Nursing102 - Exam 2

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Nursing102 - Exam 2
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2011-02-25 23:13:38
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NCLEX nursing delegation
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Nursing102 - Exam 2
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  1. Five Rights of Delegation
    • Right circumstances
    • Right task - giving an assignment that fals within delegate's scope of practice and job description
    • Right person
    • Right direction and communication - giving 4C directions
    • Right supervision

    • delegated activities only in IMPLEMENTATION phase of nursing process
    • UAPs do NOT perform sterile nor invasive procedures nor patient teaching
  2. IV, oral, liquid calculations
    drip rate (gtts/min) = ( total volume (mL) / total time (min) ) * tubing factor (gtts/mL)
  3. Tube feeding position
    Radiography remains the gold standard for ruling out respiratory placement of blindly inserted tubes. For example, testing the pH of a feeding tube aspirate, observing the appearance of the aspirate, and using end-tidal carbon dioxide monitoring are not sufficiently accurate to ensure nonrespiratory placement of blindly inserted tubes in high-risk patients.

    A feeding tube is considered malpositioned when its ports end in the esophagus or when a small-bowel tube dislocates upward into an atonic stomach.

    Note and mark proper length of radiograph-confirmed, properly-positioned tube.

    • When gastric feeding is used, it is important to elevate
    • the head at least 30° to prevent aspiration. Aspiration of gastric contents occurs to a significantly greater degree when patients are in a supine position than when in a semirecumbent (45° backrest elevation) position.
  4. Nursing diagnosis and Sputum Culture Reports
    Sputum is cultured to identify the specific agent causing infection. Sensitivity tests (before administration of antibiotic) to indicate best antibiotic to use. Collect sample first thing in AM; do not contaminate with saliva nor sinus drainage

    • pink forthy: pulmonary edema
    • white frothy: CHF
    • blood-streaked: lung cancer
    • yellow, green, musty odor: infection

    • RN-DX:
    • Ineffective Breathing Pattern - state in which a person's inspuration and/or expiration pattern does not provide adequate ventilation

    Ineffective Airway Clearance state in which person is unable to clear secretions or obstructions from the respiratory tract to maintain a clear airway

    Impaired Gas Exchange - state in which a person experiences an excess or deficit of oxygenation and/or carbon dioxide elimination at alveolar capillary level e.g. PAO2 < 93%
  5. Incentive Spirometer
    spirometer provides client with some observable indicator of how deep a breath has been taken

    8-10 breaths/hour during waking hours

    avoid hyperventilation; perform exercises slowly
  6. Adequate fluid intake WRT Oxygenation
    inadequate moisture in airway makes respiratory mucus thick and difficult to cough up; mucus that is hard to edxpectorate promotes infection because bacteria trapped have time to multiply; mucus plugs in airways can lead to atelectasis and decreased oxygenation

    intake ideally 6-8 glasses of fluid per day; avoid dairy which can thicken secretions
  7. Oxygen Therapy
    assess client's color, alertness, heart rate and breathing as indicators of effectiveness of oxygen therapy

    aim for PaO2 > 60 mm Hg or SaO2 > 93%

    oxygen is a drug; its use requires a Rx (unless emergency); high [O2] are toxic to lung tissue

    • Cannula (22-44%) 1 - 6 L/min
    • Venturi Mask (24-50%) 3 - 8 L/min
    • Simple Mask (40-60%) 6 - 10 L/min
    • Reservoir Mask / Non-rebreather (90%+) 10 - 15 L/min

    assess client's skin for dryness: nares, behind ears, face and under chin
  8. IV Complications
    • Infiltration - when fluid enters subcutaneous tissue
    • Can occur if needle or catheter slips our of vein or if IV fluid leaks from vein. Client may complain of pain and selling around infusion site which may be cool to touch. Absence of blood return may indicate but not definitive since some catheters designed to prevent backflow.

    Phlebitis - inflammation of a vein; if accompanied by clot, referred to as thrombophlebitis. Client may complain of discomfort and vein appears red and feels warm and cordlike/hard.

    Infection - local or systemic symptoms. Longer an IV is in one site, greater risk of infection

    Fluid Overload - may occur if client receives fluid too rapidly. Very young or elderly and clients with renal or cardiac impairment vulnerable. S/S: restlessness, headache, increased in pulserate, weight gain over a short period of time,cough, presence of edema, hypertension, wide variance between intake and output, distended neck veins, SOB

    Air embolism - Air entering the central vein, which is quicklytrapped in the blood as it flows forward. S/S: complaints of palpitations, lightheadednessand weakness, pulmonary findings: dyspnea,cyanosis, tachypnea, expiratory, wheezes,cough, and pulmonary edema. Cardiovascular:“mill wheel” murmur; weak, thready pulse;tachycardia; substernal chest pain; hypotension;and jugular venous distention. Neurologic findings: change in mental status, confusion,coma, anxiousness, and seizures. At first sign, place client on left, Trendenlenburg position.

    Speed shock - Occurs when a foreign substance usually amedication is rapidly introduced into the circulation. S/S: dizziness, facial flushing, headache,tightness in the chest, hypotension, irregularpulse, progression of shock.
  9. Versed (midazolam )
    given before medical procedures or before anesthesia for surgery to cause drowsiness, relieve anxiety, and prevent any memory of the event. Midazolam is in a class of medications called benzodiazepines. It works by slowing activity in the brain to allow relaxation and sleep.

    ADVERSE EFFECTS: cardiorespiratory depression, apnea, and respiratory arrest; alterations in blood pressure, arrhythmias, and ventricular irritability; Hypotension and decreases in systemic vascular resistance; nausea, vomiting, and hiccups

    Midazolam may cause some people to feel drowsy, tired, or weak for 1 or 2 days after it has been given. It may also cause problems with coordination and one's ability to think. Therefore, do not drive, use machines, or do anything else that could be dangerous if you are not alert until the effects of the medicine have disappeared or until the day after you receive midazolam, whichever period of time is longer.Do not drink alcoholic beverages or take other CNS depressants (medicines that slow down the nervous system, possibly causing drowsiness) for about 24 hours after you have received midazolam, unless otherwise directed by your doctor. To do so may add to the effects of the medicine. Some examples of CNS depressants are antihistamines or medicine for hay fever, other allergies, or colds; other sedatives, tranquilizers, or sleeping medicine; prescription pain medicine or narcotics; medicine for seizures; and muscle relaxants.Do not drink grapefruit juice or eat grapefruit while you are using this medicine. Also, do not take this medicine if you have allergies to cherries.Do not take other medicines unless they have been discussed with your doctor. This includes prescription or nonprescription (over-the-counter [OTC]) medicines and herbal or vitamin supplements.
  10. fentanyl (Fentora, Onsolis)
    a narcotic (opioid) pain medicine; indicated for cancer patients who are tolerant to opioid therapy

    ADVERSE EFFECTS: mental and respiratory depression (particularly in the elderly), stupor, delirium, somnolence, and dysphoria; potential for abuse; nausea, vomiting, and constipation
  11. morphine (Avinza, Kadian, MS Contin, MSIR, Oramorph SR, Roxanol)
    in a group of drugs called narcotic pain relievers.Morphine is used to treat moderate to severe pain. It works by dulling the pain perception center in the brain.

    may be habit-forming; do not stop taking morphine suddenly; not take morphine if you are having an asthma attack or if you have a bowel obstruction called paralytic ileus.

    serious side effects: shallow breathing, slow heartbeat;seizure (convulsions);cold, clammy skin;confusion;severe weakness or dizziness; orfeeling light-headed, fainting.

    Less serious side effects are more likely to occur, such as:constipation;warmth, tingling, or redness under your skin;nausea, vomiting, stomach pain, diarrhea, loss of appetite;dizziness, headache, anxiety;memory problems; orsleep problems (insomnia).
  12. Pressure Ulcer Treatments
    • Stage I - persistent redness or non-blanching INTACT skin
    • Film Dressing (Tegaderm) - protects from shearing force; may be left in place for 7 days if seal remains; provides moist environment and traps exudates;
    • not for draining wounds
    • Hydrocolloid (Duoderm) Used for superficial and
    • partial-thickness wounds with light to moderate drainage; facilitates autolytic debridement

    • Stage II – partial thickness loss; superficial and presents as abrasion, blister or shallow crater
    • Hydrocolloid (Duoderm)
    • Used for superficial and partial-thickness wounds with light to moderate drainage; facilitates autolytic debridement
    • Polyurethane Foam (Alleyvn; Curafoam) - partial and full-thickness wounds with minimal to heavy amount of drainage; not recommended for non-draining wounds nor dry eschar

    • Stage III – full-thickness skin loss involving damage or necrosis of subcutaneous tissue but NOT through fascia; looks like a deep crater with(out) undermining
    • Hydrocolloid (Duoderm) Used for superficial and partial-thickness wounds with light to moderate
    • drainage; facilitates autolytic debridement
    • Polyurethane Foam (Alleyvn; Curafoam) - partial and full-thickness wounds with minimal to heavy amount of drainage; not recommended for non-draining wounds nor dry eschar
    • Calcium Alginate (Algiderm; Algisite; Carrasorb) – forms a soft gel when mixed with wound fluid; partial
    • and full-thickness wounds; moderate to heavy draining wounds; contraindicated for dry eschar, 3rd degree burns and heavy bleeding

    • Stage IV – full thickness loss with extensive destruction; tissue necrosis or damage to muscle, bone or supporting structures
    • Gauze dressing (wet to dry)
    • Polyurethane Foam (Alleyvn; Curafoam) -
    • partial and full-thickness wounds with minimal to heavy amount of drainage; not recommended for non-draining wounds nor dry eschar
    • Calcium Alginate (Algiderm; Algisite; Carrasorb) – forms a soft gel when mixed with wound fluid; partial
    • and full-thickness wounds; moderate to heavy draining wounds; contraindicated for dry eschar, 3rd degree burns and heavy bleeding
  13. Antibiotic Therapy / Culture and Sensitivity / Peak and Trough / Anaphylaxis
    • Antiobiotic Therapy:
    • Empiric Therapy - not based on C&S
    • Prophylactic Therapy - treatment with antibiotics to prevent an infection
    • Definitive Therapy - antibiotic therapy tailored to treat organisms identified with C&S

    Culture and Sensitivity - 24-48H to identify microorganisms causing clinical infection; helps determine Minimum Inhibitory Count (MIC); take cultures for C&S before starting antibiotics

    Peak and Trough - peak levels (highest concentration) obtained 30-60 min (IV/IM) to 1-2 hr (PO) after administration; determines toxicity; desired to be 1mcg/ml; if >, then impared renal capacity; trough levels (lowest concentration) obtained 15min -0min before next dose; determines therapeutic effect (return to normal VS; S&S of infection diminish; negative C&S)

    • Anaphylaxis - rapid onset allergic reaction; seating; tightness in throat; bronchospasms; tingling in mouth, face or throat; itching; hives; weakness; LOC
    • rescue drugs: epinephrine, steroids, anti-histamine (benadryl)
  14. Bronchodilators / anti-tussive / expectorant
    bronchodilators (Albuterol, Atrovent)- dilates airways; may cause tachycardia; assess pulse rate. Wash/rinseMDI and mouth after use.

    anti-tussive (Robitussin, dextrometorphan)- suppress cough reflex through direct action on cough center in CNS; opioids may depress respiration rate stability; non-opioids do NOT provide analgesia nor depress CNS; assess respiration rate/quality
  15. "Door-to-dose" antibiotic regimen
    Within 4 hours after entry to hospital, should be administered with antibiotics to decrease risk of infection with pneumonia
  16. Pneumonia / flu vaccine
    • For high-risk: annual flu vaccine
    • first pneumococcal vaccine at 60 then Q5years per physician recommendation
  17. Elderly and sign of infection
    Confusion is cardinal sign of infection in elderly. May not display classic signs of infection (fever, breath sounds, cough, sputum production, dsypnea, and chills)

    "Shift to left" tell tale sign of infection; normal is 0% - 8% Bands (immature neutrophils) and 50%-70% neutrophils
  18. Fever assessment and treatment / NSAIDs/ ASA toxicity
    If > 101.4F, may use anti-pyretics; should have effect in 1hr

    NSAIDs: Do not use aspirin with children with flulike symptoms due to Reye's syndrome; take with food to minimize GI upset

    ASA toxicity: ototoxicity and nephrotoxicity, persistent GI or abd pain and easy bruising or bleeding; dizziness or ringing in ears
  19. Proper coughing / breathing techniques
    • Deep cough - inspire deeply; hold breath a second or two while closing glottis then release air while suddenly opening glottis
    • Huff cough - for clients with COPD; slows airflows, prevents collapse of smaller airways; just says "huff" 3-4x while exhaling
    • Stacked Cough - release of serveral short blasts of air instead of one deep cough; for surgical clients
    • Quad Cough - for neuromuscular clients
    • Incisional splinting

    Deep breathing helps expand alveoli and promotes cough with decrease of atelectasis

    Assess client response: color, alertness, HR and breathing effort
  20. Transmission Based Precautions
    • Contact - gown, gloves, splash shield (if needed)
    • Droplet - pneumonia, mumps, influenza; 3ft; cough, sneeze, talk
    • Airborne - TB, measles; requires N95 mask

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