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What are the phases of diagnostic testing?
- Pretest-prep for test
- Intratest-specimen collection, etc, during test
- Post test-care after test
What is invasive testing?
Any test that requires entering the patient's body
What type of tests require informed consent?
any invasive test
What precautions are taken in an iodine test if the patient is allergic to shellfish?
typically the patient is premedicated and health care providers and staff performing test are on high alert
Describe the pretest phase.
- Client is provided with detailed information.
- Client and family are provided a time frame for the procedure.
- Client and family are encouraged to ask questions.
- Client is provided with any preparation instructions like NPO or NPO x meds or bowel prep.
What are some important tasks during intratest phase?
- Gather supplies and have them ready.
- Provide emotional and physical support for patient.
- Be discreet.
- Monitor patient as needed.
- Properly deliver specimen.
Give example of specimens that should be walked to the lab and hand delivered rather than delegated.
Cerebrospinal fluid or other difficult to obtain or time sensitive specimen.
Describe stages of post test phase.
- Follow flowheet for nursing care of client
- Perfom follow up activities and observations
- Modify interventions for patient as necessary
- Report results to appropriate health team members as appropriate in a timely maner.
What are the elements of a CBC?
- RBC Count
- RBC Indices
- WBC Count
- WBC Differential
- H and H
In a serum electrolyte test what is indicated by a high CO2?
High bicarbonate level and alkalinity
What is a BUN?
Blood Urea Nitrogen
What is indicated by BUN/creatinine ratio?
normal ranges from 10:1 to 20:1--higher ratios can indicate dereased blood flow to kidneys, congestive heart failure, gastrointestinal bleeding, increased protein in the diet, or liver disease
Give some examples of drugs with very narrow therapeutic ranges.
- Anti-seizure medications
Who is responsible for making sure peak level and trough levels are drawn?
The nurse is responsible for making sure they are completed, even if the nurse is not the one drawing them.
What is the usual site for arterial blood gas? Who typically draws this?
- It can be brachial, femoral, or from an arterial line
- Respiratory typically draws it.
How must blood from an arterial gas draw be handled?
It must be placed immediately on ice and carried to the lab quickly.
What is BNP? What is indicated by high levels?
- brain natriuretic peptide-a hormone for which production increases when the ventricles of the heart are stretched
- it is used to detect and evaluate extent of congestive heart failure
What is indicated by lactic dehydrogenase (LDH)?
What is creatine kinase (CK)?
enzyme used frequently as a Cardiac marker
What is indicated by Aspartate aminotransferase (AST) and alanine aminotransferase (ALT)?
What test indicates how well blood sugar levels have been managed over the last 3-4 months?
Glycosated hemoglobin (Hemoglobin A1C-HmgA1C)
What are some tests completed in the nursery for possible early detection and intervention?
- phenylketonuria (PKU)
- Congenital hypothyroidism
- Sickle cell
FSBN or FSBS
fingerstick by nurse or fingerstick blood sugar for capillary glucose
What are nursing responsibilities during specimen collection?
- provide comfort, privacy, and safety
- explain the purpose of the procedure
- use correct procedure or make sure the patient of staff perform correct procedure
- note relevant information on lab requisition slip
- transport specimen to lab
- report abnormal findings to health care provider in timely manner and document
Difference between stool specimen and stool culture?
- stool culuture may not be delegated to UAP--it is sterile
- Stool specimen-client defecates in bedpan or bedside commode and notifies nurse after defecation
- Stool culture-sterile swab is dipped into the specimen-using sterile technique it is then placed in a sterile test tube.
What can cause a false positive for occult blood?
red meat, raw fruit (melon) and raw vegetables (raddishes), iron, aspirin, anticoagulants
What can cause a false negative for occult blood?
How is a positive guaiac determined?
Blue is positive for occult blood. Any other color is negative.
What is a priority in collecting urine?
a sign on the bathroom door
Desribe a clean-voided urine specimen
- usually first-morning urine
- free of fecal contamination
- free of contamination from toilet paper
- lid placed tightly on specimen
- Can be collected by UAP
Name some reasons that sputum specimens are taken.
- culture and sensitivity of microorganisms
- cytology-orgin, structure, function and pathology of cells/cancer
- acid-fast bacillus (AFB)-TB test-to identify and asses the effectiveness of TB
Why would an AFB test be performed in a patient who has been diagnosed with TB?
to evaluate treatment
How much sputum should be collected for a specimen?
1-2 T or 15-30 mL
Where should patients with suspected TB be located?
in a negative pressure room
Procedure for throat culture swab
- have patient say "ahh" depress tounge
- insert swab into oropharynx
- run swab along tonsils and areas that are reddened or contain exudates
- place swab in sterile test tube
- label and send to the lab
Indirect vs. direct procedures for visualizing body organ and system function
- Indirect-non-invasive-nothing enters the patient's body-x-rays, ultrasound, KUB
- Direct-invasive-Anoscopy, Proctoscopy, Colonoscopy, Cystoscopy
- uses idodine dye to detect urinary alterations
- check for shellfish allergies--if they exist premedication and close monitoring will most likely be ordered
- provides better visualization of kidneys ureters and bladder- strictures, stones and other abnormalities
x-ray kidneys/ureters/bladder-typically only good to see any existing stones
Examples of tests done to detect cardiopulmonary alterations
- Stress EKG
- Lung scan V/Q Scan
Computerized Tomography CT
- distinguishes minor differences in the density of tissues
- produces a 3D image of organ or structure
- more sensitive than an x-ray
Magnetic Resonance Imaging (MRI)
- noninvasive scanning
- magnetic field-may burn tattoos
- clients with implanted metal devices may not undergo MRI
- provides better contrast between normal and abnormal tissue than CT
Nuclear Imaging Studies
- Bone scan-common with breast and prostate cancer
- Creates-"hotspots" of hyperfuntion and "coldspots" of hypofunction
Positron Emission Tomography (PET)
- injection of inhalation of radioisotope
- images created as the isotope is distributed throughout the body
- allows study of various aspects of organ funtion
- may include evaluation of blood flow and tumor growth
- Withdrawal of fluids that have collected abnormally
- to obtain a specimen
- invasive procedure requires strict sterile technique
- removal and examination of tissue
- invasive procedure
- requires strict sterile technique
Name a reason lumbar puncture is frequently performed.
Ruling out meningitis with high fever, high WBC count, and headache
How should a patient be positioned for a lumbar puncture?
Left lateral/Sim's Position
Why of abdominal paracentesis most often performed?
to drain fluid associated with liver failure
fluid in the abdomen
How would you prepare for abdominal paracentesis? thoracentecis? lumbar puncture?
- Call sterile and get sterile tray with the appropriate tools delivered
- check the hospital intranet for procedures
- get collection jars
What is the entry site for thoracentesis?
How should a patient be positioned for thoracentesis?
- in a position that allows easy access to intercostals
- sitting on one side with arm held to the front and up
- sitting and leaning forward over a pillow
Where is the most common site for bone marrow removal?
posterior superior iliac crest
What instructions should a patient be given for a liver biopsy? Why?
- Exhale and hold breath
- to prevent movement of liver and other abdominal organs
How should a patient be positioned following a liver biopsy?
after applying pressure to the biopsy site, position patient on the biopsy site--a pillow can be placed below
Which controlled substances are double locked?
the desired effect the reason the drug is prescribed
- secondary effect
- uninted, usually predictable
- may be harmless of harmful
- more sever side effect
- may justify discontinuation of a drug
result from overdose
- immunologic reaction to a drug
- mild to severe
unusually low physiologic response to a drug
one drug alter the effect of one or both drugs
effect of one or both drugs is increased
the effect of one or both drugs is decreased
when two drugs increase the action of one or another drug
mechanism of drug action and relationships between drug concentration and the body's responses
study of absorption, distribution, biotransformation, and excretion of drugs
Factors affecting medication action
- cultural, ethnic, genetic
- illness and disease
- time of administration
- response/treatment for chest pain
- morphine, oxygen, nitroglycerin, aspirin
Fast absorption routes
slowest absorption routes
What must be done when opening a topical medication?
the date, time, and initals must be written on the tube
ambien 10 mg po hs before surgery
- multiple vitamin daily
- KCl 40 meq po twich daily X 2 days
- as needed
- Maalox 15 mL po prn q6hrs for indigestion
Essential parts of a drug order
- full name of client
- date and time
- name of drug
- doseage of drug
- frequency of administration
- route of administration
- signature of the person writing the order
- sometimes provider #
Parts of a Prescription
- descriptive info on client
- date on which it was written
- Rx symbol meaning "take thou"
- Med name, dosage, and strength
- Dispensing instructions for pharmacist
- quantity of med to dispense
how will number be written on a prescription for controlled substances?
- thirty rather than 30
- written in words rather than numerically
Process of Administering Medications
- ID Patient-name and DOB
- Inform the patient-drug name and action
- "Do you have any allergies?:
- Provide adjunctive interventions as indicated
- Administer drug
- Record drug administered
- evaluate client's response to drug
Ten "Rights" of Accurate Medication Administration
- Right medication
- Right dose
- Right time
- Right route
- Right patient
- Right client education
- Right documentation
- Right to refuse
- Right assessment
- Right evaluation
What typically happens to dose with decrease renal function?
lower dose needed
What typically happenst to dose with impaired absorption?
Nasogastric medication administration
crush only appropriate medications
- dissolve in at least 30 mL warm water
- aspirate--stomach contents and measure residual
- volume-typically if greater than 100mL leave off for a while then give meds
administer one at a time, flushing after each with 15-30 mL of warm water to clear tube
For what medication are "unit" syringes used?
Parts of the syringe
- -cannula or shaft
Characteristics of needles
- slant or length of bevel
- length of the shaft
- roll NPH
- insert air into NPH
- insert air into regular
- draw regular
- draw NPH
- give injection
For what purposes are intradermal sites commonly used?
- TB skin test
- Allergy testing
At what angle should an intradermal site be given?
Angle for subcutaneous injection
- if you can pinch 2", 90 degrees
- if you can pinch 1", 45 degrees
intramuscular sites and volumes
- ventogluteal-no blood vessels, no nerves1-3 mL
- vastus lateralis- 1-2 mL
- dorsogluteal-risky, preferred for Z-track, 1-3mL; 5mL of gamma globulin
- rectus femoris-infant .5-1 mL
- deltoid-vaccinations, no more than 1 mL
Which instramuscular site is risky and often not recommended?
What is important to remember when giving eyedrops?
- always check expiration date
- place hand on forehead
- instill into lower lacrimal sac
What is important to remember about eye ointment?
waste the first bead
Instilling ear drops in adult? child under 3?
- pull up and back
- pull down and back for babies and toddlers
What should be used for irrigation to remove cerumen?
Procedure for nasal cavity medication administration
- client blows nose first
- seated position with head tilted back
- client hold the tip of the container just inside the nares
- inhales and the spray enter the nasal passage
Inserting Rectal Suppository
- Left Sims' position
- upper leg flexed
- lubricate suppository and fingers
- encourage client to relax by breathing through mouth
- insert 4 inches for adult, 2 inches for child
- avoid embedding in feces
- press buttocks together for a few minutes
- client remain in left lateral or supine position at least 5 min
- client retain for at least 20 min
In what order should a bronchodialator and steroid be given in a metered dose inhaler?
- -always give bronchodialator
- -wait 5-10 minutes
- -then give steroid
- Growth of actualization
- a process that develops over time
- having potential and the need to grow
Mayerhoff's Major ingredients of caring
- alternating rhythms
What did Leininger say about caring in nursing?
nurses must understand different cultures to really show caring
Watson's Theory on Caring
- Basis for nursing's role in society
- Commitment to care of the whole person
Swanson's Theory on Caring
- one feels a person sense of commitment
- caring processes as nursing interventions
- five caring processes
Swanson's Four Types of Knowledge
- Empirical-science of nursing
- Personal-therapeutic use of self
- Ethical-moral component
- Aesthetic-the art of nursing
Swanson's Five Caring Processes
- Knowing the client
- Nursing presence
- Empowering the client
The 3 Cs of Caring
Why is it important to care for one's self?
- to be able to properly provide care for others
- You can not give to other our of your emptiness
What are congruent communications?
Using matching verbal and non-verbal cues.
If you are uncertain of what someone is trying to say or doubt that the verbal communication conveys what is really going on what should you do?
- clarify--I see..........what does this mean?
- validate--It seems...........am I right?
What is filter?
A person's experiences that influence him in interpreting what is being said.
What types of humor are never appropriate in the care setting?
caustic and sarcastic
Barriers to communication
- need to recognize
- failure to listen
- improperly decoding client's intended message
- placing the nurse's needs above the client's needs
What should constructive criticism be based upon?
Honest, Appropriate, Direct
Bandura (behaviorist like Skinner and Pavlov)
- claimed that most learning comes from observation
- would like return demonstration
- learning is based on learner's behavior
- response when traced to the effects of a stimulus
- positive reinforcement
Nurses who use behaviorism will
- praise correct behavior and provide positive feedback
- provide role models of the desired behavior
Bloom's 3 Domains (1956)
Bloom, Piaget, Lewin
discussed change and what is needed for change to occur
Nurses using cognitivism will
Assess develpmental and individual readiness to learn
- provide social, emotional, physical environment conducive to learning
- encourage positive teaching-learning relationships
- select multisensory teaching strategies
- recognize personal characteristics have impact on how cues are perceived
Humanism (Maslow and Rogers)
big focus on feelings, active learning,and self motivation of the learner
- Acheiving full potential
- automonmy and sef-determination
- learner is an active participant and takes responsibility for meeting learning needs
What are some tips to share with patients about conducting their own research?
- Encourage patients to find out as much as they can and to visit their doctor to confirm, validate, and clarify
- Caution about misinformation and bad websites
At what level should written information be shared with patients?
Typically at a 6th grade level
What MUST be done after patient teaching?
Evaluation/assessment of learning and documentation of assessmenet of learning
Can the RN role to teach be delegated?
What are the roles of leaders formal or informal?
- influence others to work together to accomplish a specific goal
- outstanding interpersonal skills
- exellent listeners and communicators
- innovate change, motivate, facilitate, and mentor
- guide teams that assess effectiveness of care
- implement evidence-based practice
- construct process improvement strategies
Who is responsible for day to day management?
- First Level
- Charge Nurse or Team Leader
What is the role of the nurse manager/head nurse?
- middle level
- manage first level management
- responsible for activities of departments supervised
What is the role of Chief Nursing Officer/Nurse Executives?
- Upper Level
- Establish goals and develop strategic plans
- responsible for management of nursing and practice of nursing
When a nurse delegates a procedure, who is responsible for the procedure?
Preceptor vs. Mentor
- Preceptor-person with experience assiting a new nurse with skills
- Mentor-more longterm, provides nurturing
What are the guidelines for delegating?
- -assess client
- client must be medically stable
- task routine for this client
- nor require a substantial amount of scientific knowledge or technical skill
- considered safe for this client
- have a predictable outcome
Five rights of delegation
- right task
- right circumstances
- right person
- right directions and communication
- right supervision and evaluation
- need for change recognized
- moving make a plan in detail
- change is integrated