lOMoARcPSD|10236121 Advanced Assessments Exam 1 Intermediate Interventions And Assessment (Northeastern University) StuDocu is not sponsored or endorsed by any college or university Downloaded by Alvarez Lissette (6mywknfzxz@privaterelay.appleid.com) lOMoARcPSD|10236121 Advanced Interventions Exam 1 Study Guide Module 1: Discuss goals of obtaining a patient health history and physical assessment Health History Goals ● Gather information ○ Provides the subjective database ● Identify actual & potential health problems ● Identify teaching and referral needs ● Negotiate management ● Support emotional and spiritual needs ● Contract for: ○ Positive behavioral change ○ Disease prevention Describe content relevant to categories in a traditional health history Traditional Health History ● ● ● ● ● ● ● ● Always starts with a general survey Review chart/records Understand where things go in the chart CC - Chief Complaint, in pt’s own words HPC/HPI - History of Present Concern/Illness PMH - Past Medical History FH - Family History SH - Social or Lifestyle History Discuss the importance of a genogram to developing a patient plan of care Importance of a Genogram ● Useful if patient is concerned with genetic risk or the interaction of genetic (family history- FH) and environmental factors ● Helps patient/provider determine the risk for developing a condition, understanding the reason for developing a condition, understanding if they will pass on the risk to children ● Contains 3 generations - includes gender, ages and dates of death ● Only contains medical history not social history Downloaded by Alvarez Lissette (6mywknfzxz@privaterelay.appleid.com) lOMoARcPSD|10236121 Advanced Interventions Exam 1 Study Guide Interpret symbols and drawing conventions used in genograms Know how to read a genogram (basic symbols covered in lecture) – There will be a genogram on the exam. Symbols & Drawing Conventions ● Age & health of family members ● Reason and age at death ● Male on the left, female on right (hetero couple) ● Birth order is important rather than gender ○ Oldest child to the left ○ Youngest to the right ● Use abbreviations to identify relationship: ○ PGM ○ PGF ○ MGM ○ MGF ○ MAunt ○ Muncle Downloaded by Alvarez Lissette (6mywknfzxz@privaterelay.appleid.com) lOMoARcPSD|10236121 Advanced Interventions Exam 1 Study Guide Identify appropriate techniques to assess cranial nerves Test ability to identify familiar aromatic odors, one nares at a time with e yes closed CN I (olfactory) Test d istant and near vision Perform ophthalmoscopic examination of fundi CN II (optic) CN III (oculomotor), IV (trochlear) and VI (abducens) III: Allows EOMs to move i nward, lateral, upward; responsible for upper eyelid symmetry (Ptosis) IV: Allows EOMs to move eye inward and downward toward nose VI: Allows EOMs to move eye laterally to ear Inspect pupils’ size for equality and their direct and consensual r esponse to light and accommodation ( PERRLA) Test extraocular eye movements (EOM) CN V (trigeminal) Palpate jaw muscles for tone and strength when patient clenches teeth Test s uperficial pain and touch sensation in each branch (test temperature sensation if there are unexpected findings to pain or touch) Inspect symmetry of facial features with various expressions (smile, frown, puffed cheeks, wrinkled forehead) CN VII (facial) CN VIII (acoustic) Whisper near patient’s ear and have them repeat If deafness is suspected: Rinne’s Test & Weber’s Test To test vestibular action: Romberg Test CN IX (glossopharyngeal) and X (vagus) Test g ag reflex and ability to swallow Inspect palate and uvula for symmetry and gag reflex If both are fully functioning you will notice the intact gag reflex CN XI (accessory spinal nerve) Have patient s hrug shoulders or turn their head side to side for function CN XII (hypoglossal) Have patient stick out tongue and assess for midline Downloaded by Alvarez Lissette (6mywknfzxz@privaterelay.appleid.com) lOMoARcPSD|10236121 Advanced Interventions Exam 1 Study Guide Describe components of an external and internal ear assessment External Ear Exam Internal Ear Exam Inspection ● Note the level of the ear ● Inspect the auricles and move them around gently to assess tenderness ● Inspect the auditory canal (cerumen, discharge, redness, tenderness) Palpation ● Palpate the mastoid process for tenderness or deformity and the tragus (tenderness of tragus can be sign of ear infection) ● ● ● ● ● Hold the otoscope so the ulnar aspect of your hand makes contact with the patient Have patient tilt head slightly toward opposite shoulder Pull the ear back and up for the adult (back and down for child) to straighten ear canal Insert otoscope under direct vision to a point just beyond the protective hairs angled toward the nose Use the shortest and largest speculum that will fit comfortably Interpret ear and eye examination assessment findings Eye Examination Findings Conjunctiva should be pink, sclera should be white Excess tearing can indicate blockage of nasolacrimal duct Ptosis: drooping of upper eyelid Exophthalmos: bulging of eyes (indicative of Grave’s Disease) Xanthelasma: regular, slightly raised/yellow lesions (suggests lipid disorder) Anisocoria: unequal pupils (syndromes cause cat-like pupils) Presbiopia: near focus ability is more difficult, hard to see small print clearly, increases with age and need reader glasses Strabismus: cross-eyed Miosis: < 2mm (opiates) Mydriasis: > 6 mm (cocaine, THC) Snellen Chart Record the smallest print successfully read 100% 20/40 vision: what the normal eye can read at 40ft, the tested eye can read at 20ft Cataracts: progressive clouding of the eye due to age, over age 50 Glaucoma: Damage to the ocular nerve, can be due to increased ocular pressure. Can cause vision loss, peripheral vision loss and blindness Macular Degeneration: Macular degeneration causes loss in the center of the field of vision. In dry macular degeneration, the center of the retina deteriorates. With wet macular degeneration, leaky blood vessels grow under the retina. Retinal Detachment: Retina separates in the back of the eye, retina tear. Lose vision, painless. Can be corrected with surgery. Downloaded by Alvarez Lissette (6mywknfzxz@privaterelay.appleid.com) lOMoARcPSD|10236121 Advanced Interventions Exam 1 Study Guide Ear Examination Findings Otoscope: used to look along ear canal/tympanic membrane/eardrum ; difficult to assess anything beyond Tympanic Membrane: normally shiny, translucent, pearly gray Left ear → cone of light at 7 o’clock Right ear → cone of light at 5 o’clock Fluid behind the ear can alter where the cone of light is indicating infection Note: color, any redness, drainage or deformity Picture: Upper left is cerumen (ear wax) Upper right is bulging (significant of ear infection- cannot assess bony prominences and light is displaced) Lower left is an ear tube Lower right is a perforated tympanic membrane Downloaded by Alvarez Lissette (6mywknfzxz@privaterelay.appleid.com) lOMoARcPSD|10236121 Advanced Interventions Exam 1 Study Guide Accurately identify the location of head and neck superficial peripheral lymph nodes Head and Neck Superficial Peripheral Lymph Nodes Discuss characteristics of normal and abnormal lymph nodes Normal Lymph Nodes Movable Discrete Soft Non-tender Abnormal Lymph Nodes Large & tender → check area of drainage for source of problem Acute Infection: enlarged, bilateral, tender/firm, freely movable Malignancy: hard, > 3cm, unilateral, matted/fixed to structures Downloaded by Alvarez Lissette (6mywknfzxz@privaterelay.appleid.com) lOMoARcPSD|10236121 Advanced Interventions Exam 1 Study Guide Differentiate family history from social history in a health history Family History Social History Medical events in the patient’s family Review of patient’s past/current activities Example: Patient’s mother recently died of HTN Examples: Patient’s religious preference Patient’s occupation Cranial nerves involved in HEENT assessment HEENT Assessment Cranial Nerves Facial: ● Cranial Nerve V (Trigeminal, largest) ○ Facial sensation, biting/chewing ○ Assess by asking patient to clench their teeth & palpate jaw ● Cranial Nerve VII (Facial Nerve) ○ Assess by inspecting symmetry of facial expressions (smile, frown, wrinkle forehead) Eyes: ● Cranial Nerve II (Optic) ○ Snellen Eye Chart, Rosenbaum Card, Jaeger Card, Confrontation Test Extraocular Movements: ● Cranial Nerve III (Oculomotor) ○ Allows EOMs to move eye inward, lateral, upward, upper eyelid symmetry ● Cranial Nerve IV (Trochlear) ○ Allows EOMs to move eye inward/downward toward nose ● Cranial Nerve VI (Abducent) ○ Allows EOMs to move eye laterally toward ear Ear: ● Cranial Nerve VIII (Vestibulo-Cochlear Nerve) ○ Whisper in patient’s ear & have them repeat Nose & Throat: ● Cranial Nerve IX (Glossopharyngeal nerve) ● Cranial Nerve X (Vagus nerve) ○ If both IX and X are fully functioning you will notice intact gag reflex ● Cranial Nerve XII (Hypoglossal) ○ Inspect tongue for movement side to side/symmetry ○ Inspect nares for deviated septum Downloaded by Alvarez Lissette (6mywknfzxz@privaterelay.appleid.com) lOMoARcPSD|10236121 Advanced Interventions Exam 1 Study Guide Assessment of lymph nodes /eyes /ears Lymph Nodes Gentle circular motion using finger pads to palpate Start with preauricular nodes in front of ear Gentle pressure, use both hands to assess symmetrically (except for submental gland under chin; easier with one hand) Deep cervical chain → have patient turn head towards examined side If palpable, note: Location (bilateral, unilateral) Size (pathological > 1 cm) Consistency (soft, firm, hard, smooth, nodular) Quantity (discrete, matted) Mobile, fixed Tenderness Warmth, erythema Changes over time Assessment: Eyes Make sure eyelashes evenly distributed Look for inflammation, drooping, lesions Use Ophthalmoscope → enlarges view of eye Accommodation: automatic response when object is brought closer to eyes (eyes should converge/constrict when object is close then dilate when object is distant) PERRLA: (Pupils equal, round, reactive to light & accommodation) Assessment: Ears Light Reflex: Left ear will be at 7 o’clock, right ear will be at 5 o’clock (if there is fluid/infection behind the membrane the area of light may change) Tympanic membrane normally shiny, translucent, pearly gray Downloaded by Alvarez Lissette (6mywknfzxz@privaterelay.appleid.com) lOMoARcPSD|10236121 Advanced Interventions Exam 1 Study Guide Module 2: Describe principles of cardiac physiology relevant to a cardiovascular (CV) and peripheral vascular (PV) assessment Principles of Cardiac Physiology ● 4 chambers separated by valves; purpose is to prevent backflow of blood ● Right & Left Atria & Ventricles ● 2 Atrioventricular (AV) Valves: ○ Tricuspid & Mitral ● 2 Semilunar (SL): ○ Pulmonic and Aortic ● Valves are unidirectional, open/close passively Peripheral Artery Disease Lack of blood to legs Caused by atherosclerotic plaque As the lining thickens from plaque, vessels are more constricted → reduce blood flow (numbness, tingling, claudication, cool/pale skin, ulcers) Intermittent claudication of pain when walking NO edema, NO pulse Round, smooth sores, black DANGLE LEGS OFF BED Peripheral Venous Disease Build up of blood in legs; blood unable to get back to heart Damaged or weakened veins due to injury, surgery, inactivity, obesity First symptom is pain in the area of the clot Fragile skin that tears easily Prone to stasis ulcers Edema Pulse Dull achy pain ELEVATE LEGS *No heating pads for PVD and PAD (pain is worse with vasodilation) Identify primary landmarks for conducting a CV assessment Downloaded by Alvarez Lissette (6mywknfzxz@privaterelay.appleid.com) lOMoARcPSD|10236121 Advanced Interventions Exam 1 Study Guide Accurately use techniques of inspection, palpation and auscultation in the performance of a CV and PV assessment Inspection Look for scars, prior cardiac surgery, chest deficiencies (barrel/pigeon) Look for pulsations, lift/heave Apical Impulse: pulsation created @ 5th ICS & left mid-clavicular line (result of L. ventricle moving outward during systole, easier to see in kids) Displacement: of apical impulse to the left indicates enlarged heart Lift/heave: pulsation that isn’t apical; considered abnormal; forceful thrusting as a result of increased heart workload (ventricular hypertrophy) Palpation Palpate carotid arteries separately Note strength & compare with apical pulse Position patient supine with head of bed/table slightly elevated Use palm of hand, go from apex to left sternal border to base Thrill: palpabile vibration; signifies turbulent blood flow (helps identify murmur location) Auscultation Auscultate carotids with bell, listen for bruit (can be a sign of atherosclerosis or TIA/ischemic stroke) Ask patient to hold breath momentarily 3 positions: sitting up, lying on left side, lying on back, head raised 30-45 degrees Zig-zag pattern starting at base then go downward S1 loudest at apex S2 loudest at base Identify potential causes of cardiac murmurs Cardiac Murmurs The main sign of a valvular heart disease is a murmur Causes: Valve Opening Problem Stenosis: valve tissues (leaflets) are stiffer/hardened which narrows the valve opening Valve Closing Problems Insufficiency/Regurgitation: leaflets do not close completely Blood flows backwards Heart may enlarge to compensate & lose elasticity/efficiency Pooling → r/o stroke or PE Downloaded by Alvarez Lissette (6mywknfzxz@privaterelay.appleid.com) lOMoARcPSD|10236121 Advanced Interventions Exam 1 Study Guide Grading Murmurs Grade I - Barely audible with a stethoscope in a quiet room Grade II - Quiet but clearly audible with a stethoscope Grade III - Moderately loud (like S1 or S2) Grade IV - Loud, associated with a thrill Grade V - Very loud, easily palpable Grade VI - Extremely loud, audible with the stethoscope not in contact with the chest, thrill palpable and visible Heart Murmurs ● Disruption of blood flow through the heart ● Blowing/swishing sound ● Almost always abnormal in adult ● “Innocent Murmur” → healthy children & adolescents ● Described by: ○ Timing - where does it occur in cardiac cycle? ○ Loudness - intensity? ○ Pitch - low medium or high pitch? ○ Pattern intensify (crescendo) or decrease (decrescendo) across cardiac cycle? ○ Quality - blowing? Musical? Harsh? Rumbling? ○ Location - where is it best heard? ○ Radiation ○ Loudness/Intensity Downloaded by Alvarez Lissette (6mywknfzxz@privaterelay.appleid.com) lOMoARcPSD|10236121 Advanced Interventions Exam 1 Study Guide S1 Heart Sound S2 Heart Sound ● Closure of AV valves → signals beginning of systole ● Mitral component of first sound (M1) slightly precedes tricuspid component (T1) ○ Usually hear these two components fused as one sound ○ Can hear S1 all over precordium, but loudest at apex ● Closure of semilunar valves → signals end of systole ● Aortic component of second sound (A2) slightly precedes pulmonic component (P2) ○ Although heard all over precordium, S2 loudest at base Auscultation Listen in 3 different positions: 1. Pt leaning slightly forward in expiration a. Listen with diaphragm at all 5 landmarks 2. Pt supine a. Listen with diaphragm at all 5 areas 3. Pt rolled to left lateral position a. Listen with bell at all 5 areas Downloaded by Alvarez Lissette (6mywknfzxz@privaterelay.appleid.com) lOMoARcPSD|10236121 Advanced Interventions Exam 1 Study Guide Discuss the physiology supporting key differences in the presentation of peripheral arterial and venous disease Characteristic Arterial Disease Venous Disease Shiny pale/ dependent rubor Pruritis Turns brown Cool Warm > 3 seconds 3 sec or less Weak/absent Strong + sym Hair Absent Present Edema Absent Present Necrosis Likely Unlikely Sharp/stabbing Aching, crampy Skin changes Skin temp Capillary refill Pulses Pain State the importance of obtaining an accurate ECG reading Identify factors to consider obtaining an accurate ECG reading ECG Reading **Poor placement can result in misinterpretation** Importance: it is displaying the electrical activity of the heart. This can help with diagnoses of any heart arrhythmias and most importantly can alert the nurse to any ST elevations that would be indicative of a myocardial infarction Factors to Consider: ● Warm/dry skin ● Extremity electrodes should point posteriorly ● Patient supine with HOB slightly raised ● Stay still/no shivering Document: date, time, BP, patient response Downloaded by Alvarez Lissette (6mywknfzxz@privaterelay.appleid.com) lOMoARcPSD|10236121 Advanced Interventions Exam 1 Study Guide Discuss the importance of assessing mental status and level of consciousness. Mental Status & LOC Importance: A change in either mental status or LOC is the first clue to deteriorating condition First signs of neurological deterioration are subtle - can be best detected by family members & conversation w/ patient Consciousness is the degree of wakefulness or ability to arouse the patient. Not the same as orientation, a patient may be conscious but not oriented. Explore the significance of a motor and sensory assessment. Motor & Sensory Assessment Motor Sensory Significance: To note any voluntary/involuntary movement (tics/tremors) Movements should be smooth & coordinated Significance: Majority of neuropathy issues begin distally (start assessing at the feet then move to the hands) Coordination, fine motor skills, balance can only be performed when patient is awake & alert & can respond to verbal stimuli Use a safety pin to test superficial pain Posturing: Associated with head trauma Decorticate Rigidity: rigid flexion, preserves brainstem function Decerebrate Rigidity: arms are pronated outwards, indicates brainstem damage Deep Tendon Reflexes: Testing for muscle contraction in response to direct/indirect percussion of a tendon Clonus: foot is dorsiflexed & taps multiple times (sign of neurological condition) Downloaded by Alvarez Lissette (6mywknfzxz@privaterelay.appleid.com) lOMoARcPSD|10236121 Advanced Interventions Exam 1 Study Guide Review the importance of a cerebellar assessment Cerebellar Assessment Significance: To test coordination, fine motor skills & balance To assess patient’s gait (should have smooth, rhythmic cadence with equal amount of time in swing/stance phase, opposite arm movements) Coordination: Rapid alternating movements Finger to nose to finger test - inability to coordinate could indicate cerebellar dysfunction Heel down shin - loss of coordination is abnormal Balance: Tandem: Heel-toe walking Romberg Test: Feet together, eyes closed Look for swinging (if there was a lesion, patient is able to compensate by opening eyes; removing vision will make patient sway) Gait disturbances could indicate: Spastic hemiparesis (hemiplegic gait) Cerebellar ataxia Parkinsonian gait Do not memorize Glasgow Coma scale- if you have a question the scale will be provided. Glasgow Coma Scale ● Used to quantify LOC/Neurological impairment (usually for patients with trauma and other hypoxic effects) ● Based on: Eye opening, Motor, Verbal response ● Patient receives score for best response in each of these areas (score added together) ○ Score range from 3-15 ○ Higher the number, the better ○ <8 usually indicates coma – lower scores indicate greater degree of damage ○ Infants and children slightly different Module 3:Discuss patient considerations in the selection of the type of IV therapy Downloaded by Alvarez Lissette (6mywknfzxz@privaterelay.appleid.com) lOMoARcPSD|10236121 Advanced Interventions Exam 1 Study Guide IV Therapy Patient Considerations Volume of fluid being infused Long Term/short term therapy History of drug abuse Have they had surgery there? Mastectomy on that side Type of medication Describe considerations for peripheral venipuncture site selection Peripheral Venipuncture Considerations Considerations: Medical Hx, age, body size, condition of veins, duration of IV therapy, fluid/med being infused, level of activity Start as distal as possible (if proximal damaged then you can’t use distal site) Smallest gauge Not appropriate for TPN, pH <5 or >9, osmolality >600 mOsm/L Supine with head elevated, arms supported (risk for vasovagal if sitting up) Apply tourniquet 5-6 in above site Bevel up, 10-30 degree angle Common sites: cephalic, basilic, metacarpal Avoid: Wrist → close proximity to nerves Legs/feet/ankles → lead to DVT (In emergency → use dorsum of foot & saphenous vein of ankle until central access gained) Veins below an area of phlebitis/sclerosed/thrombus Skin inflammation/bruising/breakdown AV shunt/fistula Lymph nodes removed Infection Describe considerations for central venipuncture access device selection Central Venipuncture Considerations Quality of Life and method with lowest risk of complications, nurse is the patient advocate Choose the most appropriate site for safe therapy Short term: non-tunneled and PICC lines Long term: tunneled and implantable port Uses: extended hospital stays, poor peripheral access, hypertonic, vesicant or pH extremes, TPN and chemotherapy Describe assessment considerations of peripheral and central intravenous sites Downloaded by Alvarez Lissette (6mywknfzxz@privaterelay.appleid.com) lOMoARcPSD|10236121 Advanced Interventions Exam 1 Study Guide https://www.slideshare.net/rajmagbanua/cvad-32922525 ← really helpful slides on advantages/disadvantages of CVAD Assessment Considerations Peripheral IV Sites Central IV Sites IV drug user? Mastectomy/fistula/etc… Can you find a vein to insert the IV? Assess risk for infection, if high risk then central may be the way to go ● Short term? ○ Non tunneled ○ Picc line ● Long term? ○ Tunneled ○ Implantable Short-Term IVs PICC Line Duration: Short-term (6 weeks-6 months) Uses: IV therapy at home & acute care settings Placement: ● Upper arm to superior vena cava ● Secured with wound closure strips ● Need X-Ray to confirm placement Advantages: ● Eliminates risk of pneumothorax ● Use for a ll ages ● Easier to have labs drawn ● Replaced O NLY as needed (when site is infected or when catheter is no longer patent) Non-Tunneled Duration: Short-Term (<14 days) Uses: patients who are unstable Placement: ● Inserted in jugular or subclavian ● For subclavian: put pt in Trendelenburg position Disadvantages: Sutured in place → High risk of catheter related bloodstream infections (CLABSI) Risk of pneumothorax Downloaded by Alvarez Lissette (6mywknfzxz@privaterelay.appleid.com) lOMoARcPSD|10236121 Advanced Interventions Exam 1 Study Guide Long-Term IVs Tunneled Duration: Long-Term Placement: ● Jugular or subclavian vein ● Sutured in place but stitches are removed after 7-14 days ● Dacron → seal to prevent bacteria under the skin & prevent dislodgement Advantages: ● Lower risk CLABSI ● Allows for ease of movement Implantable Port Duration: Long-Term, permanent device Placement: ● Upper chest wall ● Antecubital area of the arm ● Need radiology to confirm placement Advantages: ● No visible external porth/lines ● Minimal daily care ● Good for kids & adults (swimming) ● LOW risk for infection ● Improved self-image Disadvantages: ● Discomfort when accessing port Discuss the etiology of potential complications of peripheral and central intravenous therapy Peripheral IV Complications SYSTEMIC COMPLICATIONS: Fluid overload: Increased BP/HR/RR, crackles, JVD, edema, dyspnea Speed Shock: Foreign substance introduced too quickly, plasma toxicity/floods organs Dizziness, chest tightness, dyspnea Sepsis: Red, tender IV site, fever, fatigue, tachy, cold sweat, N/V Air Embolism: Air enters central veins, becomes trapped as blood flows Respiratory distress, decreased HR, increased BP, cyanosis, signs of pulmonary edema, change in LOC, palpitations, weakness, tachypnea Central IV Complications Pneumothorax/Hemothorax: Sudden onset of chest pain/SOB due to air accumulation in the lungs Give oxygen, monitor vitals, pressure on entry site, remove catheter CLABSI or CRBSI: Central line associated bloodstream infection & catheter related bloodstream infection If WBC low → will not see drainage or pus, will see fever/chills Air Embolism Thrombosis: Obstruction of airflow Catheter Migration: Occurs when catheter moves from where it was placed Signs: swelling of neck/chest during infusion, pain Downloaded by Alvarez Lissette (6mywknfzxz@privaterelay.appleid.com) lOMoARcPSD|10236121 Advanced Interventions Exam 1 Study Guide during infusion, no blood return, leaking Discuss strategies to promote accurate intravenous fluid infusion Strategies to Promote Accurate IV Infusion Aseptic technique Assess IV site for signs of inflammation/complications Select injection port closest to the patient Flush IV to ensure patency If patient is complaining of pain at IV site, restarting at a slower rate may relieve discomfort ● Monitor site and infusion for tolerance to fluid volume and complications ● Dressing integrity ● ● ● ● ● Must know filtration vs phlebitis vs. extravasation – this is frequent assessments for you in practice Phlebitis Infiltration Inflammation of a vein Associated w/ acidic/alkaline solutions w/ high osmolality Signs: Warmth, swelling Risk Factors: Mechanical irritation, chemical irritation, contamination (bacteria) Prolonged use of site TREATMENT: Remove catheter @ first sign of redness/pain Warm compress Restart using larger vein or smaller device but not near phlebitis Document phlebitis and treatment Extravasation Leakage of IV fluid into surrounding tissue Caused by improper placement/dislodgement Leakage of vesicant in surrounding tissue (Vesicant: medication that can cause blistering, severe tissue injury, necrosis: Signs: chemotherapy agents, Swelling, pain, Burning, catecholamines, digoxin) blanching, Signs: decreased/stopped flow rate Blistering, blanching, swelling TREATMENT: Removal/restart Elevate Check cap refill and pulse Warm compress (pH 8, 9) Cold compress (ph 5,6) Document infiltrate and treatment TREATMENT: IMMEDIATELY stop infusion Aspirate medication Notify MD ASAP - estimate how much was infused. Elevate Call pharmacy for antidote ICE Document: Medical record and incident/safety report Downloaded by Alvarez Lissette (6mywknfzxz@privaterelay.appleid.com) lOMoARcPSD|10236121 Advanced Interventions Exam 1 Study Guide Central vs. peripheral lines – what makes us decide we need a central line? What are central line complications? Localized complications vs. systemic complications Central Lines Uses: Extended length of therapy Poor peripheral access Total parenteral nutrition Chemotherapy Hypertonic, Vesicant, pH extremes Complications: (Described above) Air embolism Pneumo/hemothorax Catheter mitigation Downloaded by Alvarez Lissette (6mywknfzxz@privaterelay.appleid.com) lOMoARcPSD|10236121 Advanced Interventions Exam 1 Study Guide Module 4: Identify methods used to deliver IV medications IV Medication Administration ● Primary line ○ Primary IV bag (directly attached to patient) ○ Piggyback (medication is piggybacked on primary IV infusion) ○ IV push (through a primary line) ○ Syringe pump (either primary line or piggy backed onto primary line) ○ Volume controlled (primary line or piggybacked onto primary line) ● Saline Lock ○ Intermittent infusion ○ IV push (directly) -Describe principles used to prepare and administer IV medications safely (compatibility is key) IV Medication: Responsibilities Assessment: physical/lung/bowel sounds, contraindications, baseline data Compatibility ○ Lexicomp or compatibility chart ○ Incompatibility results when 2 or more substances react/interact and change the normal activity of one or more components; harmful/undesirable effects, loss of therapeutic effects Physical Incompatibility One drug is MIXED with another drug/solution to produce a product UNSAFE for administration - 2 drugs mixed together that form a precipitate could be harmful - (Ceftriaxone + Lactated Ringer’s → may form a precipitate & damage kidneys, lungs, gallbladder) Chemical Incompatibility REACTION of drug with other drugs/solutions → ALTERATIONS in integrity and potency of active ingredient Therapeutic Incompatibility Undesirable effect occurring as a result of 2 or more drugs being given concurrently - Can have an increased or decreased therapeutic response Infusion nursing society standard: Nurse should verify and chemical, physical, therapeutic compatibility and stability prior to administering infused medications/solutions 6 R’s ○ ○ ○ ○ Patient, Drug, Dose, Route, Time, Documentation Check medication at least 3 times prior to administration Only administer medications that you or a licensed pharmacist have prepared Label all medications appropriately, accurate dosage calculations Downloaded by Alvarez Lissette (6mywknfzxz@privaterelay.appleid.com) lOMoARcPSD|10236121 Advanced Interventions Exam 1 Study Guide Discuss infusion guidelines and assessment for the patient receiving a blood transfusion Blood Transfusion: Assessment ● Pre-Assessment ○ Baseline vitals, taken periodically once transfusion starts based on protocol ○ Kidney function, cardiovascular, lung sounds ○ Evaluate IV site, gauge of needle ■ 18 gauge needle for rapid ■ 20 gauge needle for slow (smaller can risk hemolysis) ○ Blood product matches patient ○ RBCs must be ABO and Rh compatible ● Pt identification ○ Identify unit label of blood and patient by TWO nurses before hanging blood ○ Check for expiration by TWO nurses (both nurses must document that check occurred) ● Equipment ○ Y-set filtered ■ 2 drip chambers (1 port with normal saline) ○ Normal saline Blood Transfusions: Guidelines Guidelines: ● Pump can inform us of phlebitis, easier for 4 hour period ○ Does not cause hemolysis ● Infuse slowly ○ Large enough dose that can alert the nurse of a reaction but small enough that it can be successfully treated ○ If pt shows signs of an adverse reaction, transfusion is stopped IMMEDIATELY & hang NS alone in separate tubing ○ After 15 mins have passed safely, flow rate can be increased ○ RBCs should be infused within a 4 hour period ○ RBCs should be hung within 30 mins of obtaining from blood bank *The only solution you should use to prime the line when hanging RBCs is NORMAL SALINE Downloaded by Alvarez Lissette (6mywknfzxz@privaterelay.appleid.com) lOMoARcPSD|10236121 Advanced Interventions Exam 1 Study Guide AB+ → Universal RECIPIENT O - → Universal DONOR Identify signs and symptoms of blood transfusion reactions Allergic reaction can occur immediately or within 1 hour of the transfusion Mild reaction Severe Reaction (Anaphylaxis) Urticaria, localized erythema, facial flushing, dyspnea, wheezing Anxiety, hypotension, shock, wheezing, urticaria Nursing Actions: Pause transfusion, keep vein open, notify provider, monitor vital signs, administer antihistamine orders (or benadryl 30 mins before) Nursing Actions: Discontinue transfusion, keep vein open with just NS, administer CPR, anticipate order for steroids, maintain BP; prevention using well washed RBCs where plasma has been extracted Downloaded by Alvarez Lissette (6mywknfzxz@privaterelay.appleid.com) lOMoARcPSD|10236121 Advanced Interventions Exam 1 Study Guide Febrile Reaction Reactions to antibodies directed against leukocytes/platelets Occurs immediately or 1-2 hours after transfusion is completed Signs/Symptoms: FEVER most common Chills N/V/Headache Tachycardia Nonproductive cough Interventions: Discontinue transfusion Keep vein open with NS Notify provider Monitor VS Administer antipyretic Prevention: Use leukocyte-reduced blood components Acute Hemolytic Transfusion Reaction Most serious and life-threatening reaction Occurs after infusion of incompatible RBCs ● Leads to activation of coagulation system and release of vasoactive enzymes that result in vasomotor instability, cardiorespiratory collapse, and DIC Signs/Symptoms: Fever Lumbar, Flank, Chest Pain Flushing of face Tachycardia Prevention: Extreme care during identification process Don’t give the wrong blood! Interventions: STOP TRANSFUSION DISCONNECT tubing completely Infuse NS DO NOT GIVE MORE DONOR BLOOD Call provider ASAP Monitor need for dialysis Downloaded by Alvarez Lissette (6mywknfzxz@privaterelay.appleid.com) lOMoARcPSD|10236121 Advanced Interventions Exam 1 Study Guide Accurately calculate IV medication infusion rates Accurately calculate intravenous drip rates for infusion via gravity or pump Calculating Flow Rates - IV Pumps Calculating IV Drip Rate IV Flow Rate in mL per hour: Infusion Rate is Less than 1 Hour Examples: Downloaded by Alvarez Lissette (6mywknfzxz@privaterelay.appleid.com)
