phase 2 test 2 'basic nursing skills'
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
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| Acute Pain | short duration
lasts <6 months
floods body with epinephrine (flight/flight)
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| Chronic Pain | lasts >6 months
pain can be continuous or intermittent
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| Other Types of Pain | mild or severe
intermittent or intractable
burning, dull, sharp
precisely or poorly localized
referred pain
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| Which type of pain floods the body with epinephrine causing a fight or flight response? | acute
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| 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
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| Stimuli that can Block Pain (Gate Control Theory) | auditory, visual
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| Nursing Interventions to Relieve Pain | back rub
warm compress
ice applications
auditory/visual distraction
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| Pain Assessment Characteristics | site
severity
duration
location
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| Pain Assessment Subjective | patient's own words/description
pain relief measures
interventions that don't relieve pain
what makes pain worse
pain medication
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| Pain Assessment Objective (Physiologic) | tachycardia
tachypnea
increased BP
pallor/diaphoresis
increased muscle tension
N&V with severe pain
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| Pain Assessment Objective (Behavioral) | changes in facial expression
clenching of fists
crying
moaning
tossing in bed
assuming fetal position
clutching effected body part
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| 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
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| Types of Pain Scales | Pain Assessment Scales
Visual/Numeric/Categorical Pain Scales
Wong-Baker Grimace Scale
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| 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
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| 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
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| Goals of Nursing Interventions | pain relief
resume ADLs comfortably
improved self-esteem
improved sleep pattern
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| 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
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| Nursing Responsibilities for Pain Relief Measures | use different measures
intervene before pain becomes severe
use measures patient believes works
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| Methods of Pain Control (Physical) | TENS unit
massage
hot and cold therapy
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| Methods of Pain Control (Psychological and Cognitive) | distraction
relaxation
guided imagery
hypnosis
meditation
biofeedback
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| Methods of Pain Control (Medication) | nonopioids
opioids
adjuvant analgesics
oral, IV, IM, PCA, and epidural
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| Acupressure | uses gentle pressure at points on body
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| Acupuncture | stimulate certain points on body by inserting special needles
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| Aromatherapy | uses essential oils produced from plants to provide health benefits
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| Chiropractic Therapies | includes manipulation of muscularskeletal system
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| Herbal Therapy | uses herb to provide health benefits
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| Holistic Nursing | treats mind-body-spirit
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| Imagery | create mental images to evoke physical changes in body
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| Reflexology | zones and reflexes in different parts of body correspond to all parts of body; specific areas of foot
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| Relaxation | state of generalized decreased cognitive, physiologic, behavioral arousal
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| Therapeutic Massage | manipulation of soft tissues of body to assist with healing
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| Yoga | control of body through correct postures and breathing, control of emotions and mind, meditation and contemplation
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| Complementary Therapies | alternative therapies to complement conventional
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| Alternative Therapies | just using alternative therapies
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| Conventional Therapies | traditional, allopathic
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| Goal of Herbal Therapy | restore balance within the client by facilitating the self-healing ability
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| True/False Manufactures of herbs are regulated and required to demonstrate safety, efficacy, or quality. | False
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| 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
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| Risk on using prescription drugs concurrently with herbal remedies. | possible health risks as a result of adverse interactions
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| Nursing Implications for Herbal Products and Dietary Supplements | medication history
past and present medical history
screen for herbal use
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| 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
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| 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
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| 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
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| 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
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| 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
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| Describe magnet therapy | thought to increase circulation to affected area
promotes healing, stimulates acupuncture points, increase energy, decrease pain
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| 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
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| Imagery Therapy has Power to | evoke psycho-physiologic responses
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| Imagery Therapy often goes hand in hand with | relaxation therapy
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| Benefits of Yoga | tone muscles that balance all parts of body, increases flexibility, good for treating chronic back problems, beneficial for nervous system
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| 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
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| pH range of blood | 7.35-7.45
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| NaCl concentration of blood | o.9%
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| Hematocrit for men and women | men 42-52%
women 37-47%
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| Components of Blood | red blood cells
white blood cells
platelets
plasma
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| Albumin | thicken and maintain blood volume
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| Globulin | antibodies to protect body from infections
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| Fibrinogen | necessary component for blood clotting
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| Average Adult Blood Volume | 5-6 L
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| Granular Leukocytes | neutrophils
eosinophils
basophils
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| Nongranular Leukocytes | lymphocytes
monocytes
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| Three Critical Functions of RBCs | transport
regulate
protect
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| Normal Hemoglobin Level for Men and Women | men 14-18g/dL
women 12-16g/dL
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| Average Lifespan of RBCs | 120 days
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| Erythropoiesis | process of RBC production
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| Factors of Erythropoiesis | health conditions of bone marrow
dietary substances (iron, copper, essential amino acids)
vitamins: riboflavin (B2), pryidoxine (B6), B12, folic acid
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| Erythropoietin Enzyme | released by kidneys when RBCs low
carried to bone marrow
initiates development of mature RBCs
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| Neutrophils | first responders
phagocytosis
primary phagocytic cells involved in acute inflammatory response
releases lysozyme to destroy certain bacteria
normal value 60-70%
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| Eosinophils | play a role in allergic reactions
effective against parasitic worms
normal value 1-4%
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| 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%
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| 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%
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| Lymphocytes | responsible for antibody formation
special protein combats foreign invaders/antigens
antigen-antibody process protects body
normal values 20-40%
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| B Cells | search, identify, and bind with specific antigens
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| T Cells | divide rapidly and produce large numbers of new T cells sensitized to the antigen it was exposed to
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| Platelets | smallest cells in blood
life span 5-9 days
normal value 150,000-400,000 mm3 of blood
produced in red bone marrow
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| Stages in Clotting | release of clotting factors
formation of thrombin
formation of fibrin
trapping of RBCs to form clot
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| Most Common Type of Blood Group | A
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| Indications to use Whole Blood | hemorrhage
hypovolemic shock
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| Fresh Whole Blood | considered safe in military environment
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| Indications to use Packed RBCs | when whole blood could result in circulatory overload
symptomatic anemia
hemoglobin <6 g/dL
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| 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
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| 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
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| Indications to us Plasma Exchange (Plasmapheresis) | removal of plasma that contains disease
used to treat autoimmune disease
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| Indications to us Plasma Expanders (Dextran) | not considered blood/blood product
temporary volume expansion in hemorrhagic shock
for patients who refuse blood transfusion
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| Indications to use Platelets | prevent or treat bleeding problems in surgical patients
deficiencies from aplastic anemia
deficiencies from thrombocytopenia
count below 20,000 mm3
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| Indications to use Cryoprecipitate (FEP that contains VIII, XIII, and Von Willebrand factor) | hemophilla A (missing factor VIII)
fribrinogen deficiency
Von Willebrand's disease
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| Indications to use Factor IX Complex | treatment of hemophilla B (Christmas Disease)
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| Nurse is to use at least ___ size catheter for blood transfustion | 20 gauge
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| Autologous Transfusion | patient's own blood obtained and infused during surgery or after traumatic injury
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| What is the only solution blood can be infused with? | normal saline (o.9%)
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| Blood or Blood Products must be transfused within how long of leaving the blood bank? | 30 minutes
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| Who can start blood transfusion? Rate of IV? How long must they stay? | RN
slow 10-24 mL in 15 min
first 15 minutes
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| How often vital signs are taken during transfusion? | 15, 30, 60 minutes after transfusion started
hourly therafter
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| Types of Transfusion Reactions | acute hemolytic
febrile non-hemolytic (most common)
allergic (mild, moderate, or severe)
circulatory overload
infectious disease transmission
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| 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
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| 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
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| 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
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| Clinical Manifestations of Allergic Reaction | coughing/wheezing, urticaria, N/V, hypotension, loss of consciousness, possible cardiac arrest
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| Clinical Manifestations of Circulatory Overload | cough, dyspnea, pulmonary congestion (crackles), headache, hypertension, tachycardia, distended neck veins
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| Clinical Manifestations of Infectious Disease Transmission | rapid onset of chills, high fever, vomiting, abdominal cramping, marked hypotension, flushed skin, back pain
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| 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
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| 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
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| 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
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| 3 Categories of Central Venous Access Devices | percutaneous CVCs
tunneled CVCs
implanted infusion ports
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| Percutaneous Central Catheters | inserted through chest wall into the subclavian vein
inserted through neck into the internal jugular vein
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| 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
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| 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
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| 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
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| 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
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| 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
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| SASH Method of Medication Administration | Saline
Administer
Saline
Heparin
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| Complications of VADs | infection and sepsis
pneumothorax after recent CVC insertion
occlusion
precipitate occlusion
mechanical - catheter moved from proper placement
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| 6 Rights | Right Patient
Right Medication
Right Time
Right Route
Right Dose
Right Documentation
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| Never leave medication _________ | unattended
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| 3 Basic Routes for Medication Administration | enteral
percuteneous
parenteral
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| Enteral Routes | PO - by mouth
Tubal - NG, G Tube, J Tube
Suppository
Enema
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| Enteral Forms | powders
pills
tablets - capsules, enteric coated, scored, sublingual
capsule
lozenge/troche
liquid - suspensions, elixirs, syrups
suppositories
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| Percutaneous Routes | Topical
Instillation - eyes, ears, nose, vagina, mouth
Inhalation
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| Percutaneous Forms | lotions
ointments
creams
powders
topical disk
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| Paraenteral Routes | IM
SC/SQ
ID
IV
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| Paraenteral Forms | ampules
vials
large volume of fluids (IV bags)
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| Where to read amount of liquid medication in cup? | bottom of the meniscus
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| Eye Creams Applied _______ to _______ | inner to outer canthus
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| Otic Medications Pull Ear _____ for Children Under 3 and _______ for 3+ | down and back
up and back
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| 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
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| Types of Syringes | tuberculin
insulin
3 mL
safety glide
disposable injection
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| Tuberculin Syringe | holds total of 1 mL
used for giving small doses of epinephrine, intradermal skin tests and SC medications
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| Insulin Syringe | calibrated in units
only used for insulin
concentration to match calibration of syringe
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| 3 mL Syringe | most frequently used
used for most IM injections
used to administer volumes 1-3 mL
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| Safety-Glide Syringe | prevent needle sticks
widely used
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| Disposable Injection Units | single-dose, pre-filled
Tubex and Carpuject injection systems
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| 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
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| Types of IV Needles | butterfly
over-the-needle catheters
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| 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
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| 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
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| 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
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| 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
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| Angle for Insertion of IM Medication | 90 degrees
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| 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
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| Purpose of Administration of IM Injections? | instilling serum, vaccine, skin test agents
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| Aspirate IM Injections? | no
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| Volume and Rate of IM Injection | 0.1 mL or less
slow
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| Sites for IM Injections | upper chest, inner aspect of lower arm and scapula area
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| Needle Length and Gauge for IM Injections | 25 gauge
3/8 - 5/8 inch
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| Drug Absorption Rate for SC Injections | slower than IM
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| Sites for SC Injections | upper arm, abdomen, thigh and scapula
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| Amount of Drug that can be Infused SC | no more than 1 mL
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| Needle Length and Gauge for SC Injections | 25 gauge
1/2 - 5/8 inch
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| Angle for SC Injections | 45 - 90 Degrees
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| Angle for ID Injections | 15 Degrees
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| Uses for IV Therapy Administration | provide fluid and electrolyte maintenance, restoration, and replacement
administer medications and nutritional feedings
administer blood and blood products
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| Methods of IV Therapy Administration | IV push
Intermittent Venous Access Device (heparin/saline lock)
Intermittent Infusion (IV piggyback)
Continuous Infusion
Patient Controlled Analgesia (PCA)
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| When IV Push Used | emergency situations
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| Effective and Efficient Method for Administration of Analgesic Medications | PCA
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| Another Term for Parenteral Nutrition | hyperalimentation
🗑
|
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| Types of Parenteral Nutrition | TPN
PPN
🗑
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| Which Type of Parenteral Nutrition used for Long Term? Short Term? | TPN
PPN
🗑
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| Nursing Monitoring of TPN | blood glucose
daily weight
I&O
labs
client's response
🗑
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| Checking Infusion and IV Site during IV Infusions | every hour
flow of fluid
air in tubing
infiltration
phlebitis
🗑
|
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