The Basics - Cpnre Review PDF

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CPRNE Lisencing exam review!! for RPN's...

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CPNRE EXAM REVIEW The Basics The Nursing Process (ADPIE)  Assessment – subject and objective information collection  Diagnosis o Create plan based on most serious nursing diagnosis FIRST o Airway, breathing, circulation  Planning – setting goals and expected outcomes with the patient (and patient’s family if needed)  Implementation – use of nursing interventions to activate the plan  Evaluation – determining if outcomes are met, and if not, RESTART Normal Vital Signs  TEMPERATURE: 36.5 to 37.5 – average is 37.0 o Newborn: may fluctuate during the first year of life due to the infant’s heat-regulating mechanism not being fully developed o Illness: infective agents and inflammatory mechanism may cause an INCREASE in temperature o Inspect for any inflammation, redness, swelling or discharge when taking tympanic temp **  PULSE: 60 to 100 bpm o Check pedal pulses in the older client ** o CONSIDERATIONS:  Heart rate SLOWS with age – normal  Exercise, hemorrhage, pain and stimulant medications increases HR  APICAL PULSE:  Left midclavicular line, fifth intercostal space  RESPIRATIONS: 12 to 20 breaths per min o CONSIDERATIONS:  Head injury or decreased intracranial pressure will depress the respiratory center  Shallow respirations or slowed breathing seen  Opioid analgesics depress respirations  BLOOD PRESSURE: 120mmhg (systolic) over 80mmhg (diastolic) o Orthostatic Vitals:  BP and pulse checked with the client supine, sitting and standing (readings obtained 1 to 3 minutes after client changes position) o CONSIDERATIONS:  BP increases in the older adult  Higher among African Americans  Antihypertensive medications and opioids analgesics decrease BP  PULSE OXIMETRY: 95-100% o Values below 90 are only acceptable in chronic conditions  COPD, emphysema Pain  Acute: associated with an injury, medical condition or surgical procedure (lasts hours to a few days)  Chronic: associated with long-term or chronic illnesses (months or years)  Phantom: occurs after loss of a body part

Laboratory Values **  Platelets: 150,000 – 400,000  WBC count: 5,000 – 10,000  aPTT: 30-40 seconds  HgbA1C: under 6% in an adult without diabetes  eGFR: 90-120 o If too low, renal insufficiency when combined with creatinine and BUN

LABORATORY VALUES Potassium

Sodium

Creatinine

Blood Urea Nitrogen

Normal Level

3.5-5.0 mEq/L

135-145 mEq/L

3.6-7.1 mmol/L

Higher

   



Male: 53-106 (0.6-1.2) Female: 44-97 (0.5-1.1)  Severe renal disease  In conjunction with a high BUN and low eGFR

 Lower

       

Renal failure Addison’s Disease Dehydration Massive tissue destruction Metabolic acidosis* Burns Cushing’s Diarrhea (severe) Diuretic therapy GI fistula Insulin Vomiting Starvation

        

Corticosteroid therapy Dehydration Impaired renal function Increased sodium intake Addison’s Disease Decreased sodium intake Diabetic ketoacidosis Diuretic therapy Excessive loss from GI tract Excessive perspiration



Diseases with decreased muscle mass

       

Severe renal disease Burns Dehydration Shock UTI

Fluid overload Malnutrition Severe liver damage

LABORATORY VALUES – BLOOD CHEMISTRIES INR Normal Level

0.9-1.2 On warfarin: 2-3 High dose: 3-4.5

Higher/Why use?



Warfarin treatment

INCREASED RISK OF BLEEDING** Used to monitor effects of some anticoagulants

Lower

Pt can be taking warfarin and heparin at same time – WHY? Warfarin takes time to start working- pt is kept on both heparin and warfarin UNTIL warfarin starts to work  Risk for blood

PT (Prothrombin Time) 11-12.5 seconds *Amount of time it takes in seconds for clot formation  Used to monitor warfarin sodium therapy  If within 2 seconds (+ or -) – still considered normal  If this is ordered, specimen should be drawn BEFORE giving anticoagulation theray  Provide pressure to the site for 3-5 minutes  Diets high in green

Hemoglobin *transports oxygen Women: 120 to 155 Men: 135 to 175

  



COPD Smoking cigarettes Heart or lung diseases

Lack of iron in diet

Fasting Blood Glucose FASTING: 4.0-6.0 mmol/L

    

Acute stress Cerebral lesions Diabetes Hyperthyroidism Pancreatic insufficiency

Instruct client to withhold morning insulin or oral hypoglycemic until after blood is drawn ** EAT RIGHT AFTER ** have meal ready or snack  Insulin overage

clots

Causes Over hydration Kidney damage Heart failure Long-term use of corticosteroids Excessive sodium ingestion Irrigation of wounds or body cavities with HYPOTONIC fluids

leaft vegetables, shortening PT

 

Anemia Kidney disease FLUID VOLUME EXCESS (chronic)  Severe blood loss

Data Collection  Cough/dyspnea  Lung crackles  Increased RR and HR  Increased BP  Pitting edema  Weight GAIN  Neck and hand vein distention  Increased urine output  Confusion  LAB: decreased hematocrit levels



Pancreatic tumor

Interventions - Monitor vital signs/respiratory and neuro status - Position client in Semi-Fowlers - Administer O2 - Check for edema - Monitor intake and output - Monitor daily weights - Administer diuretics if needed - Restrict fluids - Low sodium diet

General Health Survey  GORDON’S “Head to toe assessment”  Inspection, palpation, percussion, auscultation o BUT – For abdominal exam  Inspection, auscultation, percussion and lastly palpation Fluid and Electrolyte Balance  Third spacing – trapped fluid in an actual or potential body space o Result of disease or injury  Edema o Localized edema occurs as a result of traumatic injury from accidents or surgery or burns o Generalized edema (anasarca) – excessive accumulation of fluid in the interstitial space as a result of a condition FLUID VOLUME DEFICIT  Cardiac, renal, liver Causes Data Collection Interventions  Infants and older adults are at a HIGHER risk for fluid-related problems younger adults  Thirst - Treatthan cause (anti-diarrheal, Vomiting o Children have a greater proportion of body water than adults  Poor skin turgor antiemetic, antipyretic) Diarrhea  Increased HR, thread pulse, - Fluids are replaced (IV and oral) Continuous GI irrigation - Monitor vital signs closely dyspnea, postural Ileostomy or colostomy Body Fluid Intake & drainage Output - Monitor respiratory and hypotension Draining wounds, burns, fistulas  NORMAL OUTPUT = 30ml/hr  Weight LOSS Increased urine output from diuretics  Insensible water loss – through skin, WHICH MEANS individual isneurological unaware offunction loss  FLAT neck veins Administer oxygen as prescribed  Severe diarrhea results in the loss of large quantities of fluids and electrolytes  Dizziness/weakness - Check skin turgor and mucous  Decreased urine output membranes - Monitor weight DAILY (dark concentrated urine)  Confusion - Monitor I&O - Test urine for specific gravity

Acid-Base Balance  During ACIDOSIS, pH decreases and RR and depth increase in attempt to exhale acids  During ALKALOSIS, pH increases and RR and depth decrease, CO2 is retained and carbonic acid increases to neutralize excess HCO3 (bicarb)

NORMAL LEVELS  pH: 7.35 -7.45  PaCO2: 35-45 * opposite (anything over 45 is acidotic, anything under 35 is basic) (respiratory)  HCO3: 22-26 (metabolic) Nursing Responsibilities  Monitor the client’s respiratory status closely  Monitor potassium levels closely o Potassium moves in or out of the cells to maintain acid-base balance o Can result in hyper or hypokalemia  Predisposes client to risks and complications if not monitored closely

Acid-Base Balance

Data Interventions

Respiratory Acidosis

Respiratory Alkalosis

RR increases Monitor for signs of respiratory distress Administer O2 Semi-fowlers Turn/cough/deep breathe Encourage hydration Do not administer opioids, sedatives (further depress RR) Monitor: potassium level

Kidneys retain bicarb/hydrogen in urine Emotional support Breathing techniques (rebreathing mask) Monitor: potassium and calcium levels

Causes

Asthma Atelectasis Brain trauma Bronchiectasis Bronchitis CNS depressants (meds) Emphysema Hypoventilation

Fever Hyperventilation (anxiety) Hypoxia Hysteria Pain

Acid-Base Balance

Data Interventions

Causes

Metabolic Acidosis

Metabolic Alkalosis

Hyperpnea Kussmaul respirations Check LOC Monitor I&O Initiate seizure precautions Monitor: potassium level (as it resolves and during) FOR DIABETES: Give insulin

RR and depth decrease to conserve CO2

Severe diarrhea Diabetes mellitus Too much aspirin High-fat diet Malnutrition Renal insufficiency

Diuretics Excessive vomiting/GI suctioning Massive transfusion of blood

Monitor: potassium and calcium levels Underlying cause needs to be treated

Intravenous Therapy and Blood Administration  IV Cannulas o BUTTERFLY: infiltration common with these devices  May be used with children and older clients whose veins are likely to be small/fragile  Plastic Cannulas o Short term therapy o Rapid infusion  IV Gauges o Size depends on solution to be administered  LARGE: higher fluid rate  14-19 gauge (blood, anesthetics, emergency)  Standard infusion: 20 or 22 gauges  If very small veins: 24 to 25 used  IV Tubing

o Shorter secondary tubing used for piggyback solutions o Special tubing is used for medication that absorbs into plastic o Can add extension tubing to the pt who is young or old and restless OR who have special mobility needs

 Drip Chambers o Macrodrip: infusions that are thick or rapid  10 gtt/mL or 20 gtt/mL o Microdrip: slow rate (less than 50mL per hour OR if solution contains potent medication that needs to be titrated (critical care or pediatric setting)  60 gtt/mL o Filters: used for blood administration and neutropenic clients (low WBC) Peripheral IV Sites  Veins of the forearm  Lower extremities NOT suitable (at risk of thrombus formation)  Nurses should avoid: o Edematous extremity o Lower extremities o Arm that is weak, traumatized or paralyzed o Skin area that is infected  INFANTS: veins in scalp and feet Administering IV solutions  Venipuncture site changed every 72 to 96 hours (check agency policy)  IV dressing changed when it is: o Wet o Contaminated o Specified by agency policy  DO NOT let bag hang for more than 24 hours – diminishes risk for bacterial contamination and sepsis Precautions for IV Lines  Medications administered by IV route enter the blood immediately – any adverse reaction or allergic responses can occur immediately

Complications of IV Therapy  Air embolism – bolus of air enters vein (clamp tubing if this happens) – notify RN o Tachycardia o Chest pain/dyspnea o Hypotension o Cyanosis o Decreased LOC  Catheter embolism – breakage of catheter tip (may require sugery to remove) o Decreased BP o Pain along vein o Weak, rapid pulse

o Cyanosis (nail beds) o LOC  Circulatory overload – if happens – KEEP VEIN OPEN @ specified rate, keep client warm and check lung sounds, elevate HOB o Increased BP o Rapid breathing o Dyspnea o Crackles and moist cough

 Electrolyte overload o Lactated Ringer’s contains potassium and should not be given to clients with acute kidney injury or CKD **  Infection  Infiltration  Phlebitis – inflammation of the vein  Thrombophlebitis o Development of a clot  Tissue damage Blood Transfusions  PRBC’s o Used to replace erythrocytes o Infusion time for 1 unit is between 2-4 hours *DO NOT let infusion go longer than 4 hours  Transfusion Reactions o o Pallor/cyanosis o Chills/diaphoresis o Apprehension o Muscles aches, back pain or chest o Tingling/numbness pain ** o Rashes, hives, itching and swelling o Headache o Rapid, thready pulse o Nausea/vomiting/diarrhea o Dyspnea, cough, wheeze  THINGS TO KNOW: o Medications are NEVER added to blood components o Always check blood bag with another nurse o Blood must be administered ASAP  Within 20-30 minutes out of storage o Check vital signs and lung sounds before transfusion and again after 15 minutes AND every 1 hour until 1 hour passed the transfusion completion time Operative Nursing Care Obtaining Informed Consent  Surgeon is responsible for obtaining consent  NURSE must be sure the client has understood the surgeons’ explanation of the surgery  Ensure forms have been signed o Anaesthesia o Blood transfusions o Disposal of a limb

o Surgical sterilization Nutrition  NPO for 6 to 8 hours before procedure Elimination  If a pt is to have intestinal or abdominal surgery – surgeon may prescribe an enema, laxative or both the evening or day before  Pt should void immediately before surgery  Client should void 6-8 hours after surgery (ensure amount is at least 200mL) Postoperative Complications  Pneumonia and Atelectasis (most common) o 3 to 5 days after o Atelectasis can occur 1-2 days after procedure o DATA:  Dyspnea  Increased RR  Elevated temp  Productive cough and chest pain  Crackles o INTERVENTIONS:  Monitor lung sounds  Encourage fluid intake  Reposition every 1 to 2 hours  Deep breathe, cough

 Pulmonary Embolism o DATA:  Dyspnea (sudden)  Sharp chest pain (sudden)  Cyanosis  Tachycardia  Drop in BP  Hemorrhage and Shock o DATA:  Restlessness  Weak, rapid pulse  Hypotension  Tachypnea (abnormally rapid breathing)  Cool, clammy skin Procedure/Reason Burns of the face/head Burns of extremities Hemorrhoidectomy GERD NG tube insertion

POSITIONING CLIENTS Position Elevate HOB (reduces edema) Elevate extremities above the level of the heart (prevents edema) Lateral (side-lying) position – prevents pain and bleeding Reverse Trendelenburg (promotes gastric emptying) High-fowlers (closes the trachea, opens esophagus)

NG tube feedings Continuous feedings Rectal Enema or Irrigations

HOB elevated 30 degrees (1 hr) after feeding HOB remains elevated AT ALL TIMES Left sim’s position

COPD

Deep Vein Thrombosis

Sitting position, leaning forward with arms over several pillows or on to a table During FIRST 24 hrs, elevate foot of bed to reduce edema Residual limb is placed on pillows but not elevated Client upright, legs dangling over side of bed (decreases venous return) Bed rest with leg elevation (with heparin therapy)

Varicose Veins

Legs elevated above level of the heart

Stroke – Hemorrhagic Stroke – Ischemic Spinal Cord Injury

HOB elevated 30 degrees (reduce intracranial pressure) HOB elevated minimally Head in a neutral position – logroll client

Total Hip Replacement

Avoid external and internal rotation and adduction Side lying – IF abduction pillow is in place Place a wedge pillow in between client’s legs

Amputation of lower extremity Heart Failure/Pulmonary Edema

Care of a Client with a Tube  Perform irrigation every 4 hours o Instill 30 to 50 mL of water or NS o Pull back on syringe to check patency Types of Administration  Bolus: normal feeding (30-60-minute period) every 3 to 6 hours  Continuous: administer over 24 hours (feeding pump regulates flow) Administering Feedings  If residual is less than 100mL – feeding is administered o If more – do not administer (can cause aspiration)  Check bowel sounds  High fowlers – if comatose (also on right side)  Check tube placement by aspirating gastric contents and measuring pH (3.5 or lower)  Aspirate all stomach contents and then return to maintain electrolyte balance (unless amount greater than 250mL)  Change feeding container every 24 hrs o Change every 4 hours if not in closed system (for 24-hr feeds)  Gently flush 30-50mL of water after feeding

Types of Insulin

Type

Brand Name

Appearance

Onset (Length of time before insulin reaches the blood stream)

When is it used?

Rapid-acting

Clear

10-15 minutes

Most often at start of meal

Short-acting

Humalog (Lispro) Novorapid (Aspart) Regular ®

Clear

30 minutes-1 hour

Intermediate Acting

NPH (N) (Humulin N)

Cloudy

1.5 – 4 hours, lasts for up to 16 hours

Used 30-60 minutes before a meal so it has time to work Contains buffers (cloudy look)

Long Acting

Lantus (Glargine) Levemir (Detemir)

Clear

Up to 6 hours, lasts for up to 24 hours

Made to last overnight particularly

Mixing Insulins – Steps  Not all insulin can be mixed  CLEAR before CLOUDY  After infection control procedures and removing lids and gathering supplies * o Pull syringe down to correct mark for CLOUDY insulin o Inject air into cloudy insulin vial o Withdraw EMPTY syringe from vial – set aside o Pull syringe down to correct mark for CLEAR insulin o Inject air into clear insulin vial and DRAW back amount needed o Pull syringe and needle out and put into CLOUDY vial and pull back correct dosage needed Random Tips!  Weight is the best indicator of dehydration  When the patient is in distress, administration of medication is RARELY the best choice  Always check for allergies before administering medications  Nitroglycerin patch is administered up to THREE times with intervals of 5 MINUTES  Never give potassium in IV push  In the event of a fire, the acronym most often used it RACE o Remove the patient o Activate the alarm o Contain fire (attempt) o Extinguish (attempt)  The first nursing intervention in a quadriplegic client who is experiencing autonomic ddysreflexia is to elevate the head as high as possible  Patients who have the SAME infection and are in STRICT isolation CAN share the same room...