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PVCC NUR171

Exam #1

QuestionAnswer
Lymphatic Vessels Bring fluid from interstitial space back to blood vessels. Empty into the subclavian veins.
Spleen Functions Produces antibodies, filters old RBCs, and destroys old RBCs
Splenectomy procedure and risk Removal of the spleen which results in an increased risk for infection due to the removal of the immunity functions of the spleen.
Thrombocytes Platelets with coagulation factors
Universal donor O-; can donate to all blood types
Blood type A or B can donate to... AB
Can Rh+ donate to Rh- NO...Rh- cannot receive + blood.
Can Rh- donate to Rh+ Yes.
Only IV fluid hung with blood products Normal Saline
Time for s/s to appear for a reaction to donated blood products. 15-20 minutes. RN must stay with pt during this time to verify no adverse reaction to blood.
S/S of blood transfusion reaction Chills, Fever, SOB, Tachycardia, back pain, HA, chest pain, hypotension.
If s/s of hemolytic reaction occur when a patient is receiving blood transfusion... STOP infusion immediately, notify physician and notify blood bank. Incident report may be needed, per agency policy.
Length of time a unit of blood can hang 4 hrs. Must then discard. If greater duration is required or fluid overload occurs, may call blood bank and have unit split into smaller units.
Procedure when additional fluids are needed during blood transfusion. RN will need to start another line. Additional fluids may NOT be piggybacked.
Pre-transfusion check 2 RNs needed to positively identify patient and blood unit ID. Blood hung on pump.
IV gauge for blood transfusion IV gauge 18-20
Liver function Produces bile, Metabolizes, Synthesizes coagulation factors VII, IX, X, and prothrombin. Stores Vitamins and glycogen.
Lymph nodes to be concerned about Greater than 1 cm, hard, and immobile.
Hematology diagnostic tests Blood chemistry, Hematologic studies, Bone marrow aspiration/biopsy, Coagulation studies, Bone scan, Schilling test.
When use of radioisotopes during diagnostic test is required, RN needs to assess for what type of allergy. Shellfish allergy
Hematocrit should be about __x greater than hemoglobin 3x
HgB value when blood transfusion is usually required. 9
Lovenox dosing is based on.. Patient's weight
INR normal value 1-2; patient's with cardiac issues may be 2.5-3.5
Platelet normal value 150,000-400,000.
Increase in platelet value = Blood clot, affects on the cardiac and respiratory system due to higher blood viscosity.
Decrease in platelet value = Increased risk for bleeding
Primary blood dyscrasias Problem with the blood...i.e sickle cell
Secondary blood dyscrasias A cause other than defect in blood...i.e malnutrition, drugs, disease processes.
Sickle cell is more prevalent in... African Americans
Sickle cell can cause Clots which lead to hypoxia which leads to tissue necrosis.
Anemia Result of decreased production, increased RBC destruction, or blood loss
Polycythemia Results from hypoxia, erythropoietin, secreting tumors, kidney disease, genetic defects. Increases blood viscosity = clot.
Hypochromic Anemia Iron or vitamin deficiency. Most common anemia.
Pernicious Anemia Lack of intrinsic factor. Occurs with GI issues. TX: B12 shots monthly for the rest of their life.
Erythroblastosis Fetalis Anemia Pregnant mother with Rh- blood, is exposed to baby's Rh+ blood. The mother produces antibodies and attacks fetus' blood. AKA hemolytic anemia
Secondary Anemia Caused by bleeding, trauma, leukemia, cancer, kidney disease.
Anemias caused by genetic factors Sickle Cell Anemia or Spheroidal
Aplastic Anemia Caused by malfunctioning bone marrow.
Anemia is more prominent in... Women then children, especially pregnant women.
High risk groups for anemia Pregnant women, women, children, poor dietary intake, PUD, long term ASA use, colon cancer.
Signs and symptoms of anemia Pallor, fatigue, weakness, dyspnea, brittle nails, pica, headache.
Iron supplements Best on empty stomach, vitamin C increases absorption. SHOULD NOT be given with milk or antacid.
Vitamin that increases iron absorption Vitamin C
Considerations when giving IV iron Could have anaphylactic reaction. MUST do test dose first. Requires a separate IV site
Considerations when giving IM injection of iron Deep IM injection using z-track. Change the needle and aspirate.
Dietary sources of iron Dark green leafy vegetables, Beans and peas, dried fruits, eggs, nuts, raisin, seafood, spinach, whole grain
Dietary sources of B12 Eggs, meat, poultry, shellfish, milk and milk products.
Dietary sources of Folate Fruits and vegetables.
Dilantin use related to folate Dilantin (used for seizure control) does not allow patient to absorb folate.
Patients who may have trouble absorbing folate... Pts using dilantin, ETOH, or hemodialysis.
Treatment for polycythemia vera Removal of blood, IV fluids
Possible complications of polycythemia vera Stroke, MI, embolism, infection (due to immature WBC), bleeding (platelets are immature), poor perfusion, stasis ulcers.
Hemophilia Genetic disorder which could cause excessive bleeding.
Increase in WBC precursors with accumulation in bone marrow or lymph tissue is sign of... Leukemia
Blasts Immature WBCs
Decrease in WBCs Neutropenia, lymphocytopenia
Increase or decrease in WBCs causes and increase in... Risk for infection. (When WBCs increase rapidly there is decreased immune function due to immature cells)
Neutropenia Decrease in neutrophils. Caused by cancer, immunosuppressive disease/therapy, HIV, Lupis
Leukopenia Decrease in WBC
Increase in WBC is what kind of infection Bacterial
Decrease in WBC is what kind of infection Fungal or viral
Patients with leukopenia need to have what type of precautions Reverse isolation: no kids, keep in room as much as possible, no sick visitors or staff, wash fruits and veggies thoroughly (cooked is best), monitor temp every 4 hours, mask gown when leaving room.
Precautions for radiation therapy site. No soap or lotion can be applied to area. Wash with warm water only.
Signs and symptoms of leukemia Fever or night sweats, frequent infections, feeling weak or tired, headache, bleeding/bruising, bone and/or joint pain, swollen lymph nodes, weight loss
Blood tests for leukemia CBC, platelets and HCT/HgB. Bone marrow biopsy.
Side effects for chemo Bruising, fatigue, infection, bleeding, hair loss, nausea, vomiting, diarrhea, anorexia
Monoclonal antibodies Used for tx of CLL(Chronic lymphocytic leukemia. Binds to leukemia cells and enables immune system to kill cell.
Interferon Slows growth of cells. Mostly used for GI/Colon cancer
Biological therapy side effects Rash/swelling at injection site, anemia, flu like symptoms. Not as severe as with chemo/radiation.
Radiation and chemo must occur before ... Bone Marrow Transplant
Radiation therapy side effects Fatigue, redness, dryness, tenderness at the site of therapy.
If there is an order for wound care on a radiation site, the nurse needs to .... Talk to the radiologist before performing wound care.
Side effects of Bone Marrow Transplant Infection, bleeding, s/e from high doses of chemo and radiation (which must occur before BMT)
Hodgkin's lymphoma Malignant.
Lymphatic cancer is usually... Systemic
Lymphoma signs and symptoms Fatigue, night sweats, temperature, swollen lymph nodes (greater than 1 cm, hard, and immobile).
PICC and central line dressing changes are... STERILE
Thrombocytopenia Deficient number of platelets
Teach pts with thrombocytopenia to avoid.. ETOH, ASA, and NSAIDS
Symptoms of thrombocytopenia Sudden onset of petechiae, malaise, fatigue, general weakness.
Epistaxis Nose bleed
PICCS are usually used for about....weeks before changing. 6 weeks. Keep clean, flush, and perform sterile dressing changes.
Ferrous sulfate and antacids must be taken at least __ hours apart. 2 hours
Prior to surgery, any abnormal labs need to be reported to... The surgeon/physician
Clinical signs of stress Nausea, vomiting, diarrhea, increased pulse, increased respiratory rate, increased blood pressure, diaphoresis
Anxiety can impair... Cognition, decision making, and coping skills. Pts will not learn while anxious.
Perhaps the strongest positive coping mechanism... Hope
Pre-op assessment includes.. Health history and physical. Ask about Medications, family history, allergies, past reactions to anesthesia, past surgeries, infections (especially airway), COPD, asthma, smoking history, skin integrity.
Postoperative delirium can occur with... Dehydration, hypothermia, and adjunctive medications.
Problems affecting the neck or lumbar spine need to be relayed to PCP because... They can affect airway management and anesthesia delivery.
Patient's with diabetes mellitus are especially at risk for... Hypo/hyperglycemia, ketosis, cardiovascular alterations, delayed wound healing, infection.
Assessment for pts with diabetes mellitus prior to surgery.. Serum glucose tests morning of surgery (baseline). Clarify with physician if insulin should be taken.
Drugs to check with doctor before giving the morning of surgery. Insulin, thyroid meds, steroids
Abruptly stopping replacement corticosteroids could cause... Addisonian crisis
Given oral meds when pt is NPO May take meds with sip of water. Document appropriately.
IF a pt is NPO, the RN needs to double check to see if there is an order for... IV fluids. If not the RN needs to call the physician and see if one needs to be ordered.
Implications of obesity on surgical procedures. Stresses cardiac and pulmonary systems, increased risk of wound dehiscence and infection, slower recovery from anesthesia (meds hide in the adipose tissue), slower wound healing.
Considerations for underweight pts May need to provide extra padding to prevent pressure ulcers.
Legal preparations prior to surgery. Informed consent, signature for blood transfusion, advance directives and power of attorney.
If MPOA is approving a procedure over the phone... 2 RNs need to witness
Immediately prior to transportation to holding room for surgery, the nurse should have the patient....prior to medication administration. VOID :)
All patients are urged to stop smoking .....weeks before surgery. 4-6 weeks
Patients prone to latex allergies may also be allergic to... Avocados, bananas, peaches. Have asthma or hay fever.
Pre-op labs and diagnostic tests Blood studies (CBC, electrolytes, coagulation, blood type and match), UA, EKG, CXR
Pre-op teaching Deep breathing, incentive spirometry, splint incision, turn, reposition (prevent atelectasis/pneumonia). Leg exercises and antiembolic SCDs.
Role of the Scrub Nurse Provides the surgeon with required instruments, sponges, drains, and other equipment, anticipating what will be needed. Prepares sterile tables prior to surgery.
Holding area Complete preoperative preparations
Circulating nurse Manages/coordinates patient care in the OR, protects safety/health needs, ensures rights are protected (controlling cleanliness, temp, humidity, and lighting).
The circulating nurse and the scrub person are responsible for accounting for all..... Sponges and instruments at the close of surgery.
One of the most significant potential hazards to the pt in the OR is... Electricity (electric shock and burns)
Time out or procedural pause Before surgery or a procedure, surgeon and nurses will verify correct patient, surgical site, informed consent, etc.
General anesthetic Produces analgesia, relaxes muscles, results in a sleep-like state. Patient will be intubated.
Regional anesthetic Produces decreased sensation and pain in selected body parts by way of nerve blocks, intrathecal blocks (in brain), or epidural blocks.
Local anesthetic Depresses superficial peripheral nerves and blocks conduction of pain impulses from their site of origin.
IV Conscious Sedation Diazepam/Valium, Midazolam/Versed. Usually need RN present constantly during conscious sedation.
Cardiac meds need to be Ok by..... prior to discontinuation for a procedure. Cardiologist
Skin staples Reduces tissue handling and accomplishes wound closure faster than suturing. Usually removed within the first week after surgery.
Malignant hyperthermia Reaction to anesthesia. Ask pts prior to surgery if they have any family member who have experienced this. Without antidote, the pt dies.
S/S of malignant hyperthermia Increased temperature, rigid muscles
PACU Care One on one. Monitor pain, vitals, drains, cardiac monitor, take vitals every 15 mins and document.
Loud, irregular respirations may indicate....after surgery. May indicate obstruction of the airway, possibly from emesis, accumulated secretions, or patient positioning that allows the tongue to fall to the back of the throat.
If respiratory rate in decreased or O2 sats are 90-92... Raise HOB and encourage patient to take deep breaths.
Decreasing BP and increased pulse rate in the post-op patient may signify... Hemorrhage or shock
Sinus Bradycardia All intervals of PQRST wave normal, just slow pulse. Monitor V/S
Sinus Tachycardia All intervals of PQRST wave normal, just fast pulse. Monitor V/S. Assess pt for cause.
Atrial Fibrillation Atria contracting spontaneously, ventricles can contract normal part of the time. Atrial rate may appear to be 350-600 while ventricle rate is 100-160
2 shock-able waves V tach and V fib
Ventricular Fibrillation DEADLY RHYTHM. Rapid uncoordinated firing of the ventricles. This rhythm does not generate a pulse. Interventions: Quickly check pulse, if no pulse, De-fibrillate immediately.
Before giving water or ice chips to post-op patient... Assess for gag reflex.
When a pt is transferred from PACU to Med/Surg, assess condition every... 15 minutes for the first hour, every 30 minutes for 2 hours, every hour for 4 hours, then every 4 hours as needed.
If bleeding is noticed on a post-op bandage... Circle blood and time bandage, then recheck every 15 minutes.
Before discharge from an ambulatory surgical center, the patient should... Be able to void and ambulate independently (or up to baseline), be alert and oriented, have minimal nausea and vomiting, have a person to accompany them home.
If pt has flatulence or risk of paralytic ileus, or DVT, it is best to... Get pt up and walking. Best way to prevent these issues.
Nutrition for post-op Diet with significant amounts of protein and vit A and C help rebuild tissues and promote wound healing. Adequate carbs and fat are also needed to avoid depleting protein stores.
Time at which patients should void post-op Within 6-8 hours. Janice gets nervous around 4 hours w/o voiding.
Inadequate urinary output may indicate ... Hypovolemia, hemorrhage, electrolyte imbalance, inadequate circulation, hypoxia, or impending shock.
Paralytic ileus Very painful, usually responds to TX with an NG tube, bowel rest, and IV.
If PO meds are crushed and inserted into NG tube... Need to turn off suction for 30-50 minutes.
Hemo-vac output measured every ... 8-12 hours.
Programming of PCA pumps need to be verified by... 2 RNs
Trust vs. Mistrust Newborn or infant
Autonomy vs Shame and Doubt Toddler
Initiative vs Guilt Preschool
Industry vs Inferiority School-age
Identity vs Role Confusion Adolescence
Intimacy vs Isolation Young adult
Generativity vs Stagnation Middle-age
Ego integrity vs. Despair Old age
IS should be done every... while awake 10x every hour
Turn, cough, deep breathe should be done .... Every hour
Obese patients tend to breathe poorly when..... increasing the risk of hypoventilation and post-op pulmonary complications Supine
Antidote for malignant hyperthermia Dantrolene sodium (Dantrium)
S/S of shock Pallor, cool moist skin, rapid breathing, cyanosis, rapid or weak pulse, low BP and concentrated urine.
Drugs that turn urine red. Anticoagulant
Drugs that turn urine orange or orange-red Pyridium
Drugs that turn urine green or blue-green color Elavil or B-complex vitamins
Injectable componds that can turn urine/stool black or black-brown. Injectable iron
Reasons for irrigating the bladder To instill medication and to flush out old blood and clots (post TURP, injury, or bladder surgery.
TURP Transurethral resection of the prostate.
TURBT Transurethral resection for bladder tumor.
Monitoring irrigation fluid in I&O. Irrigation fluid is intake.
Areas to avoid placing leads for EKG Avoid bony prominences and fatty areas.
Rhythm strip 6 second strip that can be printed from a monitor normally in lead II
Precordial leads V1-V6
Limb Leads Leads I, II, III (White, black, and red)
Isoelectric line Baseline on EKG
The normal running speed for EKG 25mm/sec (Dr. may ask to increase speed if extreme tachycardia is present)
Artifact or wandering baseline occurs: Look to see if patient is moving or jerking, if there is muscle tremors. If there is a loose cable or lead.
What position should a pt be in prior to EKG Supine or semi-fowlers
When can magnets be placed over pace-maker for EKG. Only place magnet over pacemaker with physician order and document. (also have emergency equipment ready)
Electrodes in good condition may be reused within... 24 hours
The limb electrodes may be placed on... Lower extremities or on rib cage (avoid bony prominences or fatty tissue)
Cardiac Alert System Goal is to obtain 12 lead EKG within 5 minutes of admission to ED or per hospital policy. This is in place to increase door-to-ballon times and improved patient care.
Normal Sinus Rhythm Normal rate, normal rhythm
Arrhythmia Abnormal heart rhythm
How to determine heart rate from 6 sec strip Count R waves and multiply by ten. i.e. 4 waves x 10 = 40.
Bradycardia HR less than 60
Tachycardia HR more than 90
Atrial Fibrillation. Heart is quivering. Fast irregular activity can cause blood clots and stroke. May require medication.
Ventricular Fibrillation Lethal. Requires immediate defibrillation
Asystole AKA Flatline. No rhythm and no pulse=legally dead.
MI on EKG Diagnosed by ST elevation and/or reciprocal changes.
Myocardial ischemia on EKG Flipped T waves. May be caused by lack of O2 to heart or previous MI.
Pulse-less Electrical Activity (PEA) Perform CPR. Electrical activity is occurring but no heart beat.
Purpose of a chest tube To expand the lung to normal negative intrathoracic pressure.
Pneumothorax (pneumo) Pressure builds in pleural space = shrinks lung.
Two types of pneumothorax Open (sucking chest wound) and Closed.
Which is more dangerous, and open or closed pneumothoroax? Closed. It allows pressure to build and will eventually cause a tension pneumothorax.
Hemothorax Blood in pleural space.
Pleural effusion Transudate (clear fluid from CHF or renal and liver failure), Exudate (from TB or pneumonia) or Empyema (pus) in pleural space.
Tension Pneumothorax EMERGENCY. Causes rapid cardiovascular collapse from pressure on the heart.
S/S of Tension Pneumothorax Decreased BP, Increased Pulse, JVD, Deviated trachea
S/S of Pneumothorax Shallow respirations, decreased breath sounds, anxiety, SOB, Decreased O2 sats.
Tx for Tension Pneumothorax Needle Decompression using a large bore IV catheter. After decompression it will be a sucking wound and will need a chest tube.
Thoracostomy Procedure Insertion of chest tube and drainage system. Drainage system does not need to be sterile but the chest tube does.
Always keep the chest tube ....the level of the pt. Below the pt. Drainage system works on gravity.
Chest tubes need to be.... after placement. verified with CXR
What should you do if a chest tube gets pulled out on accident. Immediately apply a Vaseline gauze. It should be taped to the bed.
CDI Clean, dry, intact.
Order to obtain blood samples Blood cultures are always first. Then Blue, Red, Green, Purple, Grey.
Diagnostic tests for Lavender Tube CBC, Blood counts, blood sugar
Diagnostic tests for Light Blue Coagulation studies (PT, PTT, INR)
Diagnostic tests for Green top Ammonia, troponin, iSTAT
Diagnostic tests for Gray top Alcohol levels
Diagnostic tests for Red top CMP (chemistry)
Gray tops are drawn after what type of prep is used.. Betadine (NOT Alcohol or Chloraprep. They contain alcohol which may interfere with alcohol levels in blood)
Gray top tubes are kept....after blood is drawn. On the person that performed the phlebotomy (in their pocket)
Arterial blood gas (ABG) procedure. Must immediately go on ice, hold manual pressure for at least 5 minutes, and should be hand delivered to the lab.
Lab specimens that go on ice Ammonia (green), lactate or lactic acid (green), ionized calcium (green), ABG (syringe)
If patient has a vagal reaction when drawing blood.... Stop draw, call for help, lower HOB, and Check airway.
Purpose of NGT Lavage stomach, assess for GI bleed, Decompress stomach.
Check continuous tube feedings every... 4-6 hours.
Prodrugs Drugs that are designed so that their 1st metabolite is the active form of the drug. If this drug is given IM or IV it will take longer to get a therapeutic effect.
Drug half-life Time in which half of original dose is removed. It takes about 5 half-lives to remove a drug.
Additive effect Similar drugs and response
Antagonistic effect Less effective than each alone
Synergistic effect Greater effect than each alone
Teratogenic Causes Fetal deformities
Mutagenic Mutates DNA
Carcinogenic Predisposes PT to cancer
Created by: crna2b