins. Common in patients with allergies. |
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What are the manifestations of mild reaction to a blood transfusion? |
* Flushing * Pruritis * Urticaria |
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What is the management of an a mild reaction to a blood transfusion? |
* Give antihistamines, corticosteroid or epinephrine as ordered * If symptoms are mild and transient, transfusion may be restarted slowly with physician's order * Do not restart if fever or pulmonary symptoms develop |
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What are the manifestations of anaphylactic and severe allergic reaction to a blood transfusion? |
* Anxiety * Urticaria * dyspnea * wheezing * progressing to cyanosis * bronchospasm * hypotension * shock * Possible cardiac arrest |
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What is the management of a circulatory overload reaction to a blood transfusion? |
* Place patient upright with feet in a dependent position (90 degree angle)
* Obtain chest X-ray STAT if ordered * Administer prescribed diuretics, O2 & morphine * Phlebotomy may be indicated |
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What is the management of anaphylactic and severe allergic reaction to a blood transfusion? |
* Initiate CPR if indicated * Have epinephrine ready for injection * Antihistamines, corticosteroids, Beta-adrenergic antagonists may be prescribed * Do not start transfusion |
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What is a Circulatory Overload reaction to a blood transfusion? |
When the fluid is administered faster than the circulation can accommodate. People with cardiac or renal disease are at risk. |
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What are the manifestations of a circulatory overload reaction to a blood transfusion? |
* Cough * dyspnea * pulmonary congestion * adventitious breath sounds * headache * hypertension * tachycardia * distended neck veins |
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What are the manifestations of a sepsis reaction to a blood transfusion? |
* rapid onset of chills * high fever * vomiting * diarrhea * marked hypotension * shock |
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What is the management of a sepsis reaction to a blood transfusion? |
* obtain culture of patient's blood and send bag with remaining blood and tubing to blood bank for further study * Treat septicemia as directed (antibiotics, IV fluids, vasopressors) |
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How is an acute hemolytic reaction to a blood transfusion avoided? |
visually comparelabel on sample collection andblood component with patientidentification |
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How is a febrile, nonhemolytic reaction to a blood transfusion avoided? |
* Consider leukocyte-reduced bloodproducts (filtered, washed, orfrozen) for patients with a historyof two or more such reactions. * Give acetaminophen ordiphenhydramine (Benadryl)30 min before transfusion. |
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How is a mild allergic reaction to a blood transfusion avoided? |
* Treat prophylactically withantihistamines. * Consider washed RBCs andplatelets. |
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How is an anaphylactic and severe allergic reaction to a blood transfusion avoided? |
* Transfuse extensively washed RBCproducts from which all plasmahas been removed. * Use blood from IgA-deficient donor. |
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How is a circulatory overload reaction to a blood transfusion avoided? |
* Adjust transfusion volume and flowrate based on patient size andclinical status. * Have blood bank divide future unitsinto smaller aliquots for betterspacing of fluid input. |
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How is a sepsis reaction to a blood transfusion avoided? |
Collect, process, store, andtransfuse blood productsaccording to blood bankingstandards and infuse within 4 hrof starting time. |
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What is a sepsis reaction to a blood transfusion? |
Transfusion of bacteriallyinfected bloodcomponents. |
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What are the causes for ECF volume deficit? |
• ↑Insensible water loss orperspiration (high fever,heatstroke) • Diabetes insipidus • Osmotic diuresis • Hemorrhage • GI losses: vomiting, NG suction,diarrhea, fistula drainage • Overuse of diuretics • Inadequate fluid intake • Third-space fluid shifts: burns,intestinal obstruction |
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What are the clinical manifestations of ECF volume deficit? |
• Restlessness, drowsiness,lethargy, confusion • Thirst, dry mucous membranes • Decreased skin turgor,↓capillary refill • Postural hypotension,↑pulse,↓CVP • ↓Urine output, concentratedurine • ↑Respiratory rate • Weakness, dizziness • Weight loss • Seizures, coma |
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Analyze these ABGs: pH 7.30 PaCO2 60 HCO3 26 PaO2 88 |
Uncompensated Respiratory acidosis |
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Analyze these ABGs: pH 7.34 PaCO2 60 HCO3 34 PaO2 68 |
Respiratory acidosis with partial compensation |
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Analyze these ABGs: pH 7.55 PaCO2 27 HCO3 16 PaO2 98 |
Respiratory Alkalosis with partial compensation |
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Analyze these ABGs: pH 7.33 PaCO2 34 HCO3 16 PaO2 100 |
Metabolic acidosis with partial compensation |
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What is the Parkland Formula and how is it applied? |
A formula to calculate the fluid requirements of a burn victim in the first 24 hours. It is given as half in the first 8 hours and then half given over the next 16. 4 mL Lactated Ringers/ kg/ TBSA = total requirements TBSA = total body surface area that is burned |
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What is the rule of nines? |
It is a way to estimate the Total Body Surface Area in a way that's easy to remember. Each leg is approximately 9% (on one side), Each arm is 4.5%, the trunk is 18% and the head is 4.5% |
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Using the rule of nines: If a patient had circumferential burns on both legs, burns on the groin and front of the chest and abdomen, what is the TBSA that is burned? |
55% Circumferential of both legs = 36% (18 x 2) Groin = 1% Anterior surface of Chest and abdomen = 18% 36 + 18 + 1 = 55% |
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The physician has ordered a Dobutamine drip at 5mcg/kg/min. The drip is available as 1000mg/250ml. The patient weighs 169lbs. What is the ml/hr the drip will infuse? Round to the nearest tenth A. 5.7 ml/hr B. 5.76 ml/hr C. 5.77 ml/hr D. 5.8 ml/hr |
D. 5.8 ml/hr 169/2.2 = 76.82kg 5mcg = .005mg .005mg x 76.82kg x 60min = 23.046mg 23.046mg x 250ml/1000mg = 5.7615ml/hr Rounded to the nearest 10th is 5.8ml/hr |
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The nurse cares for a patient with SIADH. The nurse is MOST concerned if what is observed? A. The patient's serum sodium level is 137 mEq/L B. The patient is eating ice chips C. The patient is oriented to person place and time D. The patient is lying in bed with the rails up |
B. The patient is eating ice chips Water is restricted because of water excess. |
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What are the clinical manifestations of SIADH? |
* decreased LOC (cerebral edema, inc. ICP) * seizures * coma * hyponatremia |
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Why is skin turgor not always a reliable predictor of fluid deficit? |
In older people, skin loses it's elasticity and tends to "tent" even if hydration is not an issue. |
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When should a patient stop smoking prior to surgery to decrease the risk of complications during and after surgery? How does smoking affect the risks? |
6 weeks. The longer and the more a person smokes, the greater the risk of complications during or after surgery. |
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In the operating room, how are the roles different for the scrub nurse and the circulating nurse? |
The scrub nurse dons sterile gloves and gown and remains in the sterile field. The circulating nurse remains in the unsterile field. |
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What is malignant hyperthermia? |
A rare disorder characterized by hyperthermia with rigidity of skeletal muscles that can result in death. The manifestations are variable but the fundamental defect is hypermetabolism of skeletal muscle which affects calcium and leads to muscle contracture, hyperthermia, hypoxemia, lactic acidosis, and hemodynamic and cardiac alterations. |
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What is the emergent care of a burn patient? |
* Fluid therapy * Wound care * Pain and anxiety * PT & OT * Nutritional therapy * Respiratory therapy * Psychosocial care |
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What fluid therapy needs are assessed in emergent care of a burn patient? |
* Assess fluid needs * Begin IV fluid replacement * Insert Indwelling urinary catheter * Monitor urine output |
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What wound care needs are assessed in emergent care of a burn patient? |
* Start Daily shower and wound care * Debride as necessary * Assess extent and depth of burns * Administer tetanus toxoid or tetanus antitoxin |
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What PT and OT needs are assessed in emergent care of a burn patient? |
* Patient needs to be placed in a position that prevents contractures and reduces edema * assess need for splints |
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What respiratory needs are assessed in emergent care of a burn patient? |
* Assess oxygenation needs * Provide supplemental O2 as needed * intubate if necessary * Monitor respiratory status |
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What psychosocial needs are assessed in emergent care of a burn patient? |
Provide support to patient andcaregiver during initial crisis phase. ` |
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What special care is given when the face is burned? |
It is often covered with ointment and gauze but not wrapped to limit pressure on delicate facial features. The ears, if burned, should not be on pillows. A rolled towel should be placed under the neck instead. |
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What special care is given to the arms and hands when burned? |
The arms are elevated or plastic covered foam wedges to minimize edema. Hands may be put in splints to maintain them in a position of function. The splints need to be removed frequently for skin care and inspection. |
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What foods can help replace the nutrients needed for erythropoiesis? |
* Red meats * Green leafy vegetables * legumes * eggs * dairy foods * potatoes |
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How often should tracheostomy care be performed? |
Three times a day and as needed? |
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What are the voice restoration options after a laryngectomy? |
* Esophageal speech (swallowing air, trapping it in the esophagus and releasing it to create sound)
* electrolarynx (hand-held batter powered device) * transesophageal puncture (a fistula is created between the esophagus and trachea, air vibrating against the esophagus and is formed into words by moving the tongue and lips) |
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What is the treatment for epistaxis? |
* Place patient in sitting position with head tilted forward * apply direct pressure by pinching the entire soft lower portion of the nose against the nasal septum for 10 to 15 minutes (if bleeding doesn't stop for 20 minutes, seek medical attention) * nasal tampon may be used impregnated with an anesthetic and/or vasoconstrictive agents (if bleeding still does not stop, packing may be used) |
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Name some nurse assessments for pneumonia. |
* Health - past and present (DM, COPD, allergies) * Medications * recent surgeries * Health habits (smoking, diet, level of exercise) * Pain with breathing, chest pain, sore throat) * fever * tachypnea * crackles * tachycardia |
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If a patient has pneumonia, what is recommended about fluid intake? |
* Increase fluids to 3000L/day * recommend the fluids be warm * recommend the fluids be ingested between meals instead of with meals |
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What is the typical treatment for asthma? |
Drug therapy (anti-inflammatories and bronchodilators) |
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How do you calm an asthma patient during an attack? |
gain eye contact and in a calm but stern voice, teach them pursed lip breathing (exhaling through pursed lips making the exhalation 3 times longer than inhalation) |
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What purpose does serum creatinine serve? |
It is a reliable indicator of kidney function. For men, the levels should be .5 - 1.5 and for women, they should be .6 - 1.2. If they are higher, it shows that kidney function has been impaired. It could show a transient rise from dehydration. |
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How is an accurate baseline Blood Pressure measured? |
* Patient should not have smoked, exercised or drank caffeine within 30 min. * Patient to sit up in chair with legs uncrossed and feet on the floor * Patient is to relax and not talk for 5 minutes * Use proper cuff size and proper placement * Use an accurate machine * Deflate cuff 2 - 3 mmHg/sec * Record the SBP and the DBP. Note the SBP when the first of twoor more Korotkoff sounds is heard and the DBP when sounddisappears * average 2 or more readings * Provide patient with reading, goal BP and recommendations |
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What are the characteristics of MI chest pain? |
Severe, immobilizing chest pain not relieved by rest, position change, or nitrate administration is the hallmark of an MI. Persistent and unlike any other pain, it is usually described as a heaviness, pressure, tightness, burning, constriction, or crushing. Common locations are substernal, retrosternal, or epigastric areas. When epigastric pain is present, the patient may relate it to indigestion and take antacids without relief. The pain may radiate to the neck, lower jaw, and arms or to the back. It may occur while the patient is active or at rest, asleep or awake. However, it commonly in the early morning hours. It usually lasts for 20 minutes or longer and is more severe than usual anginal pain. |
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What are serum cardiac markers? |
Proteins released into the blood from necrotic heart muscle after an MI. They are: * Cardiac specific Troponin T * Cardiac specific Troponin I (both troponins increase 4 - 6 hours after MI, peak at 10 - 24 hours and return to baseline 10-14 days) * Creatine Kinase (levels rise about 6 hours after MI, peak at 18 hours and return to within 24-36 hours) |
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What is used to aid in stent placing? |
Low-molecular-weight heparin is used to help keep the vessel open during stent placement |
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What are the signs and symptoms of increased right atrial pressure? |
* Jugular venous distention * hepatosplenomegaly * vascular congestion of the GI tract * peripheral edema |
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What is paroxysmal nocturnal dyspnea? |
It occurs when the patient is asleep. It is caused by the reabsorption of fluid from dependent body areas when the patient is flat. The patient awakes in a panic, has feelings of suffocation, and has a strong desire to sit or stand up. |
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When is a CHF patient eligible for hospice? |
When they are expected to live 6 months or less.
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What treatment is given for A-fib? |
Warfarin (Coumadin). |
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What are the patient instructions after a pacemaker is inserted? |
* Patient can be out of bed once stable * Patient must limit arm and shoulder activity on that side to prevent dislodging the new device until MD says it's ok * Observe site for bleeding and check incision to be sure it is intact * Note any temp elevation or pain at the site * keep incision dry for 4 days * avoid direct blows to pacemaker site * avoid high-electric output generators * No MRI (unless it's MRI proof) * Avoid standing near anti-theft devices (can walk through at normal pace) * Monitor pulse and inform MD if drops below predetermined rate * Carry pacemaker info card and current list of meds at all times * Wear a medic alert bracelet at all times |
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When is sinus bradycardia not dangerous? |
* May be a normal sinus rhythm in an aerobically trained athlete * Administration of certain drugs (beta blockers) * Valsalva maneuver * Vagal stimulation |
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What actions does a patient need to take when they've had a mitral valve replacement? |
anaphylactic antibiotics when: * having any dental procedure (cleaning or otherwise) * having a biopsy * having a tonsillectomy or adenoidectomy * have a wound infection * UTI |
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What causes Rheumatic Fever? |
Group A Streptococcal pharyngitis. |
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What does Rheumatic fever affect? |
* Heart (all layers of the heart) * skin * joints (rheumatoid arthritis) * CNS |
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What are the risk factors for an abdominal aortic aneurism? |
* age * male gender * HTN * CAD * Family history * High cholesterol * lower extremity PAD * Previous stroke * tobacco use * obesity or excess weight |
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What are the signs of peripheral artery disease? |
* Intermitten claudication * paresthesia * skin on legs is thin, shiny, taut and no hair * femoral, popliteal or pedal pulses are diminished or absent * capillary refill >3 seconds * toe nails thickened and brittle * pallor in the lower legs (esp. when elevated) * Lower leg edema * ulcers in the lower legs |
