Fundamentals HESI Study Guide

Fundamentals HESI Study Guide Vital Signs: August 22  Temperature, pulse, respiration, blood pressure, pulse ox  Temperature: lower in the morning, highest in the evening, 98.6 F-100.4 F, 36-38 C  Pulses: carotid, brachial, radial, ulnar, femoral, popliteal, dorsalis pedis, posterior tibial  Loudest heart sounds heard at apical pulse  Normal heart rate: o Infants: 120-160 o Toddler: 90-140 o Adolescent: 60-90 o Adult: 60-100  Tachycardia vs. bradycardia o Tachycardia: greater than 100 o Bradycardia: less than 60  Strength of pulse: 0: absent, 1: weak, 2: normal, 3: full, 4: bounding  Amplitude: volume of blood pushed against the wall of an artery during ventricular contraction  Ox saturation: usually 95% to 100%  Systolic: force exerted as left ventricle contracts and pumps blood into aorta  MAX PRESSURE  Diastolic: force exerted during ventricular relaxation, when heart is filling  MINIMUM PRESSURE  Blood pressure ranges o Normal: <120, <80 o Prehypertension: 120-139, 80-89 o Stage 1 Hypertension: 140-159, 90-99 o Stage 2 Hypertension: >160, >100  Blood pressure cuff… o Too wide: false low o Too narrow: false high Patient Safety and Quality: August 22  Fall risk: age, medication, post op, confusion, previous history, repeated falls, bone fractures, etc.  Make sure patient is aware of environment  items at reach, call light, phone, etc.  Restraint: o Last resort – try all other options first ** all other possibilities have been tried and failed, benefits outweigh the risks o Behaviors that result: wandering, restlessness, violence, agitation, pulling out tubes, resisting care o Alternatives: treat pain, rule out physical causes for agitation, involve family, reduce stimulation, noise, light, environmental factors, use therapeutic touch, discontinue bothersome treatment o NEED ORDER WITHIN 1 HOUR AFTER APPLICATION o RENEWED EVERY 24 HOURS o Only one restraint at a time (physical or chemical – no two at once) o REMOVE EVERY 2 HOURS FOR ASSESSMENT AND NEEDS (skin integrity, ROM, circulation)  Fire Safety o RACE  Rescue, alert, contain, extinguish o PASS  Pull, aim, squeeze, sweep Hygiene: August 24  Wash legs from distal to proximal to promote venous return  Observe skin for warmth, redness, swelling, rashes, tenderness, pain, etc. while bathing  Do not massage reddened areas on client’s skin  Wear gloves when: washing perineum, anal areas, skin infections, skin not intact, open wounds, draining, oozing skin, performing oral care  Female: front to back  Male: retract foreskin, wash from urethral meatus and outward, return foreskin to natural position  Apply lotion  skin barriers especially on pressure points  Empty urine drainage bag at least every 8 hours  Keep catheter bag lower than patient to prevent backflow of urine  Condom catheter: check for skin irritation, change in 24 HOURS Infection Prevention and Control August 24  Infectious agent  reservoir  portal of exit  mode of transmission  portal of entry  susceptible host  Susceptible host for germs: strength in numbers, impaired nutritional status, chronic disease, trauma  Blood borne pathogens: HEP B, HEP C, HIV  Transmission: accidental injuries (needle pricks, sharps, blood/fluid splashes), sharing needles, blood and blood product transfusion, sexual contact  Universal precaution  treat all patients as if they were infectious  Hand hygiene: wash for 15 seconds, GLOVES DO NOT TAKE PLACE OF HAND HYGIENE  PPE: o PUT ON: 1: gown, 2: mask, 3: goggles, 4: gloves o TAKE OFF: 1: gown, 2: gloves, 3: goggles, 4: mask, 5: wash hands  Precautions: o Airborne  Mask  Negative pressure (door shut)  Common: TB, measles o Droplet  Mask  Gloves  Common: meningitis, pneumonia, influenza, rubella o Contact  Gown  Gloves  Common: MRSA, VRE, lice, major draining wounds, e-coli o Contact (C. Diff)  Gown  Gloves  WASH HANDS  NO HAND SANITIZER o Airborne/Contact  Mask  Gown  Gloves  Common: varicella, herpes, SARS, small pox o Droplet/Contact  Gown  Gloves  Mask  Common: flu, MRSA, pneumococcus, VRSA, ESBL Nutrition August 29  Digestion: begins in mouth ends in small and large intestine  Absorption: small intestine is primary site  Enteral tube feeding: o Orogastric  mouth to stomach o Nasogastric  nose to stomach o Nasointestinal  nose to intestines o Gastrostomy  stomach tube from outside o Jejunostomy  intestine tube from outside  NG Tube: measure from nose to ear lobe to xiphoid process  NG tube placement: pH of 1 to 4 is good indication  Continuous feeding: always going  Intermittent or bolus feeding: nurse gives food at certain time through tube  Complications o Clogged tube: flush 30 mL of water every 4 hours after checking residual volume, flush  med  flush o Develops nausea and vomiting: withhold feeding, notify physician, check patency of tube, aspirate for gastric residual, for cramping and nausea, decrease the administration rate o Gastric residual exceeds normal volume: notify physician, elevate to at least 30 degrees, reassess residual volume after 1 hour you stop the feeding to see if volume has changed o Hyperglycemia: measure glucose every 6 hours o Develops diarrhea 3+ times in 24 hours: notify physician, report type, status of tube, patient tolerance, adverse effects, etc.  Placing an NG tube: o 1: verify order o 2: place patient into high fowlers o 3: measure intended length o 4: lubricate the tube tip with water soluble lube o 5: direct the tube upward and backward along the floor of the nose o 6: instruct the patient to place chin to chest o 7: advance the tube while patient swallows Sleep August 29  Stage I, II, III, IV, REM  Common: insomnia, sleep apnea, narcolepsy, sleep deprivation  Epworth Sleepiness Scale: score 0-3 on likeliness for an activity to happen  Pittsburgh Sleep Quality Index: score 0-3 on how common it is to do such activity  Improving sleep: routine, pharmacological approaches, stress reduction, control environment Immobility August 31  Mobility assessment focuses on: ROM, gait, exercise, activity tolerance, body alignment  Supine: laying upwards  Prone: laying downwards  High fowlers: 90  Mid fowlers: 45  Low fowlers: 30  Active ROM: client moves all joints unassisted  Passive ROM: client unable to move independently, nurse moves joint through ROM  Center of gravity near hips, line of gravity in the middle of body  Consequences of immobility: o *** renal calculi, altered metabolic function o Metabolic  Decreased rate, negative nitrogen and calcium balance, anorexia o Respiratory  Decreased movement, pooling of secretions, atelectasis, hypostatic pneumonia o Cardiovascular  Diminished cardiac reserve, increased heart rate, orthostatic hypotension, venous vasodilation, stasis (dependent edema, thrombus formation) o Musculoskeletal changes  Decrease in muscular strength o Elimination  Urinary stasis, renal calculi, retention, infection, constipation o Integumentary  Reduced skin turgor, skin breakdown o Psychosocial  Lowering self-esteem, withdrawn, angry, aggressive  Care for immobilized patient o High protein, high caloric diet with vitamin B and C, fluids, veggies, fiber o Cough and deep breath every 1-2 HOURS o Chest physiotherapy o Slow progression when client is ready o Passive/active ROM o Reposition every 1-2 hours o Adequate hydration o Routine and informal socialization  Lifting: close to body, bend at knees, tuck pelvis  WORKPLACE INJURY  Do not drag patient across bed  shear skin  If more than 35 pounds, use assistive devices Therapeutic Communication August 31  Communication barriers: bias, culture, education  Nonverbal communication: appearance, posture, gait, facial expressions, eye contact, gestures, sounds  Active listening: being attentive to verbal and nonverbal  Open ended questions  One question at a time  Best communicators = develop critical thinking skills Non-therapeutic Communication August 31  False reassurance, rejecting, minimizing, probing, defending, sympathizing, changing the subject, advising, stereotyping, socializing, judging, closed-ended questions, why questions Medication Administration September 7  Drug names o Chemical: provides description of medication composition, ex. n-acetyl-p-amino-phenol o Generic: assigned name, ex. acetaminophen o Trade: brand name, ex. Tylenol  FORM DETERMINES ROUTE  Pharmacokinetics: study of medications and what they do in the body  Absorption, distribution, metabolism, excretion  Absorption: passage of medication molecules into the blood from site of admin  Factors that affect ABSORPTION: o Route of administration o Ability to dissolve o Blood flow to site o Body surface area  Distribution: occurs within the body to tissues, organs, and specific sites from the blood to the tissues  Factors that affect DISTRIBUTION: o Circulation o Membrane permeability o Ex. person with heart problems does not have good circulation = slower distribution  Metabolism: meds are metabolized into a less potent or inactive form  Factors that affect METABOLISM: o Enzymes that detoxify, break down, and remove active chemicals o Liver, kidney, blood, intestines, lungs  Excretion: med out of the body  Factors that affect EXCRETION: o Kidney, liver, bowel, lungs, exocrine glands o ** chemical makeup of medications determines the organ of excretion!  Biotransformation = DETOXIFY  Idiosyncratic reaction = overreacting or underreacting to meds  Medication interactions: when one med modifies the action of another  Medication errors: report, PATIENT SAFETY IS TOP PRIORITY  Routes: oral (sublingual under tongue, buccal side of mouth), topical, inhalation, parenteral (ID, sub-q, IM, IV), intraocular  Always check with pharmacy before crushing pills  Do NOT give water after cough meds, mouth rinses, or antacids  VERBAL orders: write down, read back, confirms  Medication reconciliation: review meds with what patient should take and decrease the amount of unintended med interactions  Topical meds: use gloves, use sterile gloves if patient has open wound, clean skin first  Adult: pinna up and outward  Child: pinna down and back  DO NOT DELEGATE NURSES ROLE FOR MED ADMINISTRATION  Syringes o o o o      A: 5 mL syringe B: 3 mL syringe C: Tuberculin syringe (PPD) D: Insulin syringe o Top 1: 19 gauge, 1 ½ inch length o 2: 20 gauge, 1 inch length o 3: 21 gauge, 1 inch length o 4: 23 gauge, 1 inch length o 5: 25 gauge, 1 inch length Parts of a syringe: plunger (avoid touching), barrel, tip Parts of a needle: bevel, shaft, hub, gauge number Guage: thickness Measurement: length INJECTIONS o Intramuscular (IM): into the muscle, 90 degree  Faster absorption than subq route  Mank risks  ASPIRATE: if blood, remove and repeat  Needles: 21-23 gauge  Z-track method: take one hand and pull skin back with side of hand (use when sensitive)  SPREAD SKIN  Patient BMI affect needle size selection  VENTROGLUTEAL, VASTUS LATERALIS, DELTOID o Subcutaneous (Sub-Q): into the subq tissue, 45 or 90 degree  Slower absorption than IM injections (blood supply is not as rich in the fat)  PINCH SKIN  Body weight indicates depth of fat layer  choose length and angle of needle insertion based on patient weight  Blood thinners (heparin): do NOT aspirate, administer at least 2 inches from umbilicus or any scar tissue, do NOT rub injection site  Needles: 25-27 gauge  OUTER POSTERIOR OF ARMS, UPPER BACK, DORSAL GLUTEAL, ABDOMEN, ANTERIOR ASPECTS OF THIGHS o Subcutaneous  Insulin: injected because GI tract breaks down and destroys oral form of insulin  100-unit syringe  ** know onset, peak, and duration of ordered insulin doses  do not mix insulins unless approved by prescriber  inject rapid-acting insulins 15 minutes before a meal  MIXING: draw up CLEAR (fast acting) before CLOUDY (long acting!!! NPH) to prevent contamination  Air in cloudy, air in clear, draw up clear, draw up cloudy o Intradermal (ID): into skin (dermis), 15 degrees  Used for TB, allergies  Need to see injection site clearly for changes or reactions  Slow absorption  Needle: 27 gauge Math: September 12  Practice problems Oxygenation: September 14  Blood is oxygenated through ventilation, perfusion, and transport of respiratory gases  Ventilation: the process of moving gases in and out of the lungs  Inspiration/expiration: active/passive process stimulated by receptors in the aorta  Pulmonary circulation: blood to capillaries  deoxygenated blood, blood away from capillaries  oxygenated blood  Hyperventilation: breathing in excess to eliminate carbon dioxide  Hypoventilation: inadequate breathing to meet oxygen demands of the body  Hypoxia: not enough oxygen to the tissues  may appear restless, get anxious, agitated, treated with OXYGEN THERAPY  Assessment: o Dyspnea o Wheezing, coughing o Pain o Hx of respiratory infections o Smoking, environmental exposures o Allergies o Medications  Examination: inspection, palpation, percussion, auscultation o Inspection: color, LOC, breathing patterns, chest wall movement o Palpation: any areas of tenderness, abnormal masses o Percussion: presence of abnormal fluid o Auscultation: abnormal lung sounds  posterior, anterior, lateral  Incentive spirometer encourages voluntary deep breathing, lung expansion  Chest physiotherapy: rhythmically clapping on the chest wall to drain secretions from lungs o Respiratory therapist’s job o Not painful  Dyspnea: heavy breathing  Types of oxygen therapy: o Nasal cannula: 1-6 liters, limited, short term use o Simple face mask: provides up to 60% concentration (610 liters) o Partial rebreather mask: two way valve to stimulate breathing by rebreathing exhaled air, provides 65-75% concentration (6-10 liters) and HAS reservoir bag (keep inflated at all times) o Non-rebreaher mask: has vents to allow exhaled air to escape, delivers 60-95% concentration (10-15 liters), HAS reservoir bag (keep inflated) o Venturi mask: percentage of oxygen is delivered from what is set on machine  **** NON REBREATHER HAS ONE WAY VALVES  Oxygen is combustible!!!!!!!  Caring for chest tubes: o Keep system closed and below chest o Tube should be secured to chest wall o Watch for slow and steady bubbling in the suction control chamber o Keep it filled with sterile water at prescribed level o Water seal chamber is filled  BUBBLING IN WATER SEAL CHAMBER IS BAD, LEAKAGE IN DRAINAGE SYSTEM o Mark the level of drainage o No kinked tubing o Frequent repositioning o Do not clamp tube  Artificial airways: o Oral: prevents obstruction of trachea by displacing tongue  comatose patient?