Skills Final Exam

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Hypothermia:

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Hypothermia:

  • abnormally low body temperature

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Hyperthermia:

  • abnormally high body temperature

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Shock:

  • increased risk when you lose too much blood

  • cause extracellular fluid loss

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Signs of Shock:

  • hypotension

  • tachycardia

  • restlessness and apprehension

  • skin cold, moist, pale, cyanotic

  • decreased O2 sat.

  • decreased circulating volume

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Heat stroke:

  • continued exposure to extreme heat that raises the core body temperature to 105° or higher.

  • altered mental state, nausea, vomiting, slurred speech

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Tachycardia:

  • increased HR

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Pyrexia:

  • fever

  • raised body temp

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  • proximal to it

When doing vitals, if a distal pulse is absent, check the pulse:

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  • apical pulse

If the radial pulse is low check the:

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Acidosis:

  • pH below 7.35

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Alkalosis:

  • pH above 7.45

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R.O.M.E. acronym

<ul><li><p>Respiratory Opposite: high pH=low CO2, low pH=high CO2</p></li><li><p>Metabolic Equal: high pH=high HCO3, low pH=low HCO3</p></li></ul>
  • Respiratory Opposite: high pH=low CO2, low pH=high CO2

  • Metabolic Equal: high pH=high HCO3, low pH=low HCO3

<ul><li><p>Respiratory Opposite: high pH=low CO2, low pH=high CO2</p></li><li><p>Metabolic Equal: high pH=high HCO3, low pH=low HCO3</p></li></ul>
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Respiratory Acidosis:

<ul><li><p>low pH, high CO2</p></li><li><p>hypoxia, decreased BP, muscle weakness, dizziness, increased potassium</p></li><li><p>causes: COPD, pneumonia, atelectasis</p></li></ul>
  • low pH, high CO2

  • hypoxia, decreased BP, muscle weakness, dizziness, increased potassium

  • causes: COPD, pneumonia, atelectasis

<ul><li><p>low pH, high CO2</p></li><li><p>hypoxia, decreased BP, muscle weakness, dizziness, increased potassium</p></li><li><p>causes: COPD, pneumonia, atelectasis</p></li></ul>
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Respiratory Alkalosis:

<ul><li><p>high pH, low CO2</p></li><li><p>seizures, confusion, nausea, decreased/normal BP, decreased potassium</p></li><li><p>causes: hyperventilation (stress), mechanical ventilation</p></li></ul>
  • high pH, low CO2

  • seizures, confusion, nausea, decreased/normal BP, decreased potassium

  • causes: hyperventilation (stress), mechanical ventilation

<ul><li><p>high pH, low CO2</p></li><li><p>seizures, confusion, nausea, decreased/normal BP, decreased potassium</p></li><li><p>causes: hyperventilation (stress), mechanical ventilation</p></li></ul>
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Metabolic Acidosis:

<ul><li><p>low pH, low HCO3</p></li><li><p>Kussmauls, headache, decreased BP, warmth, decreased LOC</p></li><li><p>causes: DKA, severe diarrhea, renal failure, shock</p></li></ul>
  • low pH, low HCO3

  • Kussmauls, headache, decreased BP, warmth, decreased LOC

  • causes: DKA, severe diarrhea, renal failure, shock

<ul><li><p>low pH, low HCO3</p></li><li><p>Kussmauls, headache, decreased BP, warmth, decreased LOC</p></li><li><p>causes: DKA, severe diarrhea, renal failure, shock</p></li></ul>
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Metabolic Alkalosis:

<ul><li><p>high pH, high HCO3</p></li><li><p>restlessness, tachycardia, confusion, tremors, muscle cramps</p></li><li><p>causes: severe vomiting, excessive GI suctioning, diuretics, excessive NaHCO3</p></li></ul>
  • high pH, high HCO3

  • restlessness, tachycardia, confusion, tremors, muscle cramps

  • causes: severe vomiting, excessive GI suctioning, diuretics, excessive NaHCO3

<ul><li><p>high pH, high HCO3</p></li><li><p>restlessness, tachycardia, confusion, tremors, muscle cramps</p></li><li><p>causes: severe vomiting, excessive GI suctioning, diuretics, excessive NaHCO3</p></li></ul>
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BUN (Blood Urea Nitrogen):

  • indicates renal function and hydration status

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Normal Range of BUN:

  • 10-20 mg/dL

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Critical Range of BUN:

  • above 100 mg/dL

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Symptoms of Increased BUN:

  • dehydration

  • impaired renal function

  • excessive protein intake

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Symptoms of Decreased BUN:

  • malnutrition

  • overhydration

  • liver damage

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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

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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

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Signs of Low Hemoglobin:

  • tiredness and lack of energy

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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

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Urinalysis:

  • looks for bacteria that causes UTIs

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  • an antibiotic sensitivity test

If you have a UTI, what test can pinpoint the bacteria?

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  • identifying yourself and your patient

  • bed locked

  • bed lowered

  • side rails up

  • call light near

General Safety Checks include:

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  • YES

Do you need an order to use restraints?

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  • why the restraint is being used

If you use a restraint, what is one thing you must document?

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  • checking the circulation

  • color and nerve pain

What is a nursing priority with restraints?

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Circadian Rhythm:

  • responses to light and dark

  • internal clock

  • tired at night; awake during the day

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  • excessive daytime sleepiness

Patients with sleep apnea have:

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  • CPAP machine

Treatment for Sleep Apnea:

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Insomnia:

  • persistent problems with falling and staying asleep

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  • give them earplugs

  • play music

  • limit noise and distractions

  • dim lights

What actions can you take to help a pt. with insomnia?

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  • extra sleep

When a patient is under stress, they need:

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  • 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?

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Glaucoma:

  • a gradual increase of intraocular pressure to the nerve of the eye

  • produces very poor eyesight

  • peripheral vision is poor

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  • 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?

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Vertigo:

  • dizziness

  • feels like the room is spinning

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  • Snellen chart

Tools to evaluate vision:

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  • tuning fork

Tools to evaluate hearing:

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PCA Pump:

  • patient-controlled analgesic

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  • morphine, fentanyl, hydromorphone

What drugs are used in PCA pumps?

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Features on PCA Pumps:

  • a loaded dose

  • predetermines safety limits

  • lockout mechanisms

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  • cancer patients

Morphine is commonly used in:

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  • handles and perceives pain

Coping styles can determine how a patient:

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  • 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?

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  • oxygen and protein

For a pressure ulcer to heal it must have:

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  • infections due to bacteria getting into the open wound

Patients with pressure ulcers are at higher risk for:

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  • a wound vac

What can you use to help with a pressure ulcer?

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Eschar:

  • a black substance on pressure ulcers

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  • debridement

How is Eschar treated?

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SBAR

  • situation

  • background

  • assessment

  • recommendation

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Respiratory process:

  • ventilation

  • perfusion

  • diffusion

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Ventilation:

  • moving gases into and out of the lungs

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Perfusion:

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

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Diffusion:

  • exchange of respiratory gases in the alveoli and capillaries

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Albumin:

  • protein made by your liver

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  • albumin levels

If you want to look at statistic of a patients protein levels, what will you draw?

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TPN infusions:

  • high in fluids, electrolytes, minerals, vitamins, and fats

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How is a TPN infusion inserted?

  • IV access

  • Central line

  • PIC line

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  • 24 hour period

TPN is given over a:

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Tonicity:

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

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Hypertonic:

  • sodium and volume replacement

  • used for hypernatremia (water insufficiency)

  • go slow

  • cells shrink

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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

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Isotonic:

  • expands the volume, dilutes medications, and keeps veins open

  • same osmolarity as body fluid

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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

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Laboratory findings for fluid volume deficit:

  • increased hematocrit

  • increased BUN above 20 mg/dL

  • urine specific gravity above 1.030

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How to identify extracellular fluid volume overload:

  • sudden weight gain

  • edema

  • full neck veins

  • crackles in lungs

  • confusion

  • pulmonary edema

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Laboratory findings for fluid volume Overload:

  • decreased hematocrit

  • decreased BUN below 10 mg/dL

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  • their Oxygen

If a patient with CHF has an infection that increases their body temperature, what do you need to increase?

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  • requirement for oxygen

If the metabolic rate goes up, so does the:

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Normal Sodium level:

  • 135-145

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Hypernatremia:

  • 145 or higher

  • decreased LOC (confusion, lethargy, coma)

  • thirst

  • seizures

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Hyponatremia:

  • 135 or below

  • decreased LOC (confusion, lethargy coma)

  • seizures

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Normal Potassium Level:

  • 3.5-5

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Hyperkalemia:

  • 5.1 or higher

  • bilateral muscle weakness in quadriceps

  • transient abdominal cramps

  • diarrhea

  • dysrhythmias

  • cardiac arrest

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Hypokalemia:

  • 3.5 or lower

  • bilateral muscle weakness that begins in quadriceps and ascends to respiratory muscles

  • abdominal distensionion

  • decreased bowel sounds

  • constipation

  • dysrhythmias

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Dysuria:

  • pain during urination

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Ketosis:

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

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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

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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

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  • dehydrated

If fluid labs are high when a patient is on Lasix, that means they are:

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  • in fluid overload

If fluid labs are low when a patient is taking Lasix, that means they are:

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Kayexalate:

<ul><li><p>lowers potassium</p></li><li><p>need to get rid of potassium or it can kill you</p></li><li><p>watch for constipation, gastric irritation, diarrhea, sodium retention, and hypokalemia</p></li></ul>
  • lowers potassium

  • need to get rid of potassium or it can kill you

  • watch for constipation, gastric irritation, diarrhea, sodium retention, and hypokalemia

<ul><li><p>lowers potassium</p></li><li><p>need to get rid of potassium or it can kill you</p></li><li><p>watch for constipation, gastric irritation, diarrhea, sodium retention, and hypokalemia</p></li></ul>
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  • their heart rate

What bodily function do we monitor when a patient is taking Kayexalate?

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  • Normal Saline 0.9%

What solution is hung with blood during a blood transfusion?

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  • 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?

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  • with an ampule

When do we use a filter needle?

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Infiltration:

  • occurs when IV catheter becomes dislodged and vein ruptures so IV fluids inadvertently enter subcutaneous tissue around the IV site

  • potentially dangerous

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  • to decrease pain

Why do we inject IV medications slowly?

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  • add an NSAID to the regime to give better relief

  • decrease opioid intake

How do we get a surgical patient off of morphine?

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  • the surgeon and the patient

Who signs the informed consent forms for surgery?

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  • before the surgery

When are informed consent forms signed?

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Primary Healing:

  • edges of wound are pulled together and approximated with sutures or staples

  • healing occurs by connective tissue deposition

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Secondary Healing:

  • wound edges are not approximated

  • healing occurs by granulation tissue formation and contraction of the wound edges

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Evisceration:

  • protrusion of the internal organs through an incision

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Dehiscence:

  • when a wound opens (partially or totally)

  • may see bleeding, pain, swelling, fever, and broken sutures

  • maybe use a wound vac

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