Final Exam Study Guide PDF

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Fundamentals of Nursing Final Exam ...

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Final Exam Study Guide IV Therapy (4) -NS 0.9% NaCl (iso)  Expand volume, dilute medications, keep vein open -LR  Fluid resuscitation -D5W (hypo)  Isotonic until inside the body, glucose is metabolized and becomes hypotonic  DON’T give to infants or head injury pts. o May cause cerebral edema -D5 ½ NS (D5NS) (hyper)  Used for Na and volume replacement  Go slow  Monitor BP, Pulse and quality of lung sounds and serum Na and urine output - IV fluids used for hypovolemia  Isotonic (0.9% NaCl, or LR) NORMAL SALINE  Then LR if not working  Fluid volume deficit -effect on intravascular space with isotonic, hypotonic & hypertonic solutions  Isotonic: fluid remains in the IVS w/o ant net flow  HYPERtonic: water moves out of cells and in to the IVS, causing the cells to shrink  HYPOtonic: solution moves out of the IVS and into the cells, causing the cell to swell o NEVER on pt. w/ neurological issue or cerebral edema 2. Prime a primary IV solution  Open clamp and prime tubing, close clamp  Removes air from tubing and preserves sterility  Air embolism is a potential complication of any intravenous therapy  The way to control bubbles: Close the roller clamp on the tubing before spiking the IV bag. Hang the IV bag from an IV pole before priming the tubing. Fill the drip chamber by squeezing it until it is one third to one half full before priming the tubing. Use the roller clamp to control the flow at a rate that allows you to invert the injection ports before the fluid reaches them and to tap them as the fluid fills them. Use the roller clamp to control the flow at a rate that minimizes turbulence, which can create bubbles, and at a rate that allows you to check for bubbles and to tap and invert the tubing to remove any air you see.

 3. Calculate IV drip rates to include drops per minute, mL/hr & . 4. Place an IV on an infusion pump at the prescribed rate 6. Identify complications of IV therapy (S & S)  Tip of the catheter can break off, creating an embolus  Infiltration (fluid leaks into surrounding tissue) o Signs: coolness, swelling, pallor, tenderness, skin blanching  Venous access device-related infection  Phlebitis (inflammation of the vein) o Red warm, edema o Remove line immediately  Thrombus (blood clot)

Speed shock: the body’s reaction to a substance that is injected into the circulatory system too rapidly; too rapid a rate  Fluid overload: too large a volume of fluid is infused  Air embolism: air in the circulatory system o Pinch off cath or secure system to prevent entry of air o Place pt. on L side in trendenburg position Nutrition (4) -Prealbumin: earliest indicator of protein malnutrition  Short term- CURRENT -Albumin: long half life (transports medications)  Takes a while to change- CHRONIC -warfarin daily (blood thinner)  AVOID excess Vitamin K -High potassium= avocado -BEST lab test for nutritional status: PREALBUMIN 

** stress response  blood glucose levels 4-Identify developmental nutritional considerations.  Growth: infancy, adolescence, pregnancy, and lactation increase nutritional needs  Activity increases nutritional needs  Age-related changes in metabolism and body composition  Nutritional needs lower off in adulthood (  BMR)  Fewer calories required in adulthood b/c of decreased BMR o Protein (meat), Vit K (leafy greens), carbs (pasta) 11-Describe therapeutic diets commonly found in health care facilities.  NPO o Watch how long pt. is on it (can cause sepsis)  Clear liquids  Full liquids  Soft  Puree  Cardiac (2g Na, low fat, low cholesterol)  Diabetic (carbohydrate counting)  Eternal feedings o Short term- NG tube  Keep head elevated (@ least 30 degrees)  Turn off 20 mins prior to laying down  Vomiting, aspiration o Long term- PEG/ J tube  TPN (total parenteral nutrition o Through central line (dextrose 10%) o Sterile tech (b/c central line acquired infection)  Tube feedings- DON’T lie pt flat  COPD need calorie count  Assess nutrition for pts. w/ burns, nurgeries, trauma, sepsis o They need more

 Vitamin B detoxifies alcohol 8-Plan nursing care related to nutritional problems.  Advocate for limitations on NPO status o Being NPO make pt. @risk for developing sepsis  Be alert to length of time for NPO  Monitor pts. Diet orders  Observe intake and appetite  Eternal (NG tube) and parental (Iv- central line) should NEVER be mixed  Assist pt w/ eating  Consult w/ dietitian and physician  Address potential for drug-nutrient reactions o A lot react w/ grapefruit juice o Antacids o Milk products o Iron should NOT be given w/ milk  Monitor food brought by visitor (diabetic, renal)  Nutrition edu  Provide oral hygiene (bacteria, MM dry- will travel to lungs- pneumonia)  Assess ability to chew  Small frequent meals  Control odors  Attractive looking food

Fluids & Electrolytes (6) - Fluid intake: 2,600 mL -Fluid output: 2,500- 2,900 mL  Sensible loss: urination, defecation, wounds  Insensible loss: cannot be measured; evaporation through skin, water vapor from respirations -Patient assessment with sodium & potassium loss  Physical o Skin, MM, VS, neurological assessment o Symptoms: excessive thirst, nausea, vomiting, diarrhea, draining wounds  I&O  Urine volume and concentration o  urine volume and  specific gravity= fluid volume deficit o  urine volume and  specific gravity= renal disease o  urine volume= fluid volume excess o Hypovolemia causes  renal perfusion and oliguria o Hypervolemia causes  urinary volume if kidneys are functioning normally  Body weight o 1kg=1L of fluid  CBC  Serum electrolytes, BUN and creatinine levels o  BUN: found w/ impaired renal function, diabetic ketoacidosis, burns o  Creatinine: found w/ impaired renal function, heart failure, shock, dehydration

Hyponatremia: low sodium weak, dehydrated, swelling (norm 135-145) o Leads to swelling of cells -> hypotension, edema, muscle cramps, weakness, dry skin o Signs:  intracranial pressure, lethargy, muscle twitching, focal weakness, hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs and facial muscles) & seizures o = to hyperkalemia  Hypokalemia o Leg cramps -Lab norms for Hgb, Cr., & Na.  Hgb: M=13-18 F= 12-16  Cr: 0.7-1.4 mg/ 100 mg (2+ BAD)- KIDNEY FUNCTION  Na: 135-145 

1.

Discuss the function, distribution, movement and regulation of fluids and electrolytes in the body (sodium, potassium, chloride, magnesium, calcium and phosphate).  Function: transport nutrients to cells and waste from body o Many more  ICF= w/in cell (70%)  ECF= outside cell (30%) o Intravascular o Interstitial fluid (outside vessel)  Electrons o Sodium: controls and regulates volume of body fluids (135-145) o Potassium: chief regulator of cellular enzyme activity (cardiac cells) and water content (3.8-5)  heart o Calcium: nerve impulse, blood clotting, muscle contraction, B12 absorption (8.5-10.5)  Hypocalcemia - face twitch o Magnesium: metabolism of carbohydrate and proteins, vital actions involving enzymes (reflex activities (muscle contraction) and cardiac muscle) (1.5-2.5)  Check reflexes o Chloride: maintain osmotic pressure in blood, produces hydrochloric acid (95-105)  Regulating organs o Kidneys, cardiovascular system, lungs, adrenal glands, thyroid gland, parathyroid gland, GI tract, nervous system

2.

Discuss sources and losses of the main electrolytes of the body. 

Diarrhea, vomiting, renal failure (kidneys), sweating, diuretics, stoma, urine, stool

3.

Discuss risk factors, causes, and clinical presentations of fluid and electrolyte imbalances.  Blood loss  Vomiting, diarrhea  Fistulas  Sweating  Diuretics  Fever  Renal failure  Medications o Heparin (warfarin) ***know K level o ACE inhibitors o NSAIDS  Inadequate diet o malnourished  Inadequate Ca absorption  Cancer  Tube feeding  With draw  Diabetes  Burns  Hormone imbalance

4.

Collect assessment data related to the patient’s fluid and electrolyte status. -CBC, Serum electrolyte, urine pH and specific gravity 

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Skin turgor/ tongue turgor o  fluid volume: skin flattens more slowly, additional longitudinal furrows on tongue and its smaller o Sodium excess: tongue red and swollen Moisture and oral cavity o  fluid volume: dryness of mem b/w cheek and gum o Sodium excess: dry sticky MM Tearing and salvation o  fluid volume: absence or tearing and saliva Appearance of skin and temp o Metabolic acidosis: warm flushed skin Facial appearance o  fluid volume: pinched and drawn facial expression  Deficit of 10% of body weight causes sunken eyes Edema o Retention of 5-10 lbs. of excess fluid occurs (edema occurs) o Localized: thrombophlebitis

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o Generalized: heart failure, cirrhosis of the liver, nephrotic syndrome Body temp o  temp: increase fluid requirments Pulse o  fluid volume: tachycardia o K+ imbalance and mg deficit: irregular pulse o Pulse quality and amplitude is  w/ fluid volume deficit and  w/ fluid volume excess Respirations o Crackles: fluid volume excess BP o  fluid volume:  BP

Describe the role of dietary modification, modification of fluid intake, medication administration and intravenous therapy in resolving fluid and electrolyte imbalances. (8) Describe basic nursing assessments and interventions used in caring for a patient receiving intravenous therapy.

Grief & Loss (5)  Kubler Ross’s 5 stages of grief (DABDA) o Denial o Anger o Bargaining o Depression o Acceptance  Signs of impeding death o Difficulty talking or swallowing o Nausea, flatus, abdominal distension o Urinary/ bowel incontinence or constipation o Loss of movement, sensation and reflexes o Decreasing body temp w/ cold or clammy skin o Weak slow or irregular pulse o Decreasing BP o Noisy, irregular, or Cheyne-stokes respirations o Restlessness/ agitation o Cooling, mottling, and cyanosis of the extremities and dependent areas  Postmortem care of the family o Listen to family’s expressions of grief, loss and helplessness o Offer solace and support by being an attenuative listener o Arrange for family members to view the body o In the case of sudden death, provide a private place for the family to begin grieving

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o It is appropriate for the nurse to attend the funeral and make a follow up visit to the family Patient o Has the right to consent or refuse  Should be made aware of this right Components of a good death o Pain and symptom management  Sky is the limit- NO max dose o Clear decision making o Preparation for death o Completion o Contributing to others o Affirming of the whole person o Pt. centered Postmortem care o Care of the body  Anatomical position, replace dressings, and remove tubes (unless autopsy scheduled)  Keep central line in  Keep dentures in  Raise HOB  Place ID tags on body  Follow local law if pt. died of communicable disease o Care of the family o Discharging legal responsibilities o Death certificate issued and signed o Labeling body o Reviewing organ donation arrangements if any o Care of other pts. Palliative care: involves taking care of the whole person- body, mind and spirit, heart and soul o Hospice: care provided for pts. W/ limited life expectancy Advance directive o For anyone 18+ o Provides instructions for future treatment Death certificate: clinicians signature is required Consent for an autopsy is legally required

Peds Growth &Development (20) -Permanence develops @ 12-18 months -Anterior fontanelles close @ 15-18 months -Common type of allergy in infants= food -FOLLIC ACID: B vit. That Is recommended in pregnancy to prevent neurological-tube defects – Normal infant VS

 T: 98.7-100.5 F (37.1- 38.1 C)  P: 80-160  R: 20-40  BP: 85/37 – Toddlers reaction to hospitalization – regression Box 21-4 pg. 523  Anticipate possible regression during difficult periods or times of crisis, then accept and support a person’s return to a followed progression in development  Children often regress during difficult periods or crisis (during stress) o Ex: bed wetting (loss of control over elimination) o Excessive clinging to caregiver o Use of more infantile speech patterns – Erikson – Developmental theory on adolescents, Infants  Infants: Trust vs. Mistrust o Infants learn to rely on caregiver to meet basic needs  Warmth, food, comfort, and forming trust in others o Mistrust can result from inconsistent, inadequate, or unsafe care  Adolescence: Identity vs. Role confusion o Trying on roles and even rebellion can be normal o Acquires a sense of self and decides what direction to take in life o Role confusion occurs if unable to establish identity and a sense of direction o Struggling to accomplish identity  Toddler: o Toddler is struggling to accomplish autonomy – Piaget’s Concrete Operational stage &  Stage of development from 7-11yrs  The beginning of logical thinking****  Incorporates others’ perspectives  Abstract thinking and deductive reasoning  Test beliefs to establish value – Safety for infants to sleep  Place infants on BACK to sleep  Prevents SIDS – Toddler and “Negativism”  Toddler repetitively saying NO  Outburst of temper  Result from the toddler’s efforts at control over the environment – Motor development in 3 yr-olds – should be able to ride a tricycle, hop on 1 foot & kick a ball – Enuresis in children – pg 1346 paragraph 1, 2, & 3  Enuresis: continued incontinence of urine past the age of toilet training o Occasional daytime incontinence of urine in a child is usually not a cause for concern o Nocturnal enuresis (nighttime bedwetting) usually subsides by 6 years of age o Child should grow out of this by 6 years  Reassure parents that any regression of toileting skills that occur during a child’s illness or hospitalization is to be expected and usually short-lived

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Cultures approach toilet training differently

- Anticipatory guidance: Teaching caregivers safety for the next stage of development – Adolescent safety – pg. 766 “Teaching Tips”  Responsibilities of new freedoms that accompany being a teenager  Enroll teen in safety courses o Driver edu, water safety, emergency care measures  Emphasize gun safety  Get physical examinations before participating in sports  Make time to listen to and talk with your adolescent o Helps with stress reduction  Follow healthy lifestyle (nutrition)  Teach about sexuality, STI’s and birth control  Encourage child to report any sexual harassment or abuse of any kind  Risks: motor vehicle accidents, drowning, guns and weapons, inhalation and ingestion – Toddler – safety pg. 765  Have poison control center phone number in readily accessible location  Use appropriate car seat for toddler  Supervise child closely to prevent injury  Childproof house to ensure that poisonous products, drugs, guns and small objects are out of toddler reach  Never leave child alone and unsupervised outside  Keep all hot items on stove out of child reach  Risks: falls, cuts from sharp objects, burns, suffocation or drowning, inhalation or ingestion of foreign bodies/poison – Voicing concerns of suicide & nurses responsibility  History of previous attempts and depression are possible risk factors  Indicators should not be ignored  Immediate referral should be made to a professional trained in suicide intervention  – When will an infant sit alone?  8 months – Preschoolers (3-6Y) –vivid imaginations, Demonstrate procedures on a doll then the child.  Fears are often made worse by the child’s imagination and ability to fantasize  Support and validation of the preschooler’s feelings by caregivers are essential  Encourage caregiver to take an active role in the child’s care to help reduce fear and separation anxiety  Allow child to express feelings openly  Explain procedure in childs language that they can understand and be honest about how much pain  Have imaginary friends 2. What are signs and symptoms of dehydration in an infant (12-month-old) ***Know assessments  Urinates less frequently (less than 6 wet diapers per day)

o Weigh diapers  Dry mouth  Few or NO tears when crying  Fontanelles drop (must be younger than 15 months)  Sunken eyes  Lethargy, less active, fussy  Loss of weight o I&O and daily weight  Cap refill, skin turgor 3. What should an infant of 12 mos. be able to do?  Motor abilities develop: use building blocks, attempt to feed themselves, crawl and walk (only a few steps)  Standing momentarly  Eyes begin to focus and fixate  Can sit alone  Simple words ( “mama”, “dada”) Medication Administration (9) -****add in meds admin for 2 SG -7 Rights  Patient  Medication  Dosage  Route  Time  Reason  Documentation -General  Compare med label w/ MAR 3X  Know actions, safe range, purpose and potential side effects  Check expiration dates  Break ONLY scored tablets  Keep in sight @ all times  Don’t leave till they take it or turn back  Use 2 identifiers  Allergy check  Necessary assessments  Upright/lateral position  Document immediately  Evaluate response w/in appropriate time frame -Otic admin  Up and back for adult  Down and back for infant/ child under 3 -MDI  Release med in small particles that can be inhaled deepley -Orders (know what to question)

 Pts name  Date & time  Name of drug  dosage  Route  Frequency  Signature -metronidazole: cautioned w/ alcohol -naloxone (Narcan): opioid antagonist -Acetaminophen (Tylenol): liver damage  Acetylcysteine used for Tylenol ovverdose - ASA- Aspirin: GI bleeding  DON’T give to children w/ fever  DON’T give b4 surgery -IM administration  FASTER  Deltoid, vastus lateralis, ventral gluteal (preferred site), dorsagluteal  Displace skin- Z track method o Prevents injected medicine from leaking o Stretch skin flat  Check for blood return before injecting  Inject slowely over 10 seconds, wait 10 seconds b4 withdrawing needle  Remove hand only AFTER needle has been removed -SubQ admin  Give site complete time to dry  Slower  Used for insulin and heparin (lovenox)  Skin fold  45-90 degrees  once needle in inserted, release skin  inject medicine slowely (10sec/mL)  do NOT message site -trougth level 15 – 30 mins b4 admin

-opioids  Opioid (narcotic): powerful pain meds (oxycodone, morphine, codeine) o Respiratory depression (be careful in elderly) o Depresses CNS (decrease sensory awareness) *no driving o Suppress cough reflex= choking o constipation o decrease urine output  monitor VS & respirations (BP & R) & mental status  pain assessment

 educate on side effects  constipation: use stool softeners,  fluids, fiber and activity -NSAIDS (ketorolac) side effects  potential for GI bleeding  ketorolac (Toradol) = NSAID o should Not be given to people allergic to Motrin and NSAIDS (don’t give w/ another NSAID)or asthmatics o can put people in renal failure  make sure they have good renal function o sometimes not given pre-op b/c it can increase bleeding o can’t be given to pregnant women o not usually given to ppl over 60 o look @ BUN and creatinine o moderate to severe pain

Peri-op (5) Risk for surgical infection   risk w/ surgery involving INTESTINES (fecal material)  dry skin  hyperglycemic (DIABETIC)  hair on site  Obese/malnourished  Smokers  Alcoholics  HAIs  Contamination  Poor hand hygiene  Improper cleansing on skin pre-op  Preexisting infection  NOT finishing ABX as prescribed  NOT changing dressing regularly  Immunosuppressed

Wound care post op  Assess dressing for drainage: amount, consistency, color, odor  Assess any tubes or drains and amount and type of drainage by route  Large amounts of bright-red blood w/ other abnormal assessments (restlessness, pallor, cool most skin, BP, HR (pulse) and respirations may indicate o Hemorrhage: excessive internal or external blood loss and could lead to shock  Do NOT remove dressing, reinforce w/ additional bandage o Hypovolemic Shock: body’s reaction to acute circulato...