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M6Nursing Skills
phase 2 test 2 'basic nursing skills'
| Question | Answer |
|---|---|
| Acute Pain | short duration lasts <6 months floods body with epinephrine (flight/flight) |
| Chronic Pain | lasts >6 months pain can be continuous or intermittent |
| Other Types of Pain | mild or severe intermittent or intractable burning, dull, sharp precisely or poorly localized referred pain |
| Which type of pain floods the body with epinephrine causing a fight or flight response? | acute |
| Gate Control Theory | pain impulses regulated/blocked by gating mechanisms pain impulses flow freely when gates open "gate" blocked when another stimulus if another stimuli besides pain are transmitted |
| Stimuli that can Block Pain (Gate Control Theory) | auditory, visual |
| Nursing Interventions to Relieve Pain | back rub warm compress ice applications auditory/visual distraction |
| Pain Assessment Characteristics | site severity duration location |
| Pain Assessment Subjective | patient's own words/description pain relief measures interventions that don't relieve pain what makes pain worse pain medication |
| Pain Assessment Objective (Physiologic) | tachycardia tachypnea increased BP pallor/diaphoresis increased muscle tension N&V with severe pain |
| Pain Assessment Objective (Behavioral) | changes in facial expression clenching of fists crying moaning tossing in bed assuming fetal position clutching effected body part |
| Pain Scales | allows patient to rate pain pain intensity is measured allows nurse to take proper measures to assist in pain control allows nurse to plan care without causing further pain |
| Types of Pain Scales | Pain Assessment Scales Visual/Numeric/Categorical Pain Scales Wong-Baker Grimace Scale |
| Nursing Responsibilities | begin intervention ASAP reduce patient's anxiety clarify and answer questions assess pt's ability to participate choose measures appropriate for severity assist the patient to make decisions be an effective patient advocate keep trying protect pt |
| How to be an Effective Patient Advocate | believe patient clarify responsibilities respect patient's response to pain confer with the patient explore pain with patient be with patient often |
| Goals of Nursing Interventions | pain relief resume ADLs comfortably improved self-esteem improved sleep pattern |
| How to Conduct Pain Assessment | ID patient, provide privacy wash hands, standard precautions explain procedure assess pt's perception of pain examine site assess psych. response develop plan doc. findings reassess after interventions doc. reassess. findings report unexpected o |
| Nursing Responsibilities for Pain Relief Measures | use different measures intervene before pain becomes severe use measures patient believes works |
| Methods of Pain Control (Physical) | TENS unit massage hot and cold therapy |
| Methods of Pain Control (Psychological and Cognitive) | distraction relaxation guided imagery hypnosis meditation biofeedback |
| Methods of Pain Control (Medication) | nonopioids opioids adjuvant analgesics oral, IV, IM, PCA, and epidural |
| Acupressure | uses gentle pressure at points on body |
| Acupuncture | stimulate certain points on body by inserting special needles |
| Aromatherapy | uses essential oils produced from plants to provide health benefits |
| Chiropractic Therapies | includes manipulation of muscularskeletal system |
| Herbal Therapy | uses herb to provide health benefits |
| Holistic Nursing | treats mind-body-spirit |
| Imagery | create mental images to evoke physical changes in body |
| Reflexology | zones and reflexes in different parts of body correspond to all parts of body; specific areas of foot |
| Relaxation | state of generalized decreased cognitive, physiologic, behavioral arousal |
| Therapeutic Massage | manipulation of soft tissues of body to assist with healing |
| Yoga | control of body through correct postures and breathing, control of emotions and mind, meditation and contemplation |
| Complementary Therapies | alternative therapies to complement conventional |
| Alternative Therapies | just using alternative therapies |
| Conventional Therapies | traditional, allopathic |
| Goal of Herbal Therapy | restore balance within the client by facilitating the self-healing ability |
| True/False Manufactures of herbs are regulated and required to demonstrate safety, efficacy, or quality. | False |
| Pharmaceutical Therapy | drugs that are derived from herbs have separated the active ingredients and use only that part, making them stronger and incurring more adverse effects |
| Risk on using prescription drugs concurrently with herbal remedies. | possible health risks as a result of adverse interactions |
| Nursing Implications for Herbal Products and Dietary Supplements | medication history past and present medical history screen for herbal use |
| How does chiropractic therapy work? What chiropracticters do? | adjusts the joints of body by gentle manipulation to put area in proper alignment often uses radiographs to assist with diagnosis doesn't prescribe medications hot/cold packs |
| Belief behind acupuncture | form of energy (Qi) that flows through body meridians can become blocked stimulates certain points on body by insertion of special needles |
| How acupressure works | uses gentle pressure at similar points as acupuncture uses finger or blunt object reduces tension, increases circulation, enables body to relax deeply relieves stress, increases resistance to disease, promotes wellness helps with discomfort and sleep |
| How therapeutic massage works | performed by trained professional manipulates soft tissues of body and assist in healing simple massage may be given to relax patient at bedtime |
| How oils used in aromatherapy. Risks | inhalation, applied topically, used in bathing, and for psychological effects, orally, candles or oil dispersers may have potential abortifacient effects |
| Describe magnet therapy | thought to increase circulation to affected area promotes healing, stimulates acupuncture points, increase energy, decrease pain |
| Contraindications of magnet therapy | pregnancy, pacemakers, insulin delivering system, cochlear implants, electric blanket or heating pad, myasthenia gravis, hyperthyroidism, adrenal gland dysfunction, hypothalamic or pituitary gland dysfuction |
| Imagery Therapy has Power to | evoke psycho-physiologic responses |
| Imagery Therapy often goes hand in hand with | relaxation therapy |
| Benefits of Yoga | tone muscles that balance all parts of body, increases flexibility, good for treating chronic back problems, beneficial for nervous system |
| Biofeedback | physiological control technique: use of monitoring devices that display information about the operation of a bodily function that's not normally consciously controlled, e.g. heart rate and breathing |
| pH range of blood | 7.35-7.45 |
| NaCl concentration of blood | o.9% |
| Hematocrit for men and women | men 42-52% women 37-47% |
| Components of Blood | red blood cells white blood cells platelets plasma |
| Albumin | thicken and maintain blood volume |
| Globulin | antibodies to protect body from infections |
| Fibrinogen | necessary component for blood clotting |
| Average Adult Blood Volume | 5-6 L |
| Granular Leukocytes | neutrophils eosinophils basophils |
| Nongranular Leukocytes | lymphocytes monocytes |
| Three Critical Functions of RBCs | transport regulate protect |
| Normal Hemoglobin Level for Men and Women | men 14-18g/dL women 12-16g/dL |
| Average Lifespan of RBCs | 120 days |
| Erythropoiesis | process of RBC production |
| Factors of Erythropoiesis | health conditions of bone marrow dietary substances (iron, copper, essential amino acids) vitamins: riboflavin (B2), pryidoxine (B6), B12, folic acid |
| Erythropoietin Enzyme | released by kidneys when RBCs low carried to bone marrow initiates development of mature RBCs |
| Neutrophils | first responders phagocytosis primary phagocytic cells involved in acute inflammatory response releases lysozyme to destroy certain bacteria normal value 60-70% |
| Eosinophils | play a role in allergic reactions effective against parasitic worms normal value 1-4% |
| Basophils | essential to nonspecific immune response to inflammation releases histamine during tissue damage or invasion cytoplasmic granules contain heparin, serotonin, and histamine normal values 0.5-1% |
| Monocytes | second type of WBC to arrive at scene of injury engulf antigens and cell debris removes dead bacteria and cells in recovery stage of acute bacterial infection normal value 2-6% |
| Lymphocytes | responsible for antibody formation special protein combats foreign invaders/antigens antigen-antibody process protects body normal values 20-40% |
| B Cells | search, identify, and bind with specific antigens |
| T Cells | divide rapidly and produce large numbers of new T cells sensitized to the antigen it was exposed to |
| Platelets | smallest cells in blood life span 5-9 days normal value 150,000-400,000 mm3 of blood produced in red bone marrow |
| Stages in Clotting | release of clotting factors formation of thrombin formation of fibrin trapping of RBCs to form clot |
| Most Common Type of Blood Group | A |
| Indications to use Whole Blood | hemorrhage hypovolemic shock |
| Fresh Whole Blood | considered safe in military environment |
| Indications to use Packed RBCs | when whole blood could result in circulatory overload symptomatic anemia hemoglobin <6 g/dL |
| Indications to use Deglycerolized or Washed RBCs | washed in NS to remove most plasma protein history of hypersensitivity despite prophylaxis 20% of RBCs loss in process |
| Indications to use Fresh Frozen Plasma | control of bleeding replaces plasma without RBCs or platelets contains most clotting factors given to patients with PT/PTT > 1.5 times normal warfarin overdose |
| Indications to us Plasma Exchange (Plasmapheresis) | removal of plasma that contains disease used to treat autoimmune disease |
| Indications to us Plasma Expanders (Dextran) | not considered blood/blood product temporary volume expansion in hemorrhagic shock for patients who refuse blood transfusion |
| Indications to use Platelets | prevent or treat bleeding problems in surgical patients deficiencies from aplastic anemia deficiencies from thrombocytopenia count below 20,000 mm3 |
| Indications to use Cryoprecipitate (FEP that contains VIII, XIII, and Von Willebrand factor) | hemophilla A (missing factor VIII) fribrinogen deficiency Von Willebrand's disease |
| Indications to use Factor IX Complex | treatment of hemophilla B (Christmas Disease) |
| Nurse is to use at least ___ size catheter for blood transfustion | 20 gauge |
| Autologous Transfusion | patient's own blood obtained and infused during surgery or after traumatic injury |
| What is the only solution blood can be infused with? | normal saline (o.9%) |
| Blood or Blood Products must be transfused within how long of leaving the blood bank? | 30 minutes |
| Who can start blood transfusion? Rate of IV? How long must they stay? | RN slow 10-24 mL in 15 min first 15 minutes |
| How often vital signs are taken during transfusion? | 15, 30, 60 minutes after transfusion started hourly therafter |
| Types of Transfusion Reactions | acute hemolytic febrile non-hemolytic (most common) allergic (mild, moderate, or severe) circulatory overload infectious disease transmission |
| Acute Hemolytic | transfused blood incompatible with patient's blood antibodies in the recipient's plasma attach to antigens on transfused RBCs causes intravascular destruction of transfused RBCs |
| Manifestations of Acute Hemolytic Reaction | chills, fever, low back pain, flushing, chest pain, wheezing/SOB, hypotension, N/V, hematuria, abdominal pain, decreased UOP acute renal failure, shock, cardiac arrest, death |
| Febrile Non-Hemolytic and Clinical Manifestations | sensitivity of recipient to WBCs and platelets in donor's blood sudden chills and fever, headache, flushing, muscle pain |
| Clinical Manifestations of Allergic Reaction | coughing/wheezing, urticaria, N/V, hypotension, loss of consciousness, possible cardiac arrest |
| Clinical Manifestations of Circulatory Overload | cough, dyspnea, pulmonary congestion (crackles), headache, hypertension, tachycardia, distended neck veins |
| Clinical Manifestations of Infectious Disease Transmission | rapid onset of chills, high fever, vomiting, abdominal cramping, marked hypotension, flushed skin, back pain |
| Nursing Interventions for Transfusion Reactions | stop transfusion immediately administer NS with new line notify charge nurse & physician immediately remain with patient, observing S&S obtain vital signs every 5 min prepare to give emergency drugs per physician's order prepare to perform CPR lab |
| Send __________________________ to lab after transfusion reaction. | remaining blood and tubing set used during transfusion sample of patient's blood per agency protocol urine sample from patient |
| Reasons to Place a Vascular Access Device | long term IV therapy need for frequent blood samples admin of chemo therapy blood transfusion large volume fluid replacement TPN limited peripheral venous access avoids dangers of multiple venipunctures perform hemodialysis (depends on type of cat |
| 3 Categories of Central Venous Access Devices | percutaneous CVCs tunneled CVCs implanted infusion ports |
| Percutaneous Central Catheters | inserted through chest wall into the subclavian vein inserted through neck into the internal jugular vein |
| Use for Peripherally Inserted Central Catheters (PICC) | alternative for long term IV access less risk of complications than CVCs less risk of phlebitis and infiltration than peripheral lines less expensive to maintain that CVCs |
| Placement of PICC Lines | long venous catheter 40-65 cm in length usually inserted from cephalic/balsilic veins in upper arm extends into the distal third of superior vena cava can remain in place for 7 days - 3 months or > may have single or double lumen |
| Tunneled CVCs | Central Venous Tunneled Catheters (CVTC) implanted surgically through a subcutaneous tissue creates space between catheter and vein may remain in place indefinitely advanced into subclavian vein and into superior vena cava |
| Implanted CVADs | surgically place under local anesthesia implanted into subcutaneous tissue of upper chest wall threaded into superior vena cava port easily palpated advantage: no external catheter to care for must heparinize port every 4 weeks Huber needle |
| Recommendation for Dressing Changes for Central Lines | 24 hours after insertion every 7 days thereafter (air occlusive) every 2 days (gauze dressing) caps placed on ports not in use every 3-7 days use sterile technique |
| SASH Method of Medication Administration | Saline Administer Saline Heparin |
| Complications of VADs | infection and sepsis pneumothorax after recent CVC insertion occlusion precipitate occlusion mechanical - catheter moved from proper placement |
| 6 Rights | Right Patient Right Medication Right Time Right Route Right Dose Right Documentation |
| Never leave medication _________ | unattended |
| 3 Basic Routes for Medication Administration | enteral percuteneous parenteral |
| Enteral Routes | PO - by mouth Tubal - NG, G Tube, J Tube Suppository Enema |
| Enteral Forms | powders pills tablets - capsules, enteric coated, scored, sublingual capsule lozenge/troche liquid - suspensions, elixirs, syrups suppositories |
| Percutaneous Routes | Topical Instillation - eyes, ears, nose, vagina, mouth Inhalation |
| Percutaneous Forms | lotions ointments creams powders topical disk |
| Paraenteral Routes | IM SC/SQ ID IV |
| Paraenteral Forms | ampules vials large volume of fluids (IV bags) |
| Where to read amount of liquid medication in cup? | bottom of the meniscus |
| Eye Creams Applied _______ to _______ | inner to outer canthus |
| Otic Medications Pull Ear _____ for Children Under 3 and _______ for 3+ | down and back up and back |
| Administering Inhalers | without spacer - inhaler 1/2 - 1 inch away from mouth, lips shouldn't touch inhaler with spacer - exhale fully, grasp mouthpiece with teeth and lips inhale for 2-3 seconds and hold for 10 wait 2-5 min between puffs for same 5-10 for different medicatio |
| Types of Syringes | tuberculin insulin 3 mL safety glide disposable injection |
| Tuberculin Syringe | holds total of 1 mL used for giving small doses of epinephrine, intradermal skin tests and SC medications |
| Insulin Syringe | calibrated in units only used for insulin concentration to match calibration of syringe |
| 3 mL Syringe | most frequently used used for most IM injections used to administer volumes 1-3 mL |
| Safety-Glide Syringe | prevent needle sticks widely used |
| Disposable Injection Units | single-dose, pre-filled Tubex and Carpuject injection systems |
| Needle Lengths for ID, SC, Insulin, IM | ID - 3/8-5/8 inch SC - 1/2-5/8 inch Insulin - 5/16-1/2 inch IM - 1-1.5 inch |
| Types of IV Needles | butterfly over-the-needle catheters |
| Considerations for Site Selection for an IM Injection | ensure site adequate location of bones, nerves, and blood vessels amount of solution size of individual's muscle mass integrity of individual's tissue |
| Site Position and Location for IM | ventrogluteal - adults & children >7 months dorsogluteal - no longer recommended for use vastus lateralis - preferred for children < 3 months deltoid - no more that 1 mL, too small for children and older adults |
| How to place 2 medications into 1 syringe | sterilize tops of both vials draw in air for 1st vial inject air draw in air for 2nd vial inject air 2nd vial withdraw 2nd med withdraw 1st med |
| Facts for the Administration of IM Medication | absorption faster than SC injection needle 20-22 gauge needle length 1 - 1.5 inches no more than 3 mL injection, only 1 in deltoid sites: ventrogluteal, vastus lateralis, deltoid |
| Angle for Insertion of IM Medication | 90 degrees |
| Z Track Method | used for injecting medications irritating to tissues seals medication deep within muscle tissue keeps tissue irritation to a minimum prevents staining or tracking of medication into tissue |
| Purpose of Administration of IM Injections? | instilling serum, vaccine, skin test agents |
| Aspirate IM Injections? | no |
| Volume and Rate of IM Injection | 0.1 mL or less slow |
| Sites for IM Injections | upper chest, inner aspect of lower arm and scapula area |
| Needle Length and Gauge for IM Injections | 25 gauge 3/8 - 5/8 inch |
| Drug Absorption Rate for SC Injections | slower than IM |
| Sites for SC Injections | upper arm, abdomen, thigh and scapula |
| Amount of Drug that can be Infused SC | no more than 1 mL |
| Needle Length and Gauge for SC Injections | 25 gauge 1/2 - 5/8 inch |
| Angle for SC Injections | 45 - 90 Degrees |
| Angle for ID Injections | 15 Degrees |
| Uses for IV Therapy Administration | provide fluid and electrolyte maintenance, restoration, and replacement administer medications and nutritional feedings administer blood and blood products |
| Methods of IV Therapy Administration | IV push Intermittent Venous Access Device (heparin/saline lock) Intermittent Infusion (IV piggyback) Continuous Infusion Patient Controlled Analgesia (PCA) |
| When IV Push Used | emergency situations |
| Effective and Efficient Method for Administration of Analgesic Medications | PCA |
| Another Term for Parenteral Nutrition | hyperalimentation |
| Types of Parenteral Nutrition | TPN PPN |
| Which Type of Parenteral Nutrition used for Long Term? Short Term? | TPN PPN |
| Nursing Monitoring of TPN | blood glucose daily weight I&O labs client's response |
| Checking Infusion and IV Site during IV Infusions | every hour flow of fluid air in tubing infiltration phlebitis |
Created by:
ealongo
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