HA Exam 2

Exam Two

Chapters 6, 10, 14-17

Non-Parenteral Medication Administration

• Parenteral route: injections into vein (IV), muscle (IM), subcutaneous (Sub-Q), intradermal, others outside of nursing scope like (epidural, intraarterial, intraperitoneal, etc)

• Med orders need name, dose, route, frequency and if PRN a reason

• Oral (PO)

  • By mouth, sublingual (under the tongue), buccal (in the cheek)

  • Most convenient and most used

  • Absorbed into the system through the digestive tract (hit bloodstream in small intestine)

  • Slower onset

  • Last longer (longer duration)

  • Quick acting are sublingual and buccal

  • Usually the cheapest

• Inhalation

  • oral, nasal, or anesthesia

  • Inhaled into respiratory tract and absorbed through the alveolar-capillary network

  • Quick acting

• Topical 

  • Skin (ointment, powders, patches). Otic (eye: drops, ointment). Optic (ears: drops)

  • Medication placed on skin or mucous membranes

  • Absorbed into the system through absorption into the skin and then the bloodstream

  • Slowest onset

• Suppositories

  • Vaginal or rectal

  • Absorbed through the membranes into the bloodstream

  • Quick acting

  • Most oral meds can be given rectally

  • Have the patient lie on their left side with the right leg pulled up to the chest, apply gloves, remove suppository, lubricate with water or water-based lubricant, insert the top into the rectal opening past the internal sphincter (about a finger length), hold against the rectal wall for a few seconds. You wanna make sure it’s not just being put into stool

• Medication Administration is an essential part of nursing practice that is complex and time-consuming, taking ⅓ of our time. 

• Nurses are the last line of defense with passing meds

• Participants in medication administration include the drug manufacturer, prescriber, pharmacist, system process, nurse, patient

• AC: before meals

• PC: after meals

• HS: Hour of Sleep

• PR: Per Rectum

• Types of orders

  • Standing or Routine: administered until the dosage is changed or another medication is prescribed. An automatic order that gets put on all patients

  • Single one-time: is given one time for a specific reason. Like a vaccine. Gets d/c or disappears after administering one time. 

  • Now: when a med is needed right away, but NOT stat. For things like nausea

  • PRN: given when the patient requires it, ALWAYS will need a frequency and reason

  • STAT: given immediately in an emergency

  • Prescriptions: medication to be taken outside of the hospital

• For verbal orders

  • Avoid if possible. If you must do it, write on the pts chart ASAP, always do a “read back,” state numbers individually, ask the prescriber to spell unfamiliar or similar drug names

• Always fully read labels

• Hospitals often have dual sign-offs for look- sound- alike meds

• Med admin needs a knowledge and skill set that is unique to a nurse with critical thinking at each step

• For every drug you give, you must know: what the drug is, how it works, why it is being given, what the usual dose is, and the anticipated outcome

• Assessments before meds include: can the patient safely take the med (mental status, swallow, NPO, allergy, etc), vitals, symptoms, does it make sense, can they follow treatment plan? 

• Never cut, crush, or chew extended-release or long-acting meds

• Right…

  • Patient: Always need 2 identifiers for a patient (name, ID arm band, bar code on patient armband, birth date, medical ID number)

  • Medication: compare written orders with the MAR. Need to do a med reconciliation whenever pts transfer from one care setting to another (compare most recent med list to the orders). No drugs can be administered without an order. 

    • Never give a med someone else has prepared, give a med you don’t know, ignore a patient that's questioning a med, or borrow meds from another pts bin. 

    • Always know what drug you are giving, the usual dose, how it works, and the anticipated outcome

    • Compare the med to the MAR 3 times

  • Dose: always know the usual dose, 0 always lead but never follow, only break tabs scored by the manufacturer, know calcs and conversions, ask another nurse to check calculated doses, use standard measuring devices

    • 1 oz = 30 mL

    • 1 tsp = 5 mL

    • 1 TB = 15 mL

  • Route: oral, inhalation, topical, vaginal, rectal, IM, IV, SubQ

  • Time/Frequency: know why the med is ordered for a certain time and if it can be altered, know the meanings of different orders, as long as the med is given w/in the time frame, its not considered to be a med error

  • Documentation: record as you administer the med by the bed

• Med Errors

  • Most common are the wrong med, dose, not giving the med, or route

  • Report potential errors (an error waiting to happen) and near misses (errors that were caught before reaching the patient)

  • Top Causes

    • Inadequate knowledge and skills, failure to comply with policy and procedures or lack of procedures, failure in communication, and individual/system issues

  • When you id a med error, check the pts safety first, notify patient and provider, report incident

Chapter 6: Pain Assessment

• Acute Pain: recent onset of less than 6 months. Due to tissue damage and ends when the tissue heals. May cause an increase in BP, pulse, or RR (physiologic stress responses)

• Persistent/Chronic Pain: intermittent or continuous. Lasting more than 6 months. People adapt so there is no physiologic response. Could lead to irritability, depression, and insomnia. 

• Nocioreceptive pain

  • Somatic pain: Nerves stimulated within structures of bone, joint, muscles, skin & connective tissue. It’s well-localized, intermittent or constant, aching, throbbing, cramping. 

  • Visceral pain: Nerves stimulated within the thoracic, pelvic and abdominal organs. Poorly-defined locations, dull, deep, pressure. Referred pain: many organs do not have pain receptors, so when the stimulus of pain gets to the spinal cord, it stimulates sensory nerves from unaffected organs found in the same spinal cord segment; it is in the general area, is kinda vague pain (most organs dont have pain receptors)

• Neuropathic Pain: Occurs because of an abnormal processing of sensory input by the CNS or PNS. Burning, shooting, numbness, pins and needles, tingling. Pinched nerve, diabetic neuropathy, phantom limb pain 

• There is no correlation between the amount of tissue damage and the degree of intensity of the nonverbal signs (moaning, groaning, resisting movement, clenching teeth, distorted posture) pain

• Pain threshold: the point at which a stimulus is perceived as pain; does NOT vary significantly 

• Pain tolerance: the duration or intensity of pain that a person endures or tolerates before an outward response. Decreases with repeated exposure or negative emotional factors. Increases with interventions, positive things, or prior experience. 

• Health history is subjective

• Objective physical assessment includes nonverbal signs of pain (moaning, groaning, resistance to movement, clenching teeth, distorted posture), inspect the site of pain for appearance and palpate for pt response, get vitals (all will still be in range, but systolic BP, heart rate, resp rate and pattern may increase) 

• Pain is the most common reason people seek healthcare

• Pain: “unpleasant sensory and emotional experience associated with actual or potential tissue damage,” or “pain is whatever the experiencing person says it is, existing wherever he says it does” 

• Pain pathway: nocioceptors →up the spinal cord (Large A- delta fibers for sharp, pricking, acute, well-localized, and short duration. Small C fiber for dull, aching, throbbing, burning, slow onset, and long) → thalamus → parietal lobe which causes the feeling of pain → limbic system which generate the emotional response and tolerance → descending inhibitory nerves get stimulated → produce endorphins that produce an internal anesthesia    

• Nocioreceptors: sensory nerves in the tendons, muscles, skin layers, and skeletal muscles

Chapter 16: Breasts and Axillae

• Distinctive shape but great variation in side and volume, may be asymmetrical

• Vertically from 2nd to 6th ribs, laterally from sternal margin to midaxillary line

• 4 quadrants (upper, outer, inner, lower) and tail of spence

• 3 types of tissue

  • Glandular: largest amount in upper outer quadrant, more breast cancer and tumors there, where breast milk is produced and stored

  • Fibrous tissue

  • Subcutaneous and retromammory fat tissue

• Alveolus: contain milk when producing

• Milk exits at the nipple pore

• Suspensory ligaments of cooper: for maintaining shape and support

• Tanner Staging of Breast Development

  • 1- preadolescent, elevation of the papilla only

  • 2- a small mount is formed by the elevation of the breast and papilla, areolar diameter enlarges

  • 3- further enlargement of breast and areola

  • 4- projection of the areola and papilla to form a secondary mound above the level of the breast

  • 5- mature breast, areola recessed to the general contour of the breast

• Gynecomastia- usually temporary, when the male breast becomes slightly enlarges during puberty. Can happen at any point with a decrease in testosterone

• Lymphatic system

  • Each breast has lymph nodes which → axillar lymph nodes (has 75% of lymph nodes) → sub and supraclavicular nodes

  • Other drainage routes through anterior axillae (pectoral nodes) above breast, internal mammary nodes in thorax, and subdiaphragmatic nodes toward abdomen and cross-mammary pathways to opposite breast

• Health history: “do you have any concerns regarding reproductive organs?”

  • Breast commonly reported: pain, lumps, discharge, rash, swelling, trauma, history of breast disease, surgery, self care behaviors of self examine and mammogram

  • Axilla: tenderness, lump, swelling, rash

  • Fam History: breast disease, gynecological cancer

• If any lumps are present, note location- quadrant and clock, size in cm, shape, consistency, mobility, distinctness, nipple retraction, overlying skin, tenderness, and lymphadenopathy

• Fibrocystic changes to the breast: typically occur with menstruation and leave after, tender, bilateral, soft to firm, tense, mobile, multiple little round lumps  

• Fibroadenoma: bilateral, firm/rubbery, mobile

• Cancer: unilateral, hard/stone-like, fixed location, nontender

• BSE: done just after menstruation (days 4-7) or on the same day each month if no menstruation, noting any retraction, dimpling, nipple changes, discharge, or chances in skin/surface characteristics. Not sure if it is really helpful, teach breast awareness

Chapter 17: Reproductive System and the Perineum

Female

• Urethra is about 2 inches long, much shorter than males

• Puberty: breast bud development is the first physical change → adolescents experience menarchy about 2 years after breast development → growth sputs occurs about the time of menarche → pubic hair development precedes axillary hair by about 2 years

• Tanner Staging of female genitalia

  • Stage 1: bo pubic hair, only body hair (vellus hair)

  • Stage 2: sparse growth of long, slightly dark, fine pubic hair; slightly curly and located along the labia (age 11-12)

  • Stage 3: pubic hair becomes darker, curlier, and spreads over the symphysis (age 12 to 13)

  • Stage 4: texture and curl of pubic hair is similar to an adults, but does not spread to thighs (age 13 to 15)

  • Stage 5: adult appearance in quality and quantity of hair, growth is spread to inner thighs and abdomen

• Menopause: decreased hormonal function → changes associated with aging and estrogen depletion → one full year of no menses → ovulation usually ceases 1 to 2 years before menopause

Male

• Urethra is 7-9 inches long, much longer than females

• Testes make sperm

• Prostrate gland often enlarges with age; can cause resistance when inserting catheter and hesitancy/difficulty starting stream

• Nocturia- kidneys work better at night, causing more frequent urination

• Puberty: first sign is enlargement of testes → pubic hair appears → penis size increases → complete change in development takes about 3 years

• Tanner Staging of male genitalia

  • Stage 1: prepubertal, no pubic hair, 

  • Stage 2: scrotum and testes have enlarged and have more textures scrotal skin; growth os slightly pigmented downy hair is sparse

  • Stage 3: penis has grown, especially in length; hair is darker and curlier

  • Stage 4: further penile growth in length and breadth has occurred; glans is larger and broader; hair is adult in type

  • Stage 5: testes and scrotum are adult in size; pubic hair adult in quantity and pattern, present along inner borders of thighs

• Aging: no definite end to fertility → production of sperm decreases around age 40, but continues into 80s and 90s → after 55-60, testosterone production declines → prostate normally enlarges with aging

Anus

• Canal goes from anorectal junction to the anus; lined w/ rectal columns

• Rectal columns- mucous membranes arranged in longitudinal folds that have the hemorrhoidal plexus

• Hemorrhoidal plexus- a network of arteries and veins in the rectal columns

• Hairless with moist mucosal tissue surrounded by hyperpigmented perianal skin

• Closed except during defecation

• Internal sphincter- smooth muscle and involuntary control

• External sphincter- skeletal muscle, voluntary control, allows for control of defecation

• External hemorrhoids may look like purple grapes around the anus

• Rectal examination can be performed to determine if there is stool: pt may feel pressure like a bm; glove → lubricate 2 fingers → middle finger palm side up over anus → ask pt to bear down → insert middle finger into rectum → insert index finger into vagina to locate cervix; pt should be in L lateral position w hips and knees flexed, knee-chest position, or standing bent over exam table. 

Chapter 10&15: Head, Ears, Eyes, Nose, Throat & Neurologic System (Cranial Nerves)

• 

• Central Nervous System

  • Cerebral cortex is the center for the human’s highest function. Outer layer of the brain (grey matter): associated with thought, memory, reasoning, sensation, and voluntary movement. 

  • Four lobes within the brain

    • Frontal: Primary Motor Cortex, Functions related to voluntary movement, Intellectual function, awareness of self, personality

  • Temporal: Primary Auditory Cortex

  • Parietal: Primary Sensory Cortex

  • Occipital: Primary Visual Cortex 

  • Wernicke: damage to this causes receptive aphasia; difficulty understanding words, but nonsensical words fluently. What are they talking about

  • Broca: damage to this area causes expressive aphasia; no difficulty understanding, but difficult to form words or sentences. Broken words

• Peripheral Nervous System

  • 12 pairs of cranial nerves (exit brain)

  • 31 pairs of spinal nerves (exit spinal cord)

    • 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, 1 coccygeal

    • Nerves are named by the vertebrae they exit above (7 has 1 above and below)

  • Autonomic Nervous System (involuntary movement)

    • Sympathetic- activated during times of stress; Fight or Flight; Increased blood pressure & heart rate, constrict peripheral vessels, dilate bronchioles/bronchi, inhibit gastrointestinal peristalsis 

    • Parasympathetic- controls vegetative functions; Breed and Feed; Rest or Digest: Conserve energy by decreasing blood pressure, heart rate & respiratory rate, stimulate gastrointestinal peristalsis 

  • Somatic Nervous System- voluntary movement of skeletal muscles, Provide sensory input to the CNS (touch, taste, hearing)

• Cranial Nerves

• Oh Oh Oh To Touch And Feel Very Good Ah Heaven

• Some Say Marry Money But My Brother Says Big Brains Matter More

• Common symptoms related to head: headache, dizziness, vision changes or difficulty, hearing loss or ringing of the ears (tinnitus), earache, nasal discharge, sore throat, mouth lesions, toothache

• Presyncope- feeling of faintess and impending loss of consciousness (cardiovascular symptom)

• Vertigo- sensation of movement, usually rotational such as whirling or spinning; cardinal symptoms of vestibular dysfunction

• Light-headedness- vague description of dizziness that does not fit other classifications

• Head

  • Normocephalic- the skull is symmetric and appropriately proportioned for size of the body

  • Microcephalic- small head

  • Macrocephalic- large head

  • People with Bell’s palsy may have some facial paralysis, resulting in asymmetry

  • Occipital ridge- the ridge on the back of the head, may vary to some degree which is an expected variation

• Eyes

  • Ptosis- drooping of eyelid and inability to close eye; usually from an infection or genetic

  • Conjunctive of eye should be pink and clear

  • Inflamed and red conjunctiva could indicate infection

  • Corneas with a white, opaque ring can indicate hyperlipidemia in people over 60

  • Pupils should be equal in size, round, 2-6 mm

  • Yellow sclera may indicate jaundice, redness may indicate inflammation or hemorrhage

  • Correct of glaucoma can result in part of the iris missing

  • Anisocoria- unequal size of pupils, but reflexes are normal

  • Red Light Reflex: shine ophthalmoscope into pts eye, red/orange should reflect. Absent, black, or uneven findings may indicate cataracts, obstructive abnormalities, or CN2 lesion

  • Snellen Eye Test: numerator is how far away you stand, denominator is the comparison to a normal person. Normal is 20/20. Great is 20/10. Blind is 20/200. If the patient gets 100% right, then they go down to the next line. 

  • Nystagmus- not smooth movement of the eyeball

• People with down syndrome have low set ears

• Top of the pinna should be equal with the outer eye

• Marked asymmetry of the nose and septal deviation that cause asymmetry is normal

• Snot thats unilateral and watery may indicate skull fracture, purulent may indicate foreign body

• Nasal turbinates should be deep pink in color

• Acetone odor of breath could indicate diabetic ketoacidosis

• Tonsils should be +1 or +2 in size, slightly pink, irregular surface (+3 and +4 are enlarged)

• Cleft palate- opening between hard and soft palate

• Lesions or nodules of the palate may indicate infection or tumor

• Inability of soft palate and uvula to rise when saying ah may indicate a neurological disorder

• Neck

  • Tracheal deviation is a medical emergency

  • Goiter- enlarged thyroid

  • Limited ROM or discomfort may indicate systemic infection, musculoskeletal problems, or degeneration of vertebrae

• Cranial sutures do not fuse until about 2 years old

Chapter 14: Musculoskeletal Assessment

• Ability to move

• Flexion- bending (decreasing angle between joints)

• Lateral flexion- bending to the side

• Extension- straightening or neutral position (increasing angle between joints)

• Hyperextension- over-straightening 

• Rotation- turning while keeping part of body stabilized 

• Pronation- inward movement of a joint

• Supination- outward movement of a joint 

• Have elbows at the side when assessing pronation and supination

• Muscle Strength Grading- anything less than a 5 requires further workup

  • 0: No evidence of contractility

  • 1: evidence of slight contractility

  • 2: complete range of motion with gravity eliminated

  • 3: complete range of motion with gravity 

  • 4: complete range of motion with some resistance

  • 5: complete range of motion with full resistance

• TMJ is Temporal Mandibular Joint 

• Bones provide support for soft tissues and organs, protection of organs, body movement, and more

• Skeletal muscles are controlled voluntarily

• Ligaments- connective tissue that holds bones to bones

Chapter 15: Neurological Assessment

• CNS: brain and spinal cord

• Cerebrospinal fluid: colorless and odorless fluid made in the cerebral ventricular system, and it circulates around the brain and the spinal cord to provide a cushion, maintain normal intracranial pressure, provide nutrition, and remove waste

• Gray matter- controls movement, memory, and emotions

• White matter- learning and brain functions, coordinating brain communication

• Spinal cord- continuation of the medulla oblongata and begins at the foramen magnum and ends at the first and second lumbar vertebrae

• Cerebrum- largest part of the brain and has two hemispheres with a total of 4 lobes

• Diencephalon- contains the variety of thalamus (controls some of homeostasis, body temp, hunger, autonomic responses, sleepiness)

• Basal ganglia- control smooth, coordinated voluntary movements

• Brainstem- arousal, awareness, most CN originate here, control reflex center of involuntary functions

• Cerebellum- balance, coordinating movements, muscle tone, proprioception

• Proprioception- the ability to know where your body is in relation to things when your eyes are closed

• Primary motor cortex- in the frontal lobe; controls movement of the opposite side of te body as the pathway cross at the medulla oblongata (contralateral)

• Primary sensory cortex- in the parietal lobe; receives sensory input for position, touch, shape, texture; crosses over the medulla oblongata (contralateral)

• Messages cross at the medulla oblongata

• Descending Motor Tracts: efferent, carry impulses from frontal lobe to muscles for voluntary movement

• Ascending Sensory tracts: afferent, carry sensory info from the body to the parietal lobe

• Crude touch- itch or tickle... cannot quite pinpoint exact location, but a general vicinity 

• Fine touch- knowing the specific location 

• 31 pairs of spinal (peripheral nerves)

  • Named according to the vertebrae they exit under

    • C7 has 1 above and 1 below

  • Each pair has a motor (descending/efferent/ventral) and sensory (ascending/afferent/dorsal) root

  • Motor fibers carry messages from the frontal lobe → spinal cord → muscles and glands

  • Sensory fibers carry impulses from sensory receptors of body → spinal cord → thalamus → parietal lobe and then send a response back down through motor fibers

• Dermatome maps- shows areas of skin on your body that rely on specific nerve connections on your spine

  • If a higher nerve is affected, ex T9, there will be no sensation from that area down

• Reflexes

  • Deep tendon- responses to stimulation of a tendon that stretches the neuro spindles of a muscle group; ex: patellar. Most common as a RN

  • Superficial- responses to a stimulation of a skin response; ex: Babinski)

  • Visceral- use of the autonomic nervous system to elicit a response; ex: pupils

  • Pathologic- abnormal; a reflex that should go away but remains or returns; ex: Babinski after age 2

  • Assessments

    • Biceps: C5 and C6

    • Brachioradial: C5 and C6

    • Triceps: C6, C7, and C8

    • Patellar: L2, L3, and L4

    • Achilles: S1 and S2

  • Reflex arc or reflex withdrawal: controls autonomic responses (involuntary) to stimuli at level of spinal cord; frees cerebral cortex from involvement in some muscle movements that occur in the body; it is a protective thing

    • Afferent fiber carries message to dorsal root of ventral root and travels to the muscle via efferent nerve

    • No CNS involvement

    • Has to have intact sensory nerve, functional synapse in the spinal cord, intact motor fiber, a neuromuscular junction, and competent muscle to function appropriately, which means an abnormal reflex could indicate dysfunction in any one of these areas.

  • If you cant get a tendon, try a different one

  • Assess both sides

  • Briskly tap the tendon with a flick of the wrist

  • Should be 2+ (expected). 0 is absent, 4 is brisk/intermittent clonus

    • Clonus is a rhythmic, overexaggerated response

• Cerebellar function

  • Romberg test: pt stands with eyes closed and feet together for 20 seconds w/o swaying

  • Tandem walk: heal to toe walk in a straight line

  • Assess upper and lower extremities too

• Spinothalamic tract: can sense light touch and pain; touch parts on face with q tip, have pt determine if sharp or dull end of a qtip thing

• Posterior Column Tract- vibration and position; test with tuning fork and graphethesia

• LOC

  • Lethargic- Can be aroused but return to “sleep” once stimuli ceases; say name to awaken and fall back asleep easily

  • Obtunded- Louder, more vigorous stimuli will awaken patient, but patient promptly returns to “sleep;” nudge, shake, or shout to wake; need constant stimulation

  • Stuporous- Will withdraw from painful stimuli; only wake with pain and may only wake minimally

  • Semicomatose- Responds to painful stimuli with abnormal flexion or extension

  • Comatose or Unresponsive- Does not respond to any stimuli

  • Glasgow Coma Scale

    • Decorticate- abnormal flexion in to protect core

    • Deceribrate- not protecting core, abnormal extension, head tilted back

    • Scoring: Severe 3-8, Moderate 9-12, Mild 13-15

      • A wall has a score of 3, minimum score

      • Max score is 15

      • If score is less than 8, think about protecting airway