Skills Final Exam

Hypothermia:

- abnormally low body temperature

Hyperthermia:

- abnormally high body temperature

Shock:

- 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

Tachycardia:

- increased HR

Pyrexia:

- 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:

Acidosis:

- pH below 7.35

Alkalosis:

- 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

Respiratory Acidosis:

- low pH, high CO2 - hypoxia, decreased BP, muscle weakness, dizziness, increased potassium - causes: COPD, pneumonia, atelectasis

Respiratory Alkalosis:

- high pH, low CO2 - seizures, confusion, nausea, decreased/normal BP, decreased potassium - causes: hyperventilation (stress), mechanical ventilation

Metabolic Acidosis:

- low pH, low HCO3 - Kussmauls, headache, decreased BP, warmth, decreased LOC - causes: DKA, severe diarrhea, renal failure, shock

Metabolic Alkalosis:

- high pH, high HCO3 - restlessness, tachycardia, confusion, tremors, muscle cramps - causes: severe vomiting, excessive GI suctioning, diuretics, excessive NaHCO3

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

Creatinine:

- 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

Hemoglobin:

- 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

Urinalysis:

- 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:

- YES

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:

Insomnia:

- 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?

Glaucoma:

- 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?

Vertigo:

- 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?

Eschar:

- a black substance on pressure ulcers

- debridement

How is Eschar treated?

SBAR

- situation - background - assessment - recommendation

Respiratory process:

- ventilation - perfusion - diffusion

Ventilation:

- moving gases into and out of the lungs

Perfusion:

- ability of cardiovascular system to pump oxygenated blood to the tissues and return deoxygenated blood to the lungs

Diffusion:

- exchange of respiratory gases in the alveoli and capillaries

Albumin:

- 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:

Tonicity:

- measurement of concentration of IV solutions with osmolality of bodily fluids

Hypertonic:

- sodium and volume replacement - used for hypernatremia (water insufficiency) - go slow - cells shrink

Hypotonic:

- 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

Isotonic:

- 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

Hypernatremia:

- 145 or higher - decreased LOC (confusion, lethargy, coma) - thirst - seizures

Hyponatremia:

- 135 or below - decreased LOC (confusion, lethargy coma) - seizures

Normal Potassium Level:

- 3.5-5

Hyperkalemia:

- 5.1 or higher - bilateral muscle weakness in quadriceps - transient abdominal cramps - diarrhea - dysrhythmias - cardiac arrest

Hypokalemia:

- 3.5 or lower - bilateral muscle weakness that begins in quadriceps and ascends to respiratory muscles - abdominal distensionion - decreased bowel sounds - constipation - dysrhythmias

Dysuria:

- pain during urination

Ketosis:

- a metabolic state that occurs when your body burns fat for energy instead of glucose

Spironolactone:

- 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

Lasix:

- 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:

Kayexalate:

- lowers potassium - need to get rid of potassium or it can kill you - watch for constipation, gastric irritation, diarrhea, sodium retention, and hypokalemia

- 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?

Infiltration:

- 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

Evisceration:

- protrusion of the internal organs through an incision

Dehiscence:

- when a wound opens (partially or totally) - may see bleeding, pain, swelling, fever, and broken sutures - maybe use a wound vac