Skills Final Exam

Hypothermia:

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