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

Lasix:

- gets rid of potassium, saving sodium
- removes H2O and K+
- treats hypertension, edema due to CHF, and ascites
- if systolic is

- 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