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M6Nursing Skills

phase 2 test 2 'basic nursing skills'

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