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Pulse deficit
Difference between a persons apical pulse and radial pulse.
Tells if a patient has A Fib and early diastolic ventricular ectopic beats.
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Pulse Pressure
Difference between systolic and diastolic
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Cheyne Stokes
irregular breathing characterized by hyperventilation alternating with apnea lasting 10-20 seconds
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Kussmaul's
rapid deep respirations associated with ketoacidosis
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Agonal
gasping, irregular, infrequent breaths....end of life.
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How do you tell if a person has orthostatic hypotension
when they have a 15mm or more drop in SBP or 10mm or more drop in DBP.
An increase of 15 BPM in patients HR may occur
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When seeing a patient what do I assess with their IV?
- Is there any.....
- Redness
- Edema
- Drainage
- Pain
Is the site clean, dry and without signs of complications.
ID solution, rate and the volume remaining along with the equipment/pump used for the infusion
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Before I remove an IV what 2 things do I need to do?
- Turn off the pump/or clamp tubing
- Note how much of the solution is left
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TPR
Temperature/Pulse/Respirations
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Assess LOC by asking
Orientation to person, place, time and situation/event
- What's your name
- Where are you
- Whats the date
- What brought you here
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PERRLA
Pupils Equal, Round, Reactive to light/Accommodation
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P
Q
R
S
T
Pain
- Provoked-what brought it on
- Quality-describe
- Radiating/Region-from 1 place to another
- Scale/Severity-0-10
- Time-for how long
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How high do you hold the enema bag?
18 inches above the rectum and they will hold for 2-5 minutes.
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How long does it does it take for a stoma to shrink to it's permanent size?
How large do you cut the bandage to go over the stoma?
- 2-3 months
- 1/8-1/16 inches larger than the stoma
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When do you empty a stoma bag?
What do you clean it with?
What don't you want to get on to a new stoma?
- when it is 1/2 full or inflated with gas
- water only
- don't get water on a new stoma
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Insensible losses:
stool
lungs
skin
- stool-200mL
- lungs-300mL
- skin-600mL
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ounces to mL's
x it by 30
3 ounces x 30= 90mL
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Fine Crackles
Heard where?
When heard?
Heard in the lung bases
Heard on inspiration and expiration
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Wheezes
Describe
Where heard
When heard
High pitched musical sound
Heard over larger airways
Heard on inspiration and expiration
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Course Crackles
Where heard
Heard over large airways
aka Rhonci
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1 ounce = how many mL's
30
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1 mcg = how many mg's?
0.001 mg
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1 kg = how many grams
1000 grams
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1 litre = how many mL's
1000 mL
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1 tbsp = how many mL's
15 mL's
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1 tsp = how many mL's
4-5 mL's
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1 mg = how many mcg's?
1000 mcg
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Soft bland diet
no fried foods, raw fruits and veggies
decreased amounts of fiber
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Sodium restricted diet
- limits sodium to 1000-2000
- (1-2 grams)
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Full liquid diet
anything liquid at room temperature...jello, ice cream, creamed soups, milk shakes
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Clear liquid diet
jello, tea, cranberry juice
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dysphagia
difficulty swallowing
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3 ways to test placement of NG tube placement
inject 20-30mL's of air and ausculate for sound
Aspirate for gastric secretions....should be >4 and be acidic
X-Ray
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Before I feed somebody with a G Tube what do I do
check for residual....should be 20-100mL's. If more than 100 tell nurse cuz not digesting/eliminating food
Always put what you took out back in.
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When administering tube feedings....what do I flush with before and after feeding?
What do I put in between each crushed or liquid medication?
10-100mL's of water
5-10mL's of water
**remember to record these amounts of water in the I&O!!
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When measuring distance for NG tube, prior to insertion, what are the markers?
Nose to ear to xiphoid process
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What do I irrigate a NG tube with?
Normal Saline....document amount in I&O's
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When I am feeding somebody through their NG tube what do I flush with to maintain patency?
20-30mL's of water....prior to feeding and at completion of feeding
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Which oxygen mask delivers the highest concentration of O2?
Non-rebreather mask
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Normal blood glucose
70-110
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Signs of hypoglycemia
- Irritable
- weak/shaky
- sweaty
- full/bounding rapid pulse
Rapid onset and progression....dangerous!!
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Signs of hyperglycemia
- Drowsy/Lethargic
- Flushed skin
- Thirsty
- Weak/Rapid pulse
- Deep labored breathing
Slow onset and progression
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How do you treat hypoglycemia and hyperglycemia?
hypo-give them carbs in liquids or foods
hyper-administer IV
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Where do you collect a urine specimen from a catheter bag?
from the needle-less port in the tubing....not the bag
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When do you obtain a sputum specimen?
1-2 hours after a meal or 1 hour before.....and after oral care.
Collect 2-10mL's of sputum
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When taking a wound culture.....
Where do you find aerobic cells and anaerobic cells?
Which do you collect first?
aerobic on the edge of a wound
anaerobic on the center of a wound
Obtain anaerobic first
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Lipping
pouring out a little of the first part of a sterile solution
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R
E
A
D
S
- Redness
- Edema
- Approximation
- Drainage/Dressing
- Size, site, sutures/staples/steristrips
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Pressure Ulcers
Stages 1, 2, 3, 4
- 1-in tact skin, red
- 2-blister or skin loss of dermis/epidermis
- 3-loss down to subcutaneous layers/necrosis
- 4-full thickness with damage to muscle/bone/supporting structures
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What do I clean skin tears with?
Normal Saline
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Characteristics to be assessed during a dressing change....
- size and color of the wound
- drainage
- granulating
- depth
- approximation
- odor
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What is the panic level for WBC?
<500 at a high risk for infection.....neutropenic
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Sedimentation rate tells you....
if a person has inflammation
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Hemoglobin is used for
oxygen transportation
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Hematocrit tells you if a person is
- dehydrated/overhydrated
- anemic
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Panic value for platelets
<20,000...they are at risk for bleeding out
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What is a sign that a person may be hemmoraghing?
Increased HR and Decreased BP
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7 Rights of patient medication admin....
- Right...
- Drug
- Dose
- Documentation
- Time
- Route
- Approach/Allergy
- Patient
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Prior to giving a medication injection I need to check...
- 7 rights
- check order
- expiration on the bottle
- time of last injection
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When drawing up medication from a vial, make sure to
put the same amount of air in to the bottle that I will be withdrawing from the bottle....pressurize it
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IM Injections
Fluid amount and location
Needle size
Angle of injection
3mL in large muscles of an adult or 1mL in the deltoid or in to thin elderly adults
21-23 gauge and 1-1.5 inches long
90 degrees
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With an IM injection to pushing the medication don't forget to....
aspirate to make sure I am not in a blood vessel
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What kinds of medications are given intramuscularly
- antibiotics
- antiemetics
- narcotics
- sedatives
- vitamins
- tetanus
- iron
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Z track injections
Used for?
draw up technique
after injection I will.....
But don't....
Irritating IM medications...Vistaril, Iron, B12 and some antibiotics
- add 0.2 mL of air
- Aspirate
- Count to 10 after injection
- DONT MASSAGE
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Subcutaneous Injections
Where?
Amount?
Needle size
Angle
- Loose connective tissue, fatty back of arm or belly
- 1-3 mL's or 0.5mL for infants
- 25-27 gauge and 1/2 to 5/8 inch
- 45-90 degrees
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What sort of injection is used for insulin and heparin?
subcutaneous
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What not to do after these injections....
Heparin
Insulin
Heparin...don't pinch or massage
Insulin...don't massage
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Intradermal Injection
Used for?
Angle?
Needle size
- Allergy testing and TB Tests
- 10-15 degrees
- 26-27 gauge 3/8-5/8 inch needle
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When do you read a TB test?
48-72 hours after the injection
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Prior to administering medication I need to do 3 checks....
- Check before removing from the drawer/cassette
- Before dispensing
- Recheck at bedside before opening-tell the patient what you are giving
- After pouring and before disposing of the empty container
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Prior to giving any medication it is crucial to check....
the expiration date
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Medications that shouldn't be crushed
- Sustained Released
- Long Acting
- Controlled release
- Extended Length
- Enteric Coated
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What's the time frame of the administration of medication?
Within 30-60 minutes of the written order
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Prior to giving Digoxin make sure....
- the Potassium level is btwn 3.5-5.1
- chk the serum dig level....hold if 2+
- take apical prior to admin....hold if below 60
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Before giving potassium make sure the serum level is not above
5.5mEq
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Prior to giving anithypertensives check the persons _______ and hold it if the _______
- Blood pressure and Heart Rate 30 prior to administration
- SBP is <90
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Prior to giving anticoagulants what do I check?
platelet level
PT and INR for Coumadin
don't want platelets <100,000
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Never give insulin if the BS is below
65mg/dL
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What is dangerous about narcotics and sedatives?
it depresses a persons respirations
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Prior to administering medications to a patient always....
- Wash Hands
- ID patient with 2 ID's
- Ask about allergies
- Explain why they are getting each medication
- Don't leave until it is all gone
- Wash Hands and clean up wrappers
- Document!!!
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2 medications that require a 2nd RN to check
Heparin and Insulin
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1 g = how many mg?
1000 mg
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1 Tbsp = how many tsp?
3 tsp
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Normal Hgb
Male
Female
- Male 13.5-18g/dL
- Female 12-16g/dL
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Normal Platelet Levels
150,000-400,000 uL
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Normal WBC
4,500-10,000 uL
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Normal Sodium
135-145 mEq/L
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Normal Potassium
3.5-5.3mEq/L
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Normal PaO2
80-100mmHg
Tells if person is Hypoxic
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Normal SaO2
>95%
O2 Saturation/Pulse Ox
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If this measurement is out of whack the person has metabolic acidosis/alkalosis
HCO3
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If this measurement is out of whack the person has respiratory acidosis/alkalosis
PaCO2
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How do Beta Blockers work?
reduces bp by reducing heart rate, heart workload and hearts output of blood
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How do ACE Inhibitors work?
cause the body to produce less angiotensin which allows the vessels to relax and open up...causing a lower bp
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How do Calcium Channel Blockers work?
it prevents calcium from entering the muscle cells of the heart causing the hearts contraction to be less forceful
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Maslows
- Physiologic
- Safety
- Love/Belonging
- Esteem
- Self Actualization
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