Skills Final Exam

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- abnormally low body temperature
- abnormally high body temperature
- increased risk when you lose too much blood - cause extracellular fluid loss
Signs of Shock:
- hypotension - tachycardia - restlessness and apprehension - skin cold, moist, pale, cyanotic - decreased O2 sat. - decreased circulating volume
Heat stroke:
- continued exposure to extreme heat that raises the core body temperature to 105° or higher. - altered mental state, nausea, vomiting, slurred speech
- increased HR
- fever - raised body temp
- proximal to it
When doing vitals, if a distal pulse is absent, check the pulse:
- apical pulse
If the radial pulse is low check the:
- pH below 7.35
- pH above 7.45
R.O.M.E. acronym
- Respiratory Opposite: high pH=low CO2, low pH=high CO2 - Metabolic Equal: high pH=high HCO3, low pH=low HCO3
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Respiratory Acidosis:
- low pH, high CO2 - hypoxia, decreased BP, muscle weakness, dizziness, increased potassium - causes: COPD, pneumonia, atelectasis
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Respiratory Alkalosis:
- high pH, low CO2 - seizures, confusion, nausea, decreased/normal BP, decreased potassium - causes: hyperventilation (stress), mechanical ventilation
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Metabolic Acidosis:
- low pH, low HCO3 - Kussmauls, headache, decreased BP, warmth, decreased LOC - causes: DKA, severe diarrhea, renal failure, shock
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Metabolic Alkalosis:
- high pH, high HCO3 - restlessness, tachycardia, confusion, tremors, muscle cramps - causes: severe vomiting, excessive GI suctioning, diuretics, excessive NaHCO3
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BUN (Blood Urea Nitrogen):
- indicates renal function and hydration status
Normal Range of BUN:
- 10-20 mg/dL
Critical Range of BUN:
- above 100 mg/dL
Symptoms of Increased BUN:
- dehydration - impaired renal function - excessive protein intake
Symptoms of Decreased BUN:
- malnutrition - overhydration - liver damage
- increased level of this may be a sign of poor kidney function - 0.7 to 1.3 mg/dL for men - 0.6 to 1.1 mg/dL for women
- protein in RBCs that carries oxygen to your body's organs and tissues and transports CO2 from your organs and tissues back to your lungs
Signs of Low Hemoglobin:
- tiredness and lack of energy
How to treat a pt. w/ C. Diff:
- antibiotics - place in a private room - wear gloves and gown - use soap and water for hand hygiene - use Clorox wipes for surfaces
- looks for bacteria that causes UTIs
- an antibiotic sensitivity test
If you have a UTI, what test can pinpoint the bacteria?
- identifying yourself and your patient - bed locked - bed lowered - side rails up - call light near
General Safety Checks include:
Do you need an order to use restraints?
- why the restraint is being used
If you use a restraint, what is one thing you must document?
- checking the circulation - color and nerve pain
What is a nursing priority with restraints?
Circadian Rhythm:
- responses to light and dark - internal clock - tired at night; awake during the day
- excessive daytime sleepiness
Patients with sleep apnea have:
- CPAP machine
Treatment for Sleep Apnea:
- persistent problems with falling and staying asleep
- give them earplugs - play music - limit noise and distractions - dim lights
What actions can you take to help a pt. with insomnia?
- extra sleep
When a patient is under stress, they need:
- look them in the eye when speaking to them - use tools like amplified telephones
If a patient is hard of hearing, what can you do to help them?
- a gradual increase of intraocular pressure to the nerve of the eye - produces very poor eyesight - peripheral vision is poor
- identify yourself - stay in their field of vision - make sure the room is clutter free - be on guard for falls
What are some things you can do to try to protect a patient that has problems with their vision?
- dizziness - feels like the room is spinning
- Snellen chart
Tools to evaluate vision:
- tuning fork
Tools to evaluate hearing:
PCA Pump:
- patient-controlled analgesic
- morphine, fentanyl, hydromorphone
What drugs are used in PCA pumps?
Features on PCA Pumps:
- a loaded dose - predetermines safety limits - lockout mechanisms
- cancer patients
Morphine is commonly used in:
- handles and perceives pain
Coping styles can determine how a patient:
- elderly - paraplegics - patients incontinent of urine or feces - patients that are very ill and cannot move much - comatose patients
What kind of patients are prone to pressure ulcers?
- oxygen and protein
For a pressure ulcer to heal it must have:
- infections due to bacteria getting into the open wound
Patients with pressure ulcers are at higher risk for:
- a wound vac
What can you use to help with a pressure ulcer?
- a black substance on pressure ulcers
- debridement
How is Eschar treated?
- situation - background - assessment - recommendation
Respiratory process:
- ventilation - perfusion - diffusion
- moving gases into and out of the lungs
- ability of cardiovascular system to pump oxygenated blood to the tissues and return deoxygenated blood to the lungs
- exchange of respiratory gases in the alveoli and capillaries
- protein made by your liver
- albumin levels
If you want to look at statistic of a patients protein levels, what will you draw?
TPN infusions:
- high in fluids, electrolytes, minerals, vitamins, and fats
How is a TPN infusion inserted?
- IV access - Central line - PIC line
- 24 hour period
TPN is given over a:
- measurement of concentration of IV solutions with osmolality of bodily fluids
- sodium and volume replacement - used for hypernatremia (water insufficiency) - go slow - cells shrink
- isotonic until INSIDE the body - used for hyponatremia (water excess) and hypoglycemia - don't give to infants or head injury patients (cerebral edema may occur) - cells swell
- expands the volume, dilutes medications, and keeps veins open - same osmolarity as body fluid
How to identify extracellular fluid volume deficit:
- sudden weight loss - postural hypotension - tachycardia - thready pulse - dry mucuous membranes - poor skin turgor - slow vein filling - flat neck veins - dark yellow urine
Laboratory findings for fluid volume deficit:
- increased hematocrit - increased BUN above 20 mg/dL - urine specific gravity above 1.030
How to identify extracellular fluid volume overload:
- sudden weight gain - edema - full neck veins - crackles in lungs - confusion - pulmonary edema
Laboratory findings for fluid volume Overload:
- decreased hematocrit - decreased BUN below 10 mg/dL
- their Oxygen
If a patient with CHF has an infection that increases their body temperature, what do you need to increase?
- requirement for oxygen
If the metabolic rate goes up, so does the:
Normal Sodium level:
- 135-145
- 145 or higher - decreased LOC (confusion, lethargy, coma) - thirst - seizures
- 135 or below - decreased LOC (confusion, lethargy coma) - seizures
Normal Potassium Level:
- 3.5-5
- 5.1 or higher - bilateral muscle weakness in quadriceps - transient abdominal cramps - diarrhea - dysrhythmias - cardiac arrest
- 3.5 or lower - bilateral muscle weakness that begins in quadriceps and ascends to respiratory muscles - abdominal distensionion - decreased bowel sounds - constipation - dysrhythmias
- pain during urination
- a metabolic state that occurs when your body burns fat for energy instead of glucose
- decreases sodium in the body, saving potassium - removes H2O and Na - used for hypertension and edema due to CHF - if systolic is <90 = hold meds - monitor K+ levels for hyperkalemia = cardiac dysrhythmias
- gets rid of potassium, saving sodium - removes H2O and K+ - treats hypertension, edema due to CHF, and ascites - if systolic is <100 = hold meds - monitor K+ levels for hypokalemia - monitor fluid labs like BUN, BNP, Na, and HCT - side effects: hypotension, hypokalemia, leg cramps, constipation
- dehydrated
If fluid labs are high when a patient is on Lasix, that means they are:
- in fluid overload
If fluid labs are low when a patient is taking Lasix, that means they are:
- lowers potassium - need to get rid of potassium or it can kill you - watch for constipation, gastric irritation, diarrhea, sodium retention, and hypokalemia
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- their heart rate
What bodily function do we monitor when a patient is taking Kayexalate?
- Normal Saline 0.9%
What solution is hung with blood during a blood transfusion?
- stop transfusion immediately and notify the prescriber - change the IV tubing - treat symptoms if present (O2, fluids, epi)
What steps do you take if a patient is having a blood transfusion reaction?
- with an ampule
When do we use a filter needle?
- occurs when IV catheter becomes dislodged and vein ruptures so IV fluids inadvertently enter subcutaneous tissue around the IV site - potentially dangerous
- to decrease pain
Why do we inject IV medications slowly?
- add an NSAID to the regime to give better relief - decrease opioid intake
How do we get a surgical patient off of morphine?
- the surgeon and the patient
Who signs the informed consent forms for surgery?
- before the surgery
When are informed consent forms signed?
Primary Healing:
- edges of wound are pulled together and approximated with sutures or staples - healing occurs by connective tissue deposition
Secondary Healing:
- wound edges are not approximated - healing occurs by granulation tissue formation and contraction of the wound edges
- protrusion of the internal organs through an incision
- when a wound opens (partially or totally) - may see bleeding, pain, swelling, fever, and broken sutures - maybe use a wound vac