NURS 495 PRN comprehensive study guide Complete

NURS 495 comprehensive study guide 1. ABCs (Airway, Breathing, Circulation) 2. When in distress DO NOT ASSESS! Unless 2nd hand information is received. 3. Scenario • Expected outcome with Disease Process : Continue to monitor & Document finding • Unexpected finding with Disease Process : Nursing intervention that must make a difference & Call HCP 4. Mini Maslow’s 1) ABCs (& Pain unrelieved by meds) 2) Safety 3) Comfort (Pain) 4) Psychological 5) Social 6) Spiritual 5. STAT words → Pick the answer that failing to do so will kill or cause great harm ● Highest Priority ● Most Important ● Immediate Action 6. *Least Invasive First* 7. Secondhand Info → Any time you have 2nd hand info, the right answer is ASSESS ∙ UAP ∙ Family ∙ Labs ∙ EMR ∙ EKG ∙ BP machine 8. Never ever take away the coping mechanism a patient uses during a crisis, except if the mechanism puts the patient or others @ risk 9. Eliminate answer choices & DNR 10. Never withhold Tx! If you’re left with two answer choices and the options are to Tx, or watch the patient, Pick Tx! 11. Anytime there’s a reversal from the norm, you must worry! Ex: rebound tenderness (pain after you relieve pressure) 12. Assign Stable Patients to: ∙ UAP ∙ LPN ∙ New nurse ∙ Graduate Nurse∙ Float Nurse ∙ Travel nurse 13. Anytime you see excessive findings, That’s not normal! 14. Always empower your patient 15. If a question has “ ”, pick an answer that has what they’re feeling & not what they’re saying 16. 3 R’s of Psych 1) Reality – Functional psych patient 2) Reassure – pt with Delirium 3) Redirect – pt with Dementia Automatic Correct Answers 1. Give meds either 1 hour before meal or 2 hours after meal 2. Give antacids 1 hour before med or 4 hours after med 3. When in doubt pick K (potassium) 4. 2 – 3 L of fluids 5. When in doubt pick answer that has you stay with patient 6. Anytime you see restless & ↓ level of consciousness = early sign - PICK 7. Head of Bead → 30-45 degrees for any neuro patient 8. Elderly with acute onset confusion → UTI 9. Secretions will turn Orange/Red for meds 10. Anytime you have GI problem/exacerbation = NPO 11. All surgeries RISK: 1st 24 hrs – bleeding 48 hrs – infection 12. Check daily weights if it’s a fluid problem 13. Lateral position for maternity 14. Remove answer choices that are ‘absolutes’ Rules for Delegation RN ASSIGNMENT == Do not delegate what you can E A T: Evaluate Assess Teach ● Cannot delegate assessment, teaching, or nursing judgement LPN/LVN ASSIGNMENT ● Assign stable with expected outcomes UAP ASSIGNMENT ● Delegate standard, unchanging procedures Five Rights of Delegation RIGHT TASK – scope of practice, stable client RIGHT CIRCUMSTANCES – workload RIGHT PERSON – scope of practice RIGHT COMMUNICATION – specific task to be performed, expected results, follow- up communication RIGHT SUPERVISION – clear directions, intervene if necessary Therapeutic Communication Tips DO: DO NOT: Do respond to feeling tone Do provide information Do focus on the client Do use silence Do use presence ● Do not ask ‘why’ questions - NEVER pick WHY ● Do not ask ‘yes/no’ questions, except in the case of possible self-harm ● Do not focus on the nurse ● Do not explore ● Do not say, “Don’t worry!” Who Do You See First? Consider: ∙ Unstable vs. Stable ∙ Acute vs. Chronic ∙ Unexpected vs. Expected ∙ Actual vs. Potential ∙ ABCs Common Traps ∙ Do not ask “Why?” ∙ Do not ‘do nothing.’ ∙ Do not leave the client. ∙ Do not read into the question ∙ Do not persuade the client. ∙ Do not pass the buck. ∙ Do not say, “Don’t worry!” Strategies ● Only use textbook nursing – textbook knowledge ● Pain is psychosocial, unless, it’s severe, acute, & unrelenting ● If it’s a position question, is it going to prevent or promote something – position, prevent, promote ● Teaching/learning – use T/F on each answer – same strategy for SATA questions ● Risk Questions – use Risk Factors ● If the answers have an absolute in them, do not pick them ● Question that have the phrase ‘And Then’ – did they miss something Important Lab Values WBC 4K – 11K RBC 4 – 6 Hgb 12 – 16, 0r 12-18 Hct 36 – 48, or 37-52 Plt 150K – 400K BUN 8 – 20, or 7-22 Cr/Lithiu m 0.6 – 1.2 Urine Clearanc e 85 – 135, (GFR)=maintain above 60 Uric Acid 250 – 750 mg Na 135 – 145 Cl 98 – 106 Ca 8.5 – 10.5 K 3.5 – 5.0 PO 2.5 – 4.5g Mag 1.5 – 2.5, 4-7 if pregnant and receiving Toco Warfar in IN R 2.0 – 3.5 Hepari n PT 10 – 13 Seconds PT T 25 – 35 Seconds Therapeutic PTT: 1.5 – 2x the normal value (46 – 76 Seconds) Cholesterol Therapeutic Ranges Dilantin Theophylline Acetaminophen 10 – 20 Digoxin 0.5 – 2.0 Albumin level 3.5 to 5.5 Acid-Base Balance From the ass (diarrhea) –Metabolic Acidosis From the mouth (vomitus) –Metabolic Alkalosis Potassium & Alkalosis – ALKALOSIS: K is LOW – Acidosis is just the opposite: K is High Arterial Blood Gases 1. Prior to drawing an ABG, perform the Allen’s Test to check for sufficient blood flow 2. When drawing an ABG, the blood needs to be put in a heparinized tube. ● Ensuring there are no bubbles. 3. Put on ice immediately after drawing, with a label. ● The label should indicate if the pt was on room air, or how many liters of O2. General Notes ● The person who hyperventilates is most likely to experience respiratory alkalosis. Antidotes ● Aspirin → Activated Charcoal ● Coumadin (Warfarin) → Vitamin K ● Heparin → Protamine Sulfate ● Tylenol (Acetaminophen) → Mucomyst (acetylcysteine) – administered orally ● Digoxin (Lanoxin) → Digibind (immune Fab) ● Opioids → Narcan ● Iron overdose → Deferoxamine ● PCP → Activated charcoal ● Magnesium Sulfate → Calcium Gluconate ● TPA → Aminocaproic acid ● Pancuronium Br (NM blocking agent) → Neostigmine/Atropine Blood For blood types: ● "O" is the universal donor (remember "o" in donor) ● "AB" is the universal recipient Blood transfusion – sign of allergies in order: 1)Flank pain 2)Frequent swallowing 3)Rashes 4)Fever 5)Chills Thrombocytopenia – Bleeding precautions! 1)Soft bristled toothbrush 2)No insertion of anything! (c/i suppositories, douche) 3)No IM meds as much as possible! Sickle Cell Anemia During sickle cell crisis there are two interventions to prioritize: fluids and pain relief. Iron deficiency anemia – easily fatigued 1)Fe PO (Iron) - give with Vitamin C or on an empty stomach 2)Fe via IM- Interferon via Z Track -- Peds: Kids are at risk for iron deficiency anemia if they ingest too much milk; 24oz/ day. Pernicious Anemia - s/s include pallor, tachycardia, and Sore Red, Beefy tongue; will take Vit.B12 for life! Shilling Test – test for pernicious anemia/ how well one absorbs Vit b12 General Notes ● A patient with a low hemoglobin and/or hematocrit should be evaluated for signs of bleeding, such as dark stools. Burns Rule of nines, 9 = head, 18 = arms, 36 = torso, 36 =legs, and 1= perineum = 100% The Parkland formula is a formula used for calculation the total fluid requirement in 24 hours for a burn patient 4ml x TBSA % (Total Burn Surface Area) x body weight (kg) = Total amount of fluid the patient will receive in 24 hrs 50% given in first eight hours 50% given in next 16 hours. The Number #1 Priority for Burn Patients is maintaining a patent airway 1st Degree – Red and Painful 2nd Degree – Blisters 3rd Degree – No Pain because of blocked and burned nerves Cancer A cancer patient is getting radiation. What should the nurse be most concerned about? ● Skin irritation? No. ● Infection kills cancer patients most because of the leukopenia caused by radiation. General Notes ● A breast cancer patient treated with Tamoxifen should report changes in visual acuity, because the adverse effect could be irreversible. ● Common sites for metastasis include the liver, brain, lung, bone, and lymph. ● Bence Jones protein in the urine confirms multiple myeloma (cancer of plasma cells) ● Patients with leukemia may have epistaxis (nosebleeds) b/c of low platelets Cardiac All – Aortic Valve Physicians – Pulmonary Valve Earn – Erb’s Point Their – Tricuspid Valve Money – Mitral Valve (PMI) Or APE To Man Cardiac Catheter ● Pre-Op – NPO 8-12hr prior, empty bladder, check pulses, tell pt they may feel heat, palpitations, or desire to cough with dye injection. ● Post Op – V/S, & keep leg straight, bed rest 6-8 hrs, Sleep supine. General Notes ● Blood tests for MI: Myoglobin, CK and Troponin ● Coarctation of the aorta causes increased blood flow and bounding pulses in the arms ● Cor Pulmonale is right sided heart failure caused by left ventricular failure; (so pick edema, JVD, if it is a choice.) ● Normal PCWP (pulmonary capillary wedge pressure) is 8-13. Readings of 18-20 are considered high. ● Pulmonary sarcoidosis (an inflammatory disease) leads to right sided heart failure. ● Anytime you see fluid retention. Think heart problems first. Circulation EleVate Veins; dAngle Arteries for better perfusion For PVD remember DAVE (Legs are Dependent for Arterial & for Venous Elevated) Virchow’s Triad → Risk Factors for DVT V – Vascular Trauma I – Increased Coagulability R – Reduced Blood Flow –Definitive diagnosis for abdominal aortic aneurysm (AAA) → CT scan Fat Embolism S/S ● Blood tinged sputum (related to inflammation) Pink frothy sputum ● increased erthyro sedimentation rate (ESR) ● Respiratory alkalosis (related to tachypnea) ● Hypocalcemia, increased serum lipids ● "Snow Storm" effect on Chest x-ray General Notes ● Hypotension and vasoconstriction meds may alter the accuracy of O2 sats. ● A newly diagnosed hypertension patient should have BP assessed in both ar Cranial Nerves Sensory=S Motor=M Both=B 1. Oh (Olfactory I) Some 2. Oh (Optic II) Say 3. Oh (Oculomotor III) Marry 4. To (Trochlear IV) Money 5. Touch (Trigeminal V) But 6. And (Abducens VI) My 7. Feel (Facial VII) Brother 8. Very (Vestibulocochlear/Auditory VIII) Says 9. Good (Glossopharyngeal IX) Big 10. Velvet (Vagus X) Brains 11. Such (Spinal Accessory XI) Matter 12. Heaven (Hypoglossal XII) More On Old Olympus Towering Top A Finn And German Viewed Some Hopes Cultural Greek heritage - they put an amulet or any other use of protective charms around their baby's neck to avoid "evil eye" or envy of others Lyme Disease is found mostly in Connecticut Jewish Folks: no meat and milk together Diabetes Blood Sugar ~ Hyperglycemia – Hot & Dry ~ Sugar High Hypoglycemia – Cold & Clammy ~ Need some candy To remember how to draw up INSULIN think: Nicole Richie RN Regular is clear & don't wanna put dirty needle in clear so RegularCLOUDY is pulled in first Air into NPH, then air into Regular, draw up Regular insulin then draw up NPH Oral Hypoglycemics ● Do not attempt to give an oral hypoglycemic to an unconscious pt, as this poses the risk of aspirations ● A typical adverse reaction is rash, photosensitivity. HbA1c – test to assess how well blood sugars have been controlled over the past 90- 120 days. 4- 6 corresponds to a blood sugar of 70-110; 7 is ideal for a diabetic and corresponds to a blood sugar of 130 Fluids are the most important intervention with HHNS as well as DKA, so get fluids going first. DKA ● While treating DKA, bringing the glucose down too far and too fast can result in increased intracranial pressure due to water being pulled into the CSF. ● Serum acetone and serum ketones rise in DKA. ● As you treat the acidosis and dehydration expect the potassium to drop rapidly, so be ready, with potassium replacement.