Advanced Nursing Exam 1

Five Rights of Delegation:

a) Right Task

b) Right Circumstance

c) Right Person

d) Right Direction/Communication

e) Right Supervision

What can/cannot be delegated to LPNs?

no education, no discharging/admissions, no teaching

can do NG feeds, wound dressing changes, trach care, low-risk medications

What is evidence-based practice?

problem-solving approach to clinical decision making (Best practice + patient preference + clinician expertise = EBP)

Steps of the EBP Process:

- Step 1 of the EBP process is asking a clinical question in the PICOT format: P = patients/populations, I = intervention, C = comparison, O = outcome, T = time period

- Step 2 – thorough collection of evidence based on the clinical question.

- Step 3 – critically appraising and synthesizing evidence found in the search.

- Step 4 – implementing the evidence in practice.

- Step 5 – evaluating the outcome in the clinical setting.

- Step 6 – share the outcomes of the EBP change so that other health care providers and patients benefit from what you learned from your experience.

Cultural Factors which Influence Healthcare: Native American

Use folk healers, ghost sickness (ghosts cause living people to get sick), rarely circumcise boys

Cultural Factors which Influence Healthcare: Hispanic

- Strong family values, typically use folk healers, high risk for obesity and diabetes, multi-generational living in one home

- Recent immigrants may be at risk for physical and mental health problems

Cultural Factors which Influence Healthcare: African American

Less positive healthcare outcomes, high risk for cardiovascular diseases and HTN

Types of Assessment: emergency

rapid history while maintaining vital functions

Types of Assessment: comprehensive

head-to-toe assessment w/ detailed history

Types of Assessment: focused

focused on body system with the main concern

Steps of the Nursing Process:

- Assessment — Subjective and objective data are collected and will be the bases of the plan of care.

- Diagnosis — Assessment data are analyzed and a judgment about the problem is made. It includes identifying and labeling human responses to actual or potential health problems or life processes.

- Planning — patient outcomes or goals are developed for the diagnosis, and nursing interventions are identified to accomplish the outcomes.

- Implementation — activation of the plan; the nursing interventions are performed.

- Evaluation — continual activity; it is determined whether the patient outcomes were met as a result of the nursing interventions.

Order of physical assessment:

- General survey - what you can see right when you walk in the room or with a brief interaction

- Inspection, palpation, percussion, auscultation (except for GI where auscultation is second)

How to best teach adults:

- Adult education will occur in steps & must encourage motivational interviewing

- Self-efficacy is important to strengthening commitment to change

- Nurse should not use medical terms during education

- Teach-back technique is most effective for adults

- Teach them what they want to learn first!

Stages of Transtheoretical Model of Health Behavior Change:

Precontemplation - not considering change or learning

Contemplation - thinking about change

Preparation - planning change, gathering info on how to change

Action - change has begun

Maintenance - change becomes part of regular behavior

Termination - change is now part of lifestyle

When using the Transtheoretical Model of Health Behavior Change during patient teaching, the nurse identifies that the patient who states, "I walked regularly for about a year to help prevent osteoporosis, but recently I haven't been motivated to continue," is in the stage of:

Action

Role of caregiver in teaching/learning:

- Caregiver needs should be identified before teaching to promote the patient's care and prevent complications after discharge

- Caregivers are most often women

- Caregiver stress can lead to burnout and potential abuse (encourage journaling, exercise, and use of humor)

Clinical manifestations of frailty:

unintentional weight loss, self-reported exhaustion, weakness, slow walking speed, low level physical activity

SCALES Nutritional Assessment:

-Sadness

-Cholesterol (High)

-Albumin (low)

-Loss or gain of weight

-Eating Problems

-Shopping and food preparation problems

Changes in older adult cognitive functioning:

- Most healthy older adults experience no noticeable decline in cognitive abilities.

- Short term memory recall may decline with age, but long-term and crystallized intelligence should not decrease

What is a durable power of attorney?

patient designates a surrogate to make medical decisions in event he/she loses decision making capacity

What is medicare?

- Medicare is federally funded insurance for people >65; covers those < 65 with disabilities or end-stage kidney disease

- Part A covers inpatient care, part b covers outpatient care, part d covers prescription drugs

- Does not cover long-term care, custodial ADLs or IADLs care, dental care or dentures, hearing aids, or eyeglasses

What is medicaid?

- State-administered program to assist people in poverty with medical expenses

- Can qualify for both Medicare and Medicaid

How to best manage a chronic illness:

- Most persons 65 y.o.+ have at least 1 chronic illness; the incidence of chronic disease triples after age 45

- Main goal of management is to prevent & manage crises to avoid exacerbation

- Patients should adhere to prescribed regimen, know s/s of crisis onset, and have a plan to manage a crisis when it occurs

- Social isolation should be prevented & normalize interactions with others

- Nurses should conduct comprehensive assessments & teach patient and caregiver

Roles in Patient Care: dietitian

help to create dietary plans for patients with illness or disease risk

Roles in Patient Care: speech therapy

assess & treat patients with speech & fluency issues and swallowing concerns

Roles in Patient Care: physical therapist

offer preventative and rehabilitative care to assist in increasing patient physical strength and abilities

Roles in Patient Care: occupational therapist

assist patients in developing, recovering, or improving skills necessary for daily living and employment

What are transitions of care & nurses' role in it?

- Transitions of care refer to patients moving between health care practitioners, settings, and home as their condition and care needs change

- Nurses are an essential part of care coordination by stressing actions that meet patient’s needs and facilitate safe, quality care. Collaborating with other members of the interprofessional team is critical.

Types of burns:

Thermal, chemical, smoke inhalation, electrical, cold thermal

How is the severity of burns determined?

Depth, total body surface area effected, location, patient risk factors

How are burns staged?

Superficial partial thickness (1st degree) - epidermis only

Deep partial thickness (2nd degree) - epidermis & dermis

- Partial thickness burns heal from edges and dermal bed

Full thickness (3rd & 4th) - into muscle and bone; typically experience no pain

- Full thickness burns must have eschar removed and skin grafts applied

What is the rule of nines?

Thermal burns (causes, severity):

- Caused by flame, flash, scald, or contact with hot objects

- Most common type of burn injury

- Severity of injury depends on temperature of burning agent & duration of contact

Chemical burns (causes, action):

- Caused by acids (household cleaners), alkalis (cement), and organic compounds (gasoline)

- Alkali burns are hard to manage because the damage will continue after neutralization

- Often results in injury to the skin, eyes, respiratory system, and liver & kidneys

- Action: remove clothing, neutralize chemical, monitor for further destruction for 72hrs

Smoke Inhalation (cause, importance, action):

- Damage to respiratory tract from inhalation of hot air or noxious chemicals

- Major predictor of mortality in burn victims

- Action: assess for airway compromise for 12-48hrs

What is metabolic asphyxiation?

- Oxygen is displaced by CO2, leading to inadequate oxygenation

- S/S: red face

- Treat with 100% humidified oxygen

Electrical burns (cause, severity, action):

- Caused from coagulation necrosis by heat from an electric current

- Damage to skin, nerves, vessels

- Severity depends on voltage, tissue resistance (fat & bone offer the most resistance), current pathway, surface area, and duration of flow

- Action: stabilize cervical spine, continue to assess as injury may be difficult to assess, monitor for dysrhythmias, metabolic acidosis, and myoglobinuria (leads to kidney injury)

Pre-hospital care of small thermal burns:

- Remove person from source of burning

- cover with clean, cool, tap water towel

Pre-hospital care of large thermal burns:

- Remove person from source of burning

- If responsive, follow ABC's

- If unresponsive, follow CAB (elevate limb)

- Cool burn for < 10 min

- Remove burnt clothing & wrap in dry blanket

Phases of burn management: emergent (patho, manifestations, concerns):

- Patho: massive shift of fluids (third spacing), neutrophils & monocytes accumulate, fibroblasts begin wound repair within 6-12hrs after injury, immunosuppression

- Manifestations: hypovolemic shock, blisters, paralytic ileus, shivering from inflammation, altered mental status

- Primary concerns are hypovolemic shock & edema

Complications of the emergent phase of burn management:

dysrhythmias, hypovolemic shock, VTE, airway obstruction, acute tubular necrosis due to decreased blood flow

Care of the emergent phase of burn management:

- 100% humidified oxygen

- endotracheal intubation

- escharotomies (to relieve chest tissue tightness)

- high fowler's if not intubated

- two IV lines for > 15% TBSA

Wound care for the emergent phase of burn management:

- delayed until patent airway, adequate circulation, and fluid replacement

- silver sulfadiazine for antimicrobial

Nutritional care for a patient in the emergent phase of burn management:

- Fluid replacement is priority!

- Patient will be in hypermetabolic state, so caloric needs are elevated (use enteral feeds)

Acute/healing phase of burn management (beginning & end, patho, action):

- Begins with the mobilization of fluid & subsequent diuresis; ends with wounds are healed or covered with grafts

- Patho: necrotic tissue will slough, granulation tissue forms

- Action: monitor for infection (S/S: hypo/hyperthermia, tachycardia, decreased BP, decreased urine output)

Pain management for patients with burns:

- Continuous background pain: IV opioid or BID oral slow-release opioid

- Treatment-induced pain: analgesic before treatment

Rehabilitative phase of burn management:

patient begins to cope with new disability or deformity

Electrolyte changes with burns: hypo/hypernatremia

Hyponatremia can develop from excessive GI suction, diarrhea

- Water intoxication - dilutional hyponatremia - avoid with juices, nutritional supplements

Hypernatremia may develop following successful fluid replacement

Electrolyte changes with burns: hypo/hyperkalemia:

- Hyperkalemia may occur if patient has renal failure or a massive deep muscle injury because large amounts of potassium is released from damaged cells

- Hypokalemia occurs with vomiting, diarrhea, prolonged GI suction

What occurs in the vascular inflammatory process?

- Arterioles constrict, histamine is released, and vessels dilate leading to hyperemia

- Fluid in tissue spaces turns from serous fluid to later containing plasma proteins, which exert more oncotic pressure

- Fibrinogen will also enter the tissues to form a clot to trap bacteria

What happens in the cellular inflammatory process?

- Blood flow through capillaries slows and blood viscosity increases

- Neutrophils & monocytes arrive via chemotaxis

- Enzyme cascade of the complement system holds the pathogens so they don't escape

- Lymphocytes arrive to create immunity (memory cells)

- Histamines, serotonin, and kinins are released during this time

What do neutrophils do?

arrive 1st (6-12hrs after injury) to phagocytize bacteria, then explode creating pus

What do monocytes do?

arrive 3-7 days after injury, transform into macrophages, and phagocytize debris

What do histamines do?

released by complement components causing vasodilation

What does serotonin do for inflammation?

stimulates smooth muscle contraction

What do kinins do?

cause the stimulation of pain

What do prostaglandins do?

vasodilate and encourage inflammation

What does thromboxane do?

vasoconstricts and calls platelets to the scene to form a clot

Medications to Inhibit Inflammation:

- Steroids inhibit arachidonic acid which is converted into prostaglandins

- NSAIDs inhibit the cyclooxygenase pathway

Local VS Systemic Inflammation:

- Local: symptoms include redness, heat, pain, swelling, and loss of function

- Systemic: fever, hypotension, tachycardia, nausea, malaise, labs shift to the left

Fever Pathophysiology:

- Onset is triggered by cytokine release to trigger the hypothalamus to increase temperature

- Synthesis of prostaglandins is the most important metabolic change to a fever

- Hypothalamus stimulates the ANS to cause shivering and decreased perspiration

Acute vs Subacute vsChronic Inflammation:

- Acute: no residual damage, heals within 2-3 weeks, neutrophil-dominated

- Subacute: persists past 2-3 weeks; example: endocarditis

- Chronic: lasts for years, lymphocyte & macrophage-dominated; example: auto-immune disease

Nursing Management of Inflammation:

- Recognize early & treat immediately

- Observe pt, monitor VS

- Administer aspirin, acetaminophen, NSAIDs, and corticosteroids for fever

- RICE

Regeneration vs Repair:

- Regeneration: replacement of lost cells and tissues with cells of the same type. The ability of cells to regenerate depends on the cell type.

- Repair: healing as a result of lost cells being replaced by connective tissue. Repair is the more common type of healing and usually results in scar formation

What type of healing is done with pressure ulcers?

Secondary intention

Pressure Ulcer Staging: Deep Tissue Injury

Purple or maroon localized area of discolored intact skin

Pressure Ulcer Staging: Stage 1

Intact skin with non-blanchable redness

Pressure Ulcer Staging: Stage 2

Partial thickness loss of dermis, shallow open ulcer with pink/red wound bed

Pressure Ulcer Staging: Stage 3

- Full thickness skin loss; subcutaneous tissue visible

- Undermining may be present; looks like a crater

Pressure Ulcer Staging: Stage 4

- Full thickness loss that extends into muscle or bone

- Tunneling or undermining may occur

Pressure Ulcer Staging: Unstageable

- Full thickness tissue loss where depth is obscured by slough or eschar

- Dry eschar on the heels should not be removed

What are the most common sites of pressure ulcers?

Sacrum & Heels

Risk Factors for Ulcers:

Advanced age, anemia, contractures, diabetes, elevated body temperature, friction, immobility, impaired circulation, incontinence, mental deterioration

Definition of Aneurysm:

outpouching or dilation of arterial wall where the wall becomes lined with thrombi that can embolize; often seen in the aortic artery

Causes of Aneurysm:

- Atherosclerosis, genetics (Marfan’s), blunt trauma, inflammation, infection

- Risk Factors: age, males, HTN, CAD, family history, smoking

Symptoms of Thoracic Aorta Aneurysm (TAA):

asymptomatic, diffuse chest pain, interscapular pain

Symptoms of Ascending Aortic Arch Aneurysm:

- S/S: angina, TIAs, SOB, dysphagia

- If pressing on the superior vena cava, decreased venous return, JVD, edema of face & arms

Abdominal Aortic Aneurysm (AAA): (S/S, detection)

- S/S: often asymptomatic, back pain, epigastric discomfort, intermittent claudication, blue toe syndrome (patchy mottling of the feet and toes in the presence of palpable pedal pulses)

- Pulsatile mass in the periumbilical area slightly to the left of the midline with a bruit may be present

- Frequently detected on physical exams and when being scanned for unrelated problems

Dissection/rupture of a AAA:

- Bleeding may be tamponade by surrounded organs preventing death

- will present with severe back pain & Grey Turner's sign

- S/S: diaphoresis, pallor, weakness, tachycardia, hypotension, periumbilical pain, change in LOC, pulsatile abdominal mass

- requires immediate surgery

Grey Turner's sign

bruising in flank area (lower back area)

Purpose of chest & abdomen x-ray and ECG with aneurysms:

- Chest - look if there are any mediastinal involvement

- Abdomen - looks for any calcification within the aneurysm

- ECG - to rule out MI

Purpose of echocardiography, ultrasonography, CT & MRI with aneurysms:

- Echocardiography - diagnosis of aortic valve insufficiency

- Ultrasonography - screens for aneurysm size

- CT - most accurate scan to determine length, diameter, thrombus presence, and surgical repair

- MRI - assess location & severity

What is considered a small aneurysm?

- 4-5.4cm

- Treated with risk factor modification - lower BP, scan to monitor size Q6-12 months

What is the threshold for a repairable aneurysm?

5.5cm +

What is an open aneurysm repair (OAR)?

clamp above and below aneurysm, place graft & remove existing plaques, remove clamps; if renal arteries are clamped, you may permanently damage the kidneys

What is an endovascular graft procedure?

- non-invasive alternative to OAR

- Placement of a suture-less aortic graft into the abdominal aorta

- Done through femoral artery

Post-op care for endovascular graft procedure:

- maintain normal BP (systolic around 90)

- IV fluids

- CVP pressure monitoring

- hourly urine output monitoring

- pulse assessment (mark pulse locations with pen, routine ABI)

- NPO post op

- NG placed to low-intermittent suction

- parental nutrition

Complications in an endovascular graft procedure:

endoleak, aneurysm growth, aortic dissection, stent migration, renal artery occlusion, thrombus, infection