Skills Exam 2

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Phlebitis:

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Phlebitis:

  • inflammation of a vein

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  • Inspect for localized redness, tenderness, and swelling over vein sites.

How to assess for phlebitis:

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  • Stop infusion and discontinue intravenous therapy; Restart new intravenous line if continued therapy is necessary

  • Place moist, warm compress over area

How to treat phlebitis:

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  • blood clots/emboli (thrombophlebitis)

What can phlebitis cause?

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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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Fluid overload:

  • hypervolemia

  • too rapid administration

  • excessive amount of fluids (edema)

  • can lead to vascular congestion impairing body’s ability to deliver oxygen to tissues

  • swelling, bloating, headache

  • treat with diuretic

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Diuretics:

  • given PO, IV, IM

  • decreases BP, Na, Cl, K, weight, I&O, dehydration, hyperglycemia

  • furosemide, aldactone, kayexalate

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Aldactone:

  • saves the potassium

  • gets rid of water and sodium

  • blocks aldosterone in kidneys

  • watch for headache, diarrhea, hyperkalemia, electrolyte imbalance, fatigue, and GI disturbance

  • can cause weakness in heart muscles

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kayexalate:

  • PO or enema

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

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

  • watch heart rate and sodium levels

<ul><li><p>PO or enema</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><li><p>watch heart rate and sodium levels</p></li></ul>
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furosemide:

  • PO or IV

  • potassium wasting

  • loop diuretic

  • used for edema, hypertension, and ascites

  • side effects: decreased BP, photosensitivity, hyperglycemia, decreased potassium

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  • through lab work

Best way to assess fluid and electrolyte imbalances:

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hyperkalemia:

  • potassium level 5.1 or higher

  • need kayexalate

  • look for peaked T waves and dysrhythmias

  • abdominal dissension

  • muscle weakness, cramps, irritability anxiety, low BP, pins and needles sensation

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hypokalemia:

  • potassium level 3.5 or below

  • administer potassium rich diet

  • arrhythmia (thready pulse), tachycardia

  • weakness, fatigue, intestinal mobility decreases, drowsiness

  • metabolic alkalosis

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potassium deficiency symptoms:

  • alkalosis

  • shallow respirations

  • irritability

  • confusion

  • weakness

  • arrhythmias

  • lethargy

  • thready pulse

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hypernatremia:

  • sodium level above 145 in blood

  • rehydrate

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hyponatremia:

  • sodium level below 135 in blood

  • fluid restriction

  • water intoxication

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hypercalcemia:

  • loop diuretics

  • increase hydration

  • synthetic calcitonin

  • monitor I&O, vitals, and HR

  • administer diuretics (kayexalate)

  • constipation

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hypocalcemia:

  • give foods high in calcium with vitamin D supplements

  • watch for bleeding gums and mucus membranes

  • chvostek's sign

  • trousseau's sign

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factors contributing to fluid loss:

  • vomiting

  • diarrhea

  • bleeding

  • sweating

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alkalosis:

  • pH above 7.45

  • kicking up the pH

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acidosis:

  • pH below 7.35

  • sliding the pH down

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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

<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:

  • low pH, high CO2

  • hypoventilation, hyperkalemia, shallow respirations, nausea and vomiting, numbness and tingling

  • use ventilator

  • causes: COPD, pneumonia, atelectasis

<ul><li><p>low pH, high CO2</p></li><li><p>hypoventilation, hyperkalemia, shallow respirations, nausea and vomiting, numbness and tingling</p></li><li><p>use ventilator</p></li><li><p>causes: COPD, pneumonia, atelectasis</p></li></ul>
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respiratory alkalosis:

  • high pH, low CO2

  • hyperventilation, hypokalemia, deep respirations, muscle weakness, cyanotic pale skin

  • causes: hyperventilation (stress), mechanical ventilation

<ul><li><p>high pH, low CO2</p></li><li><p>hyperventilation, hypokalemia, deep respirations, muscle weakness, cyanotic pale skin</p></li><li><p>causes: hyperventilation (stress), mechanical ventilation</p></li></ul>
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metabolic acidosis:

  • low pH, low HCO3

  • hyperventilation, hyperkalemia, muscle twitching, increased body temp.

  • check renal labs

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

<ul><li><p>low pH, low HCO3</p></li><li><p>hyperventilation, hyperkalemia, muscle twitching, increased body temp.</p></li><li><p>check renal labs</p></li><li><p>causes: DKA, severe diarrhea, renal failure, shock</p></li></ul>
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metabolic alkalosis:

  • high pH, high HCO3

  • hypoventilation, hypokalemia, tremors/cramps/tingling, nausea

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

<ul><li><p>high pH, high HCO3</p></li><li><p>hypoventilation, hypokalemia, tremors/cramps/tingling, nausea</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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10-20 mg/dL

Normal range of BUN (Blood Urea Nitrogen):

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above 100

Critical range of BUN (Blood Urea Nitrogen):

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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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when to take a patients weight:

  • at the same time every day with the same circumstances

  • indicates fluid status

  • its a gold standard

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  • Normal saline IV solution

What type of solution is hung with blood?

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  • 30 minutes from the blood bank

  • 2-4hr infusion rate

How long do you have to hang a bag of blood for a blood transfusion?

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  • "Y" tubing

  • for the blood and saline

  • change after 4 hours

What tubing is used for blood transfusions?

<p>What tubing is used for blood transfusions?</p>
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  • based on hospital policy

  • when any change occurs

  • stay with patient for the first 15 minutes

when to take vitals during blood transfusions?

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Febrile reaction to blood transfusion:

  • chills, fever, headache, flushing, tachycardia, increased anxiety

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allergic reaction to blood transfusion:

  • mild: hives, pruritis, facial flushing

  • severe: shortness of breath, bronchospasm, anxiety

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Hemolytic transfusion reaction:

  • Low back pain, hypotension, tachycardia, fever and chills, chest pain, tachypnea, hemoglobinuria, may have immediate onset

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  • stop transfusion immediately and notify the prescriber

  • change the IV tubing

  • treat symptoms if present (O2, fluids, epi)

what to do when complications arise during a blood transfusion?

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5 mL

1 tsp = ___ mL

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ways to transfer a patient:

  • gait belt

  • pivot

  • cane

  • crutches

  • if patient is obese, utilize equipment!!!

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sequential compression devices

SCDs

<p>SCDs</p>
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  • promote venous return as a prevention of DVT

What do SCDs do?

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how to open an ampule:

  • break away from body with gauze

  • use filter needle to extract meds

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antidiuretic hormone (ADH)

  • promotes retention of water by kidneys

  • when we are low on volume

  • released from pituitary gland

  • helps control blood pressure

  • KEEP 1

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renin-angiotensin-aldosterone system (RAAS)

  • a hormone cascade pathway that helps regulate blood pressure and blood volume

  • watches fluid levels and helps protect volume through the kidneys

  • sodium reabsorption and potassium secretion

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Atrial natriuretic peptide (ANP)

  • causes sodium loss and inhibits the thirst mechanism

  • influences sodium and water release

  • hormone secreted in response to atrial stretching and an increase in circulating blood volume

  • RELEASE 2

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what do you do if a patient is trying to get out of bed, but the doctor will not order restraints?

  • try to distract with videos, puzzles, toys, etc.

  • bed alarm

  • move close to nursing station

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how to start an IV:

  • Inform client about procedure and indication

  • Gather supplies

  • Wash hands and Wear gloves

  • Apply tourniquet

  • Locate vein

  • Clean area with alcohol

  • Position and insert needle-looking for a flash of blood

  • Advance catheter

  • Release the tourniquet

  • Remove the needle

  • Secure the catheter and start IV fluid if ordered

  • Document

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  • only LICENSED personnel

  • not us

who can start and IV?

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hypertonic solutions:

  • sodium and volume replacement

  • used for hypernatremia (water insufficiency)

  • go slow

  • cells shrink

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hypertonic IV solution examples:

  • D5 ½ NS

  • D5 NS

<ul><li><p>D5 ½ NS</p></li><li><p>D5 NS</p></li></ul>
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hypotonic solutions:

  • 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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hypotonic IV solution example:

  • D5W

<ul><li><p>D5W</p></li></ul>
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isotonic solutions:

  • fluid resuscitation

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

  • same osmolarity as body fluid

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isotonic IV solution examples:

  • lactated ringers

  • NS 0.9% NaCl

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Subcutaneous injection sites:

  • upper arms, back, abdomen, top of legs.

  • insulin and heparin

  • 45 degree angle

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Intramuscular injection sites:

  • deltoid, ventrogluteal, vastus lateralis

  • vaccines

  • 90 degree angle

  • aspirate except for deltoid

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Heparin needle size and length:

  • 27G x 1/2"

  • 1mL syringe

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Insulin needle size and length:

  • 31G

  • 1mL syringe

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IM needle size and length:

  • 23G x 1"

  • 3mL syringe

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anions:

  • negatively charged ions

  • bicarbonate and phosphate

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cations:

  • positively charged ions

  • magnesium, sodium, and potassium

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Nasogastric tube:

  • tube inserted through the nose into the stomach

  • short term use only

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  • to prevent gastric dilation, vomiting and paralytic ileus (intestinal muscle paralysis)

why is a NG tube inserted?

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  • drink water

What should you instruct a patient to do when inserting a NG tube?

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urinary incontinence

  • inability to control urination

  • pregnancy and old age

  • functional, overflow, reflex, stress, urge

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colostomy:

  • creation of an artificial opening into the colon

  • opening is called a stoma which is at the end of the colon protruding through the skin

  • ileocecal valve allows food to pass from small intestine to large

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UTI:

  • E. coli

  • common in females due to shorter urethra

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micturition:

  • urination

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PACO2

  • 35-45mmHg

  • how well lungs excrete CO2

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HCO3

  • 21-28meq/L

  • how kidneys excrete metabolic acid

  • increased means not enough metabolic acid

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PAO2

  • 80-100

  • how well gas exchange occurs in alveoli

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ABG’s

  • ph 7.35-7.45

  • measures blood acidity

  • PACO2, HCO3, PAO2

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Aldosterone

  • keeps sodium, releases potassium

  • KEEP 1 RELEASE 1

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Fluid overload values:

  • hemoglobin

  • blood glucose

  • hematocrit

  • BUN

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Fluid overload

  • give sodium

  • give diuretic

  • edema and crackles

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Abnormal fluid output:

  • wound drainage

  • vomiting

  • hemmorage

  • diarrhea

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Carbonic acids:

  • Respiratory

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Cardiac rhythms

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Dehydration

  • sodium, specific gravity, hemaocrit go up

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Overhydration

  • sodium, specific gravity, and hematocrit go down

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Angiotensin II

  • vasoconstriction (increases BP)

  • kidneys retain sodium and water

  • stimulates aldosterone from adrenal cortex

  • KEEP 2

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Functional Incontinence

  • inability of urethral sphincter to function properly

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overflow incontinence

  • bladder holds so much

  • only 1000mL

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Reflex incontinence

  • hands in water and feeling the need to urinate

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Stress incontinence

  • increased urination pattern

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Urge incontinence

  • disease process

  • neuromuscular and obesity

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