HAP 3 FINAL

purpose of head to toe assessment in acute care

to establish baseline health status at the beginning of the shift and detect changes through the shift (reassessing)

why must assessments be repeated throughout the shift

patients status is dynamic and unpredictable

what triggers a focused assessment even if a full assessment was done

any new symptom or concern (severe pain, respiratory distress)

4 core physical exam techniques

inspection

palpation

percussion

auscultation

which assessment technique is always performed first

inspection

what is inspection

Concentrated watching of the patient and each body system

what is palpation used to assess

texture

temperature

moisture

organ size

swelling

vibration

lumps

tenderness

which part of the hand is best for detecting temp

dorsa (back) of hands

what is percussion used for

to assess underlying structures by sound and vibration

what does auscultation evaluate

sounds of the heart, lungs, blood vessels, and abdomen

first step before beginning any assessment

environmental scan for safety hazards

what should the nurse look for during an environmental scan

devices attached to patient, hazards, equipment avilability

why must the rrom be quiet during auscultation

to avoid roaring noise interference in the stethoscope

most important step to prevent microorganism transmission

hand hygiene

what is a point of care risk assessment (PCRA)

evaluating the likelihood of exposure before choosing PPE

what are examples of source control measures

masks for coughing patients

physical barriers

early diagnosis

atelectasis and how do nurses prevent it

collapse of alveoli

deep breathing, coughing, incentive spirometry, and early ambulation

what is vichows triad and how does it relate to post-op venous thromboembolism

venous stasis = immobility

endothelial injury = surgery

hypercoagulability = inflammation immobility

what assessment findings suggest a developing DVT

calf swelling

tenderness

warmth

redness

what are the signs of hypovolemic shock in post-op orthopedic patient

sudden decrease in BP

rapid, thready pulse

bleeding at surgical site

urine output less than 30 mL/hr

restlessness

decreased Hgb/Hct

what must the nurse verify before assisting a post-op patient to mobilize

weight bearing orders

presence of internal fixation (rods/screws)

safe use of assistive devices

physiotherapy instructions

what is gastrintenstinal intubation

insertion of a flexible tube into the stomach, duodenum, or jejunum for decompression, feeding or medication administration

what are the main purposes of NG tubes

decompress stomach

enteral feeding

administer meds

remove gastric contents

what is NOT within the LPN scope regarding NG tubes

inserting an NG tube with a stylet

when is NG tube insertion contraindicated

when there is risk of intracranial placement

basal skull fracture

cribriform plate fracture

facial fractures

recent jaw surgery

epistaxis

sinusitis

increased ICP

what is a levin tube and what is it used for

single lumen, flexible NG tube used for short-term decompression or feeding

what is the only definitive method to confirm NG placement

X-ray confrimation

what is a salem sump tube and what makes it unique

double-lumen NG tube with large lumen for suction, blue pigtail vent to prevent mucosal damage that is used for gastric decompression

what suction pressure is used with a salem sump

below 25 mmHg to protect gastric mucosa

what position should the patient be in for NG tube insertion

high fowlers sitting upright

what is the correct method for measuring NG tube length

nose

ear

xiphoid process

(NEX)

what should the patient do during tube advancement

lower head slightly and swallow

what should the nurse do if the tube coils in the mouth

stop, remove slightly, reposition and re-advance

what should the nurse do if resistance is met when placing NG tube

stop advancing, rotate slightly and try other nostril.

what assessments help verify NG placement after X-ray

measure external tube length every shift

visualize aspirate (green, tan, off-white, bloody, brown)

pH testing ( 1-5 = gastric)

why is auscultation (air bolus) NOT reliable

because air can enter into lungs or esophagus and mimic gastric sounds

how often should NG tube be irrigated

every 4-6 hours with water or normal saline

what assessments must be done for NG suction

abdominal distention

nausea/vomiting

bowel sounds

electrolytes

drainage amount/color/consistency

check for kinks or blockages

what comfort measures help with dry mucosa

throat lozenges

chewing gum

frequent oral care

what electrolyte imbalance is common with NG suction

metabolic alkalosis and hypokalemia ( loss of gastric acid and potassium)

what are the signs of fluid volume deficit

dry mucous membranes

hypotension

tachycardia

poor skin turgor

decreased urine output

what are signs of pulmonary complications or aspiration

coughing

dyspnea

crackles

fever

decreased o2 saturation

tachypnea

what is done before removing NG tube

clamp intermittently to assess tolerance

flush with 10 mL water

assess for nausea/distention

how is NG tube removed

patient exhales

withdraw gently to esophagus

remove quickly through nares

what must be documented after NG insertion

tube type and size

nare used

measurement (exteneral length)

confirmation method (X-ray)

patient tolerance

aspirate characteristics

suction settings if applicable

what is the purpose of a blood transfusion

restore/maintain blood volume

increase Hgb/Hct

improve oxygen carrying capacity

maintain coagulation ability

replace specific components

what are the main types of blood products

PRBCs

platelets

plasma

cryoprecipitate

albumin

what patient history must be assessed before giving blood

previous reactions

number of pregnancies

cardiac/pulmonary/vascular disease

what physical assessment findings indicate risk for fluid overload

edema

crackles

dyspnea

JVD

what pre-transfusion checks must be completed before starting blood

consent

MD order

patient understanding

prior reactions

allergies

baseline vitals (within 30 min)

IV patency

catheter gauge

compatibility

why is a second nurse required for an independent double check

Verify patient identity

blood type

unit number

expiry

compatibility

what IV solution is compatible with blood products

0.9 % sodium chloride ONLY

why is filtered IV tubing required for PRBCs

to trap clots, debris and aggregates

what equipment must be prepared before starting a transfiusion

2 bags of NS

Y set tubing with filter

sphygmomanometer

thermometer

tape

single unit IV set

why is blood started slowly for the first 15 min

to detect acute reactions early as most occur within first 15 min

what are the signs of a febrile non-hemolytic reaction

chills

fever increased above 1 degree C

muscle stiffness

what are the signs of acute hemolytic reaction

fever

chills

low back pain

nausea

chest tightness

dyspnea

anxiety

hypotension

bronchospasm

vascular collapse

what are the signs of transfusion associated circulatory overload (TACO)

hypervolemia

dyspnea

crackles

hypertension

JVD

tachycardia

what is the first action if a transfusion reaction is suspected

stop transfusion immediately

what vital sign schedule is required during a transfusion

baseline within 30 min, 15 min after start the per policy

what is the maximum time allowed to infuse 1 unit of PRBCs

4 hours max

what assessments must be done on the IV site before transfusion

catheter gauge 18-20 G

patency

no infiltration

no infection

what assessments must be done on the IV bag before transfusion

expiry date

clots

leaks

discoloration

when is IV iron preferred over blood transfusion

stable patients with low Hgb

pre-op Hgb <130

pregnancy <110

postpartum/post-op 50-120

refusal of blood

why is IV iron faster than blood transfusion for raising hemoglobin

IV iron

faster Hgb production

fewer risks

what must be documented after a transfusion

vitals

patient tolerance

amount infused

reaction signs

interventions

what must be documented if a transfusion reaction occured

reaction signs

time

interventions

physician notified

blood returned to lab

parenteral

method of delivering fluids, medications, or nutrition to the GI tract through:

IV

IM

SQ

what are the goals of parenteral fluid and electrolyte replacement

meet fluid, electrolyte and energy needs

prevent or correct imbalances

maintain hydration

support circulation

replace losses (vomiting, diarrhea, hemorrhage)

what are crystalloids

solutions that mix/dissolve and cross membranes

dextrose solutions

normal saline

lactated ringers

colloids

large molecule solutions that do not cross membranes and stay intravascular for days.

albumin

plasma protein

dextran

What is the NPO (nothing by mouth) time requirement before surgery?

Typically 6-8 hours before surgery for solid food and 2 hours before surgery for clear liquids.

List the five elements of valid informed consent.

1) Patient must be mentally competent and understand information, 2) Information includes nature of procedure, risks, benefits, alternatives, consequences of refusal, 3) Consent must be voluntary without coercion, 4) Consent must be documented with patient signature, 5) Consent must be witnessed.

What are the key components of pre-operative patient education?

1) Surgical procedure explanation, 2) Anesthesia information, 3) Post-operative expectations, 4) Incentive spirometry technique, 5) Deep breathing and coughing, 6) Leg exercises, 7) Pain management options.

What pre-operative medications are commonly given and what are their purposes?

Anticholinergics (reduce secretions), Opioids (analgesia and sedation), Benzodiazepines (anxiolysis and sedation), Antiemetics (prevent nausea).

What special considerations apply to elderly patients undergoing surgery?

Multiple comorbidities, increased medication interactions, possible hearing/vision impairments, increased anxiety, slower recovery.

What is the pre-operative checklist and why is it important?

Verification of: informed consent signed, labs complete, NPO maintained, vital signs recorded, ID band correct, allergies marked, medications given/held, prosthetics removed, pre-med given, patient voided.

What are the four classifications of surgical wounds based on contamination level?

1) Clean, 2) Clean-contaminated, 3) Contaminated, 4) Dirty/infected.

Describe the three phases of wound healing.

1) Inflammatory (0-3 days), 2) Proliferative (3-21 days), 3) Maturation (21 days-2 years).

What are the signs of surgical site infection?

Purulent drainage, erythema, warmth, induration, fever, elevated WBC, foul odor.

What is the difference between dehiscence and evisceration? How would you respond to each?

Dehiscence: partial/complete separation of wound edges. Evisceration: protrusion of internal organs through open wound.

What is the purpose of surgical drains and what are the types?

Purpose: remove excess fluid, prevent hematoma/seroma, reduce tension on wound edges, promote healing.

What factors promote wound healing and what factors inhibit it?

Promote: adequate nutrition, good circulation, young age, infection control. Inhibit: poor nutrition, infection, chronic diseases.

Describe the procedure for sterile dressing change.

1) Verify order and assess need, 2) Gather supplies, 3) Position patient, 4) Remove old dressing, 5) Assess wound, 6) Perform hand hygiene, 7) Put on sterile gloves, 8) Cleanse wound, 9) Pat dry, 10) Apply sterile dressing, 11) Secure with tape, 12) Document.

What are the main indications for intravenous therapy?

1) Fluid replacement, 2) Medication administration, 3) Blood and blood products, 4) Nutritional support, 5) Diagnostic purposes.

Compare peripheral IV catheters and central venous catheters.

Peripheral: short catheter in peripheral vein, easy insertion, lower infection risk. Central: long catheter in central vein, suitable for long-term therapy.

Explain the difference between isotonic, hypotonic, and hypertonic solutions. Give examples.

Isotonic: 0.9% NaCl, LR - no fluid shift. Hypotonic: 0.45% NaCl, D5W - fluid moves into cells.

What is hypertonic solution?

A solution with higher osmolarity, such as 3% NaCl or 5% dextrose in 0.9% NaCl, causing fluid to move out of cells and cells to shrink.

What are the signs and symptoms of infiltration?

Swelling around the site, coolness, slowing/stopping of infusion, discomfort, blanching.

What are the signs and symptoms of phlebitis?

Redness along the vein, warmth, swelling, palpable cord, pain, possible fever.

What is the appropriate flushing protocol for peripheral lines?

Flush with 10 mL saline before and after medication, every 8-12 hours if not in active use.

What is the appropriate flushing protocol for central lines?

Flush each lumen with 10 mL saline before and after medication, every 8-12 hours if not in active use, using positive pressure technique.

List five signs of IV-related infection.

1) Fever, 2) Redness, warmth, induration at insertion site, 3) Purulent drainage, 4) Possible systemic signs (chills, malaise, hypotension), 5) Elevated WBC.

What is air embolism?

An air bubble in the vascular system caused by disconnection of tubing, improper priming, or removal of CVC dressing.

What are the signs of air embolism?

Sudden dyspnea, chest pain, hypotension, tachycardia, possible loss of consciousness.

What is the response to air embolism?

Position on left side in Trendelenburg, notify physician immediately, administer oxygen, monitor vital signs.

Explain the ABO blood group system.

Type A: A antigen on RBCs, anti-B antibodies in plasma. Type B: B antigen, anti-A antibodies. Type AB: both A and B antigens, no anti-A or anti-B antibodies (universal recipient). Type O: no A or B antigens, both anti-A and anti-B antibodies (universal donor).

What blood types can O+ receive?

O+ can receive O+.

What blood types can O- receive?

O- can receive O-.

What blood types can A+ receive?

A+ can receive A+, A-, O+, O-.