3rd Exam Review ch. 28,35,42,10,36,40,39 -Unfreezing—When a change agent convinces members of the group to change or when guilt, anxiety, or concern can be elicited. Realizes change needs to be done. Ex: pt doesn’t believe in condoms and then decides to start using some form of birth control -Primary duty is to EDUCATE and get pts concern and involve -As a nurse, always document and check IV sites -Fluid and hear crackles and see edema = fluid volume excess related to cardiac failure as evidenced by edema or crackles over the lung field -Infiltration key identifier: pain, localized swelling, coolness, numbness, no blood return–IV fluid leaks to the surrounding tissue. Pallor around the site, decreased flow rate, and coolness. Not in the vein. -Phlebitis key identifier: redness along the vein, swelling, warmth, tenderness/pain that worsens w/added pressure, hardening of vein, darkening of skin over the vein, throbbing, burning–inflammation of the vein can lead to a clot (thrombophlebitis) -What happens if you suspect phlebitis or infiltration: Stop the infusion, remove the IV and start a new one at a new site -ICF 70% -ECF 30% -BMI: Normal 18-25 Overweight 26-30 Obese 30+ -Blood transfusion reaction usually occurs without the first 15 min You stop, notify MD, run normal saline and take down every tubing associated with blood transfusion to lab, type and cross for compatibility After getting informed consent and identify pt, check VITALS (30 min before admin blood, make sure there’s no fever therefore it’s an infection) , you check the blood type (checks), VITALS 15 min after start (reaction can occur during the first 15 min—fever, swelling, change in mental status), blood transfusion can’t go over 4 hours and must not go under an hour Always goes with normal saline with 2 sets of tubing in case of a reaction, it can’t be run on the same line as blood (white tubing). Make sure there’s a working IV site. Port is faster, peripheral is slower 80cc then speed up (most people) 2 nurses go to the lab to double check the blood When blood transfusion is completed, you do vitals, check pt and compare vitals to first two then do 30 min after -Select all that apply blood transfusion: Hang Hygiene Identify pt Read doctor order Educate Informed consent* Gloves -Jehovah witness = no blood Against their religion -Pt going for surgery but they don’t want other people's blood, he wants to use his own, donates his own blood in preparation for surgery : Autonomous transfusion (autologous transfusion) -Blood transfusion (select all that applies) — check vitals 30 min before, verify pt, wear gloves, check vitals first 15 min for a reaction, check vitals once completed and compare to the first 2. Check vitals 30 min after. -I&O should be the same Normal adult between 1500-3500 total for the day -Document everything -hypotonic: having a lesser concentration than the solution with which it is being compared -hypertonic: having a greater concentration than the solution with which it is being compared -isotonic (normal saline): having about the same concentration as the solution with which it is being compared -Chest tubes (between lungs & ribs) for air tubes are placed higher, for fluid it is placed lower. Monitor RR, vitals, check dressing, patency, integrity. Drainage in the proximal end that is inserted in the pleural space. -PCA: patient controlled analgesics pump. Pain management that lets you decide when you will get a dose of pain med. No nurse needed. -Types of leadership: Autocratique–directive, involves the leader assuming control over the decisions & activities of the group. Democratic–sense of equality among the leader & other participants, decisions and activities are shared. Laissez faire–non directive. Leader relinquished power to the group such that an outsider couldn't identify the leader in the group. Task achievement is difficult since they are working independently. Servant leadership–philosophy & set of practices that enriches the lives of individuals, builds better organizations, & creates a more caring world. Natural feeling of one wanting to serve. Quantum leadership–views organization & members as interconnected & collaborative Transactional leadership–task & reward approach. Transformational leadership–revolutionary change. Inspire & motivate others. Create stimulating practice environments & challenge themselves & others to grow personally & professionally. -Fluid balance: Sodium 135-145 mEq/L—Potassium 3.5-5.0 mEq/L -ABGs: pH 7.35-7.45—PaCO2 35-45 mmHg—PaO2 80-100 mmHg—HCO3 22-26 mEq/L -Hypokalemia–never miss the signs of weakness, leg cramps, orthostatic hypotension (less than 3.5 mEq/L) IV is always diluted & admin using an infusion device NEVER push, IM, Subcu -Hyperkalemia–greater than 5mEq/L, muscle cramps, resp distress -Hypocalcemia–less than 9mg/dL convulsions, arrhythmias (diminished pulses), numbness -Hypercalcemia–greater than 10.5mg/dL bone pain, cardiac arrest -Resp Acidosis–lungs retain CO2, Kidneys excrete hydrogen but retain HCO3 pH L 7.35, CO2 G 45. Hypoxic, L BP, H RR, H HR, sleepy, confused -Resp Alkalosis–lungs losing too much CO2, kidneys excreting HCO3 & retaining hydrogen. pH G 7.45, CO2 L 35. H RR, H HR, confused -Metabolic Acidosis–too much hydrogen & too much HCO3 in the kidneys, lungs will blow off CO2. pH L 7.35, HCO3 L 22, L BP, hyperkalemia -Metabolic Alkalosis– too much HCO3, less hydrogen in kidneys, lungs retain CO2. pH G 7.45, HCO3 G 26, L K+, L RR, tremors -NG tube: After the NG tube is placed, an X-Ray is needed to confirm before usage. Check placement, measurement of length, marking on tube, aspirate pH level, monitor CO2 to confirm placement. -Neuropathic pain: Phantom pain -Caregiver fatigue: burn out -Somatic pain reflex; deep, diffuse/scattered & originates in tendons, ligaments, bones, blood vessels & nerves. -Visceral pain: from body organs, localized -Pain: transduction (activation of pain receptors), transmission, perception, modulation of pain (prohibited or modified)---Nociceptive pain: initiated by nociceptors that are activated by injury to the peripheral tissue & is representative of normal pain process. -Pain response: Behavior- voluntary (grimacing, restlessness) Physiological- involuntary (Body; H ph) Affective- psychological (mental) -Complementary therapy: complete systems of theory & practice disease, ways to promote health, & types of treatment. Mind, body practices use a variety of techniques designed to enhance the mind’s ability to affect bodily function & symptoms (yoga, meditation) -Delegation– transfer of responsibility for the performance of an activity to another person while retaining accountability for outcome. -IV -Extensive specialized education is required before a nurse can be competent to advise patients on the use of herbs and supplements. However, nurses are finding that information about certain herbs adds a plate aspect of safety to their practice. For example, some herbs and/or supplements may interact with prescribed medications patients are taking. Ginkgo biloba, the most widely sold herb in Europe and used by many to improve memory, affects platelet function and thus should not be used concurrently with warfarin or aspirin. Some nursing pharmacology courses include information on commonly used herbs. Women who are pregnant or nursing and children should be especially cautious about using herbal supplements either alone or in mixtures, since these products can act like drugs. “Natural” does not mean safe. For example, the herbs kava and comfrey have been linked to serious liver damage. -Nonverbal communication—facial expressions, cues, grimacing -Nutrition: Constipation occurs with opioids, low fiber, dairy. Resolved with hydration, high fiber —a person has a stroke sit pt up right when assisting with feeding. Mouth care prior to feeding, if dirty they will not eat (poor oral hygiene) -Alternative therapy–stress management, aroma therapy (peppermint)(caribbean nausea), guided imagery (meditation) -With aging decreased bladder contractility may lead to urine retention -Oxygen therapy–oxygen mask removed every 2-3 hours to check the skin/dry face –if a pt is placed on oxygen indefinitely you monitor resp rate, assess chest for symmetry, observe pattern of breathing, ABGs, resp effort -Monitor resp rate, chest symmetry if pt on oxygen -After giving 2L of oxygen, you reached the limit, order req. -How to use an incentive spirometer–inhale slowly but deeply through the mouthpiece without using the nose. It is to promote lung expansion. Raise head of bed if patient is in respiratory distress -Post op therapy- airway, pulse ox -Patient in excruciating pain with cough, what should the nurse do to reduce discomfort Administer prescribed pain medication 30 minutes before encouraging cough -Monitor respirations and breath sounds: patients with COPD and emphysema -Physical assessment of pt on oxygenation, what would you monitor—resp rate, ABGs, pulse ox, symmetry, breathing pattern, effort -Once pt is on oxygen, make sure there's no smoking sign (safety fire prec) -Pulse oximetry–Pulse oximetry measures arterial oxygen saturation -Which nursing interventions post op–airway, oxygen therapy, pulse ox? -Nasal cannula up to 6L, anything higher requires a simple (low flow), partial (8-11 L) non rebreather (10-15L) mask -Promote expansion of the lungs by putting pt in fowler position for resp distress—raise head of bed don't need a MD order. Raising the bed is a nursing intervention which will help relieve stress. Pt is post op and develops pneumonia, position in fowler/semi fowler to assist with breathing, full expansion of lungs. -If pt in resp distress don't try to have convo, initiate interventions to help relieve distress -A pt with COPD, emphysema, Asthma normally have an abnormal PaCO2–partial pressure of carbon dioxide (give away for COPD), ABGs– normally has: abnormal PaCO2, ABGs Based on the partial pressure of carbon dioxide -Pt has dysphagia- difficulty swallowing– had a stroke and assist with feeding, what to do– you need to sit pt up right, provide mouth care -What disease would a obese (excess abdominal fat) person would have–cardiac disease -My plate encourages whole grains and greens with all meals. 12-3(protein) 3-6(veggie) 6-12(carb) -Patient who is not eating: Encourage family members to bring food from home that the patient enjoys -Most post op pts develop pneumonia due to immobility, if they ever have pneumonia always assess pt for atelectasis -In bed and suffer from head injury you can't turn yourself and you expose yourself for pneumonia (not moving) -Coughing, expectorate secretions you would increase fluids. 2-3 liters of fluids/day. If you want to increase expectorate secretions- increase fluid intake: 2-3 L a day. Fluid loosens. -Who would be at great risk for resp illness from environmental issue, city or country? City Person in factory or farmer? Factory -If donald has hypoxia, you'd find blue, pallor, tachy, cyanotic, SOB, clubbing of fingernails -Can't leave IV in unless getting some type of infusion they are at risk for infection -Force fluid— dehydrated, before we can do anything we have to explain to the pt why “why you must drink 2L of fluid” IV therapy- force fluid -Collecting data from home care clients, what other info aside from health status are you looking for–safety -Discharge starts on admission -Pre op post op or pregnant wmn, nurses will encourage you to hold a pillow or fold a blanket over incision or gut etc to facilitate coughing to prevent dehiscence -Encourage clients to identify and verbalize fear -DNR–do not resuscitate–have you discussed w/ or document these wishes with your family -Who has responsibility to obtain informed consent– MD, Nurse can witness and can ensure/verify that it is signed and in chart before procedure -Pt wants to remove foreskin and wants circumcision–procedure set for a day, pt then questions and as a nurse you call back MD bc pt is not ready. If Informed consent is not there, call MD -Discussing weight loss and pt says they will not eat for 2 weeks to lose 10lbs, nurses would advise not to. Educate that it'll increase metabolic rate and weight loss more difficult -If educating young adult females about folic acid deficiency- how would you educate the young mother– neural tube deficit in fetus -Nutritional assessment—ask if taking otc rx for contraindications -NPO- nothing by mouth -If pt chart has a protein calorie nutrition statement, what would you look for next, interval amt? Prostat prosource esp with a wound. Need protein—Patients chart has a protein calorie nutrition statement: Look for poor wound healing -Sleep apnea– normal get cpap mask (positive pressure that holds airway open) -Narcolepsy- uncontrollable desire to fall asleep -Albumin will indicate malnutrition -Anorexia- lack of appetite -If you are feeding a blind patient but you want to maintain their dignity : Ask them what they want to eat first -Before you go to the lab, always verify the patient and wear gloves (contamination) -Third space shifting–large volume of fluid moving from intravascular space to third space and taking albumin which keeps the space open. Along with water and Na. (pitting edema occurs)--albumin and salt will be low since they are following the water. Leaving the circulatory system to go in between the tissues. Systematic, happens after an insult. Math -Dosing calculation/ Drip factor: mL of solution (mL) / total min x drop fac (gtt/mL) = gtt/min 1000ml to diffuse over 12 hours 83 (1000/12) 1000ml to diffuse over 10 hours 100 (1000/10) 100/15 6.6 if asked to round you put 7 Dosage: D/H x V IV flow rate: mL of solution (mL) / total hrs = mL/hr mL of solution (mL) / min x 60 min = mL/hr 1.) Ordered: 3000mcg On hand: 2mg How many in 24 hr? 3000mcg / 1000 = 3mg 3/2 x 1 = 1.5 Ans: 4.5 tabs ( 1.5 x 3 is 4.5)
