Nursing Exam Notes

Patient Safety and Malpractice

• Maintaining patient safety is paramount, focusing on preventing harm and ensuring patient well-being in all healthcare settings.

• Questions to consider: "Does it keep my patients safe?" and "Does it prevent harm?" guide healthcare providers in making informed decisions.

• Malpractice involves four critical components: duty (a responsibility to provide care), breach of duty (failure to meet the standard of care), injury (harm suffered by the patient), and causation (a direct link between the breach of duty and the injury).

• Malpractice is not necessarily a sentinel event but can lead to one if the error results in significant harm.

• Sentinel event: An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof, signaling the need for immediate investigation and response.

• Examples of adverse events: retained surgical items, IV site neglect leading to infection or infiltration, medication errors causing harm, patient falls resulting in injury, sexual assault.

Fluid and Electrolytes

IV Solutions

• Isotonic Solutions: Mimic the body's osmolality to refill the vasculature without causing significant fluid shifts.

  • Primarily used to replace lost fluids and electrolytes to maintain homeostasis.

  • Examples: 0.9% Saline (normal saline), Lactated Ringer's, D5W (5% Dextrose in Water), each serving specific purposes in fluid resuscitation and maintenance.

  • Help maintain blood pressure by increasing fluid volume in the circulatory system, thus supporting adequate perfusion.

  • Fluid volume = pressure, illustrating the direct relationship between fluid levels and blood pressure.

  ---

• Hypotonic Solutions: Have a lower osmolality than body fluids, causing fluid to move into cells.

  • Pull fluid from the vasculature into the cells, causing them to swell, which can lead to cellular edema.

  • Should not be given to patients with increased intracranial pressure, as it can exacerbate cerebral edema, or low blood pressure, due to the risk of further hypotension.

  • Examples: Solutions less than 0.9% Saline (e.g., 0.45% Saline), D2.5W, used cautiously and monitored closely.

  ---

• Hypertonic Solutions: Have a higher osmolality than body fluids, drawing fluid out of cells and into the vasculature.

  • Pull fluid from the cells into the vasculature, increasing blood pressure and potentially causing fluid overload.

  • Should not be given to patients with elevated blood pressure or those at risk for hypervolemia.

  • Examples: Solutions greater than 0.9% Saline (e.g., 3% Saline), D10W, often used in critical situations to stabilize blood pressure but require vigilant monitoring.

  ---

Fluid Volume Imbalances

• Fluid Volume Deficit (Dehydration): Occurs when fluid intake is insufficient to meet the body's needs, leading to decreased blood volume and impaired cellular function.

  • Symptoms: hypotension, tachycardia, dry skin and mucous membranes, decreased urine output, concentrated urine, indicating the body's attempt to conserve fluid.

  • Treatment: fluid replacement (rehydrate) through oral or intravenous routes, depending on the severity of the deficit.

  ---

• Fluid Volume Overload: Occurs when there is an excess of fluid in the intravascular and interstitial spaces, leading to edema and potential heart failure.

  • Symptoms: hypertension, tachycardia, edema (especially pedal edema), difficulty breathing (dyspnea), crackles in lungs, indicating fluid accumulation.

  • Edema builds up in the lower extremities due to the heart's inability to pump efficiently, leading to fluid accumulation in dependent areas.

  • Treatment: elevate the patient to promote venous return, administer oxygen to support respiratory function, administer diuretics to remove excess fluid, monitor potassium levels due to diuretic-induced loss, monitor input and output to assess fluid balance, monitor vital signs for changes indicating improvement or deterioration.

  • Positioning: Sit the patient up to ease breathing and reduce pressure on the diaphragm.

  ---

Urine Output

• Normal urine output: 30 {ml} per hour, an indicator of adequate kidney perfusion and function; significant deviations warrant further investigation.

Electrolytes

• Sodium (Na): Primary extracellular cation; crucial for nerve and muscle function, as well as fluid balance.

  • Imbalances affect the brain; can cause coma, seizures, and death, highlighting the importance of maintaining sodium homeostasis.

  • Safety is a major concern during seizures; protecting the patient from injury is paramount.

  ---

• Potassium (K): Primary intracellular cation; essential for cardiac function and muscle contraction.

  • Intake: through diet, with various foods contributing to daily potassium requirements.

  • Potassium is found everywhere in the body (Sodium-Potassium pump), actively regulating cellular membrane potential and electrolyte balance.

  • Excretion: through urine, with the kidneys playing a key role in maintaining potassium balance.

  • Renal failure patients have difficulty excreting potassium, leading to electrolyte imbalances and potentially requiring dialysis to remove excess potassium.

  ---

• Magnesium (Mg): Important for nerve and muscle function, as well as cardiac rhythm.

  • Imbalances affect the heart; can lead to arrhythmias and other cardiovascular complications.

  ---

• Calcium (Ca): Essential for bone health, muscle contraction, and nerve transmission.

  • Laryngospasm (throat closing) is the worst-case scenario for hypocalcemia, requiring immediate intervention to ensure airway patency.

  • Chvostek's and Trousseau's signs are indicators of hypocalcemia, aiding in early detection and management.

  ---

Scope of Practice for LPNs

What LPNs Can Do

• Administer oral, subcutaneous, intramuscular, and IV medications (for adults) under the supervision of a registered nurse or physician.

• Start a peripheral IV from the metacarpal or cephalic vein down, as long as it's less than 3 inches, following established protocols and with proper training.

• Flush with normal saline and heparin to maintain patency of IV lines and prevent clot formation.

• Administer approved fluids and antibiotics that prevent, kill, or stop infections, as prescribed by a physician.

• Change dressings and use existing central lines (but not insert or remove), adhering to sterile techniques to prevent infection.

• Stop anything causing harm to the patient, exercising critical thinking and initiating appropriate interventions.

• Increase or decrease the rate of flow of a basic IV solution with a physician's order, carefully monitoring the patient's response.

• Access a port (with appropriate training) using a non-coring needle, following established procedures to minimize complications.

• Spike and prime IV bags and tubing to remove air, ensuring accurate medication delivery and preventing air embolisms.

What LPNs Cannot Do

• Administer TPN, drips (heparin, insulin, cardiac meds, GI meds) due to the complexity and potential for adverse reactions requiring specialized knowledge.

• Anything that has central in the word is going to the heart, increasing the risk of infection and requiring advanced skills.

• Insert or remove central lines due to the high risk of complications and the need for specialized training.

• Put anything in a patient's PICC line or central line for someone else to administer, maintaining accountability and preventing errors.

• Remove a pre-existing peripheral IV if it's above the antecubital box or greater than 3 inches, as these require advanced techniques and assessment skills.

General IV Procedures

• If anything is contaminated, discard it and start over to prevent infection and ensure patient safety.

• Always date and initial any changes to dressings, IV bags, or tubing to maintain accurate records and ensure accountability.

• Spiking and Priming: removing air from the IV bag and tubing, preventing air embolisms and ensuring proper fluid delivery.

ABGs

• If stressed, either PCO2 or HCO3 (bicarbonate) is messed up (not both), indicating a primary respiratory or metabolic imbalance.

• If only one system is affected, there is no compensation, meaning the body has not yet attempted to restore pH balance.

• Partial compensation: Both systems are messed up, with the pH still outside the normal range.

• Full compensation: pH is normal, and both other systems are messed up; determine if it is acidotic (below 7.4) or alkalotic (above 7.4) to identify the underlying cause of the imbalance.

Central Lines

• Usually placed in the subclavian area or internal jugular to access large veins for medication delivery and monitoring.

• Groin placement is avoided due to contamination risks, increasing the likelihood of infection.

• Dressing changes are required every seven days, using sterile techniques to prevent infection.

• Central lines should be removed as soon as they are no longer needed to reduce infection risk and minimize complications.

• A port (or implanted port) is placed under the skin and allows patients to live a normal life once healed, providing long-term access for medication and fluids.

• PICC lines and central lines are external and exposed, requiring careful maintenance and monitoring to prevent infection.

IV Complications

• Mechanical: related to the insertion or presence of the IV catheter, such as infiltration or phlebitis.

• Bacterial: caused by bacteria, leading to local or systemic infections.

• Chemical: caused by medication or cleansing agents, resulting in irritation or tissue damage.

• Post-infusion: infection develops after IV removal, requiring monitoring and treatment.

Phlebitis Grading Scale

• 0: No infection, indicating a healthy IV site.

• 1: Redness with or without pain, suggesting early inflammation.

• 2: Redness, pain, swelling, indicating increased inflammation and potential infection.

• 3: Redness, pain, swelling, and a palpable cord, suggesting thrombophlebitis.

• 4: All of the above plus purulent drainage, indicating a severe infection requiring immediate intervention.

Infiltration

• Basic fluid (e.g., normal saline) escapes the vein and enters the surrounding tissue, causing swelling and discomfort.

• Symptoms: cool to the touch, swollen, possibly painful, indicating fluid accumulation in the tissue.

• Treatment: stop the infusion, elevate the extremity to promote fluid reabsorption, treat the pain with analgesics, and apply a warm compress to increase circulation and reduce swelling.

Extravasation

• Infiltration with a vesicant (medication that causes tissue damage), leading to severe tissue injury and potential necrosis.

• Treatment: stop the infusion, leave the IV in place to administer the antidote, disconnect the tubing, turn off the pump, contact the pharmacist and doctor for an antidote and specific instructions.

• Administer the antidote to create a barrier around the infiltrated medication before removing the IV to neutralize the vesicant and minimize tissue damage.

IV Tubing Change Schedule

• TPN (Total Parenteral Nutrition): every 24 hours to minimize bacterial growth and prevent infection.

• Primary tubing: every 96 hours to reduce the risk of contamination.

• Secondary tubing: every 24 hours due to intermittent use and potential for bacterial contamination.

• Peripheral IV and midline: every 96 hours to maintain sterility and prevent infection.

Peripheral Nerve Catheters

• Can be filled with antibiotics, chemotherapy, or pain medications for targeted delivery.

• Can be used in the hospital or home care setting, providing flexibility in treatment options.

• Can be discontinued when treatment is complete, minimizing the risk of complications.

Prioritization

• ABCs: Airway, Breathing, Circulation, the foundation of emergency assessment and intervention.

• When in doubt, prioritize airway to ensure adequate oxygenation and ventilation.