FPCC - Exam 3 with 100% correct answers 2024.

transdermal, intradermal, subQ, into joints - answer-4 routes that local and topical anesthesias can be administered through change in heart rate, burning, itching, rash, decreased sensation - answer-5 side effects/precautions for local/topical anesthesia massage, TENS, heat and cold, acupuncture - answer-4 types of cutaneous stimulation that are non-pharmacological interventions use a pain scale, reassess signs and symptoms of pain, vital signs, evaluate pain impact on physical and social function, evaluate family/friend's observations of patient pain, ASK how much or if pain prevents from ADLs - answer-6 ways to evaluate pain management cutaneous - answer-this is superficial pain, arising from subQ tissue or skin (ex. paper cut, hot to touch) visceral - answer-this pain is caused by the stimulation of deep, internal pain receptors. Can be described as a tight pressure or cramping (ex. menstrual cramps, bowel disorders, labor pain, organ cancer) deep somatic - answer-this pain originates in ligaments, tendons, nerves, blood vessels, and bones. Localized and described as achy or tender. (ex. fracture, sprain, arthritis, bone cancer) psychogenic - answer-this pain is believed to originate from the mind; patient perceives pain despite no physical cause that can be identified. visceral, somatic - answer-two types of nociceptive pain are ___ and ___. neuropathic - answer-type of pain that is a complex and often chronic pain that arises when injury to one or more nerves results in repeated transmission of pain signals even in the absence of stimuli. acute - answer-which type of pain is protective- acute or chronic? whenever you take full set of vitals (routinely) - answer-when should pain be assessed on patient? patient self report - answer-what is the most reliable way to assess patient pain? mild, moderate or severe - answer-nonpharmacological interventions are good alternatives if experiencing ___ pain, but should be used as complementary interventions if pain is __ or ___. heat - answer-___ promotes circulation, which speeds healing. contralateral stimulation - answer-stimulating skin in area opposite of the painful site localized, diffuse - answer-cutaneous stimulation is best for pain that is ___ and not ___ visual (watch TV), tactile (touch, stroking a pet), intellectual (puzzle), auditory (music therapy) - answer-4 types of distraction that can use to help distract from pain guided imagery - answer-uses auditory and imaginary processes to affect emotions and help calm, divert, and relax. diaphragmatic - answer-what type of breathing promotes relaxation opioids - answer-kind of medication we should give if patient is in severe pain n/v, constipation, itching, breakouts - answer-4 common side effects seen with opioid use 2 nurses - answer-who does PCA have to be checked by before giving? increases circulation, lowers BP, improves venous return, healthy heart rate at resting level - answer-4 cardiovascular benefits of mobility RR comes to healthy rate faster, better oxygenation, helps diaphragmatic breathing - answer-3 pulmonary benefits of mobility hypostatic pneumonia - answer-this is when infection occurs from pooling secretions (seen with immobility) tracheal deviation and unilateral chest expansion - answer-2 things you may see if patient experiences atelectasis due to a mucous plug or secretion block. (no ventilation) parathyroid - answer-With immobility, ___ gland issues are common due to hypercalcemia and there's an increased release of Ca from bones. footdrop - answer-joint contracture of immobility when the foot permanently drops into plantar flexion UTI - answer-during immobility, urine can pool in the pelvis when laying down and increases the risk for developing ___ kidney stones - answer-another name for renal calculi is disease (disorders and injuries), environment (workplace, school, community, family support), medical therapies (bed rest, splints/casts, restraints) - answer-3 categories to assess when assessing someone's mobility/immobility. sprain - answer-this is a torn ligament low, wide - answer-you want a patient with a ___ center of gravity and a __ base of support flexibility, aerobic, resistance - answer-3 types of exercise to encourage to your patients 1-1.5 - answer-daily protein intake should be ___-___ g/kg of body weight a day. high protein, high calorie, vitamins B and C - answer-3 dietary implementations to encourage in an immobile patient to aid METABOLIC function chest physiotherapy, HOB up, hydrate (2500mL/day) - answer-3 respiratory implementations to encourage in an immobile patient monitor color and amount of urine, acidify urine (cranberry juice), maintain positive fluid balance, assist to void on hourly rounds - answer-4 GU elimination implementations to encourage in an immobile patient clock in room, open shades during day, TV on, involve patient - answer-4 psychosocial implementations to encourage in an immobile patient SCDs, 8 - answer-These are used to PREVENT venothrombic events, but not as a therapy; should change every ___ hours. demineralization - answer-the goal of musculoskeletal maintenance with immobile patients is reducing ____. hand splint - answer-these are used if patient gets hand contractures, but should NOT use a washcloth. xerostomia - answer-excessively dry mouth smoking, b12 and zinc deficiency - answer-3 nutritional status indicators that can cause a loss of gustatory function anosmia - answer-sense of smell is lost yawning, sleepy, preoccupied with somatic complaints, decreased attention span, difficulty concentrating, problem solving, and remembering, hallucinations, tearful, irritable, depressed - answer-8 CMs of sensory deprivation fatigue, sleepless, irritable, anxiety, reduced ability to problem solve, scattered and racing thoughts, disoriented. - answer-7 CMs of sensory overload PICC, tunneled, nontunneled, implanted port - answer-4 types of Central Lines for central IV therapy antecubital - answer-where is a PICC line usually inserted into? antibiotic therapy, chemo, parenteral nutrition - answer-3 common uses for a PICC central line. sutured - answer-a non-tunneled catheter for central IV therapy is directly into the jugular, femoral, or subclavian and is ___ into place. measuring central venous pressure (to assess blood volume) - answer-a NON-tunneled catheter is most common for infection, catheter or air embolus, bleeding, circulatory fluid overload - answer-4 things to monitor for (possible complications) with IV therapy Abductor pillow - answer-edge shaped pillow between the patient's legs, *used to prevent internal hip rotation and hip abduction* Used after femoral fracture, hip fracture, or surgery. Two point crutch gait - answer-*partial weight bearing*, use both feet. This is faster, but offers less support than the four point. The foot opposite of the crutch goes forward, so advance left foot along with right crutch, then right foot along with left crutch simultaneously. Three point crutch gait - answer-*non-weight bearing*. Faster than a four-point gait. Can use with walker. Injured leg must be kept off the ground. Advance crutches, then advance good leg. Four point crutch gait - answer-*Partial weight bearing*, use both feet. Patient must shift weight constantly. *Offers the most support, but is also the slowest.* Patient will advance the right crutch, then advance the left foot. Then advance the left crutch, then advance the right foot. This is not done simultaneously. Logrolling - answer-special turning technique used when the pt's spine must be kept in straight alignment You will need at least two nurses for this procedure, more if the patient is large. Logrolling moves the patient's body as a unit. One nurse is positioned at the level of the patient's head. The other staff members are distributed along the length of the patient. Everyone must move the patient in unison. Trapeze bar - answer-Triangular- shaped device that is attached to an overhead bed frame. The patient can use the base of the triangle as a grip bar to move up in bed, turn, and pull up in preparation for getting out of bed or getting on & off the bed pan. Trochanter rolls - answer-made from tightly rolled towels, bath blankets, or foam pads. They are placed snuggly adjacent to the hips & thighs *to prevent external rotation of the hips* Transfer board - answer-a wood or plastic device designed to assist with moving patients. 1. Place the board under the patient on the side in which he/she will be moved. 2. It is best to use a draw sheet to slide the patient across the board. *Also used by patients with long-standing mobility problems to increase their independence* Mechanical lift - answer-hydraulic device used to transfer patients. Place a fabric sling under the patient & attach chains or straps from the sling to the lifting device. -Especially useful when providing care for *obese & immobile patients.* -Often seen in home care. -Most position patients in a *seated position, ideal for sitting them in a chair.* -Some have the patient *supine, maybe to transfer patient from bed to stretcher, or have them lifted up while we make their bed.* Transfer belt - answer-a heavy belt several inches wide that is used to *facilitate transfer or provide a secure mechanism to hold the patient when ambulating* -Apply belt *around patient's abdomen*, close to their center of gravity. -The belt may have external grip holds, or you may grip the entire belt with your hand. Active range of motion (AROM) - answer-actively moving own extremity through ROM like extension, flexion. Want to encourage & teach clients to keep moving. Passive range of motion (PROM) - answer-movements of the joints through their range of motion *by another person* -support above & below the joint -take joint to point where pt starts to feel resistance -avoid pain. if pt feels pain, stop -slow & gentle movements -pts can perform by themselves. pt should be taught to promote independence/control Continuous passive motion (CPM) - answer-*device that repetitively but gently flexes & extends the knee joint* the CPM machine is often used after knee replacement or other knee procedures to allow the joint to improve range of motion, eliminate problem of stiffness, & prevent development of adhesions which can limit motion further. Both AROM & PROM improve ____ - answer-joint mobility, increase circulation to the area exercised, & help maintain function. AROM also improves respiratory & cardiac function Fowler's position - answer-semi sitting position, head of the bed is elevated 45-60 degrees Fowler's position promotes _____ & increases _____ - answer-Promotes *respiratory function* by lowering the diaphragm allowing the best chest expansion. ideal for some patients with cardiac problems. Semi-fowler's position - answer-head of the bed is at *30 degrees.* High-fowler's position - answer-head of the bed is at *90 degrees.* Orthopneic position - answer-Head of the bed is at *90 degrees, and an over bed table with a pillow on top is positioned in front of the patient* -Have patient lean forward while resting his arms and head on the pillow. -*This helps patients who are short of breath.* Lateral position - answer-side-lying position with the top hip and knee *flexed* and placed in front of the rest of the body. Creates pressure on the lower scapula, ilium, and trochanter but relieves pressure from the heals and sacrum. Lateral recumbent position - answer-side-lying with legs in a *straight* line Oblique position - answer-patient is on side with the top hip & knee flexed, however the top leg is *behind* the body. Places less pressure on the trochanter than the lateral position. Prone position - answer-patient lies on the abdomen with his head turned to one side. -Only position that allows full extension of the hips & knees. -Also, allows secretions to drain freely from the mouth. What are the dangers of the prone position? - answer--Most difficult to move a frail or unconscious patient to this position, because it requires the greatest amount of manipulation to position the patient appropriately. -Creates lordosis (inward curving of the spine/back) and rotation of the neck, so this is not good for patients with cervical or spine problems. -Inhibits chest wall expansion so not good for patients with cardiac or respiratory difficulty. *Only use for short periods of time.* Sim's position - answer-semi-prone position -Lower arm is positioned behind the patient and the upper arm is flexed. -The upper leg is more flexed than the lower leg. -This facilitates drainage from the mouth and limits pressure on the trochanter and sacrum. Sim's position is ideal for ____ - answer-enemas or a perineal procedure. Supine position - answer-dorsal recumbent position. -Patient lies on his/her back with head and shoulders elevated on a small pillow. The spine is aligned and the arms & hands rest comfortably at the side Technique for moving patients (3) - answer-1. Use a friction reducing device to move the patient if the patient can assist with movement. Use a full body swing if patient cannot assist. 2. Remove the pillow, have patient flex his/her neck, fold her arms across the chest, & place feet flat on the bed. 3. Have a nurse on each side of the bed and on the count of three, have him/her push off with their heels as the nurses shift the weight forward. Technique for turning the patient (3) - answer-1. Use a friction-reducing device and draw sheet to move the patient. 2. Position a nurse on each side of the bed, and place the patients arm & leg to the side you are going to roll them towards. 3. One nurse places hands on the patient's shoulders while the other places on the patients hips. Each nurse will roll the patient in the intended direction. Technique for transferring the patient: *bed to stretcher* (6) - answer-1. Move the patient to the side of the bed where the stretcher will be placed 2. Position stretcher next to bed & lock it in place. 3. Keep the stretcher situated a little lower than the surface the patient is on. 4. Place a draw sheet under the patient (see turning the patient, while turning the patient you put the draw sheet under him/her) 5. Place the transfer board against the patients back halfway between the bed and the stretcher. Position a friction-reducing device over the transfer board. Turn the patient to his back and onto the transfer board with draw sheet. 6. On a count of three, use the draw sheet to slide the patient across the transfer board onto the stretcher Technique for transferring the patient: *bed to chair* (9) - answer-1. Place *nonskid footwear* on the patient. 2. Place the bed *low & locked* with the *head of the bed up.* 3. Assist the patient to *dangle* at the bedside 4. Brace your feet & knees against the patient, bend your hips at the knees, and hold onto the transfer belt. 5. If there are two nurses, have one on each side of the patient. 6. Instruct the patient to place their arms around you between your shoulders and waist. Ask the patient to stand as you move to an upright position by straightening your legs & hips. 7. Instruct the patient to pivot & turn with you toward the chair. 8. Ask the patient to flex his/her hips & knees as he/she lowers him/herself into the chair. Guide the motion while maintaining a firm hold on him/her 9. If it is a wheel chair, lock the wheels Technique for ambulating the patient (11) - answer-1. Place nonskid footwear on the patient. 2. Place the bed low & locked with the head of the bed up. 3. Assist the patient to dangle at the bedside 4. Brace your feet & knees against the patient, bend your hips at the knees, and hold onto the transfer belt. 5. If there are two nurses, have one on each side of the patient. 6. Instruct the patient to place their arms around you between your shoulders and waist. Ask the patient to stand as you move to an upright position by straightening your legs & hips. 7. Allow patient time to steady themselves. 8. One nurse: stand at the patient's side, placing both hands on the transfer belt, stand on weaker side. 9. Two nurses: one nurse stands on each of the patient's sides, grasping hold on the transfer belt. 10. *Slowly guide the patient forward, observe for signs of dizziness or fatigue.* 11. Have a goal or outcome to how far you want the patient to walk. Single ended cane with a half circle handle is used for a patient who - answer-needs minimal support and is able to negotiate stairs. Single ended cane with a straight handle is used for patients with - answer-hand weakness with good balance. Multipronged cane/quad cane - answer-4 feet to it. Patient will *use cane on strong side.* The cane goes forward with the weaker side to promote a balance. It should fit at the *top of the hip with a 30-degree angle flexion* Walkers - answer-*should be at hip level, with 30 degrees of flexion.* -Make sure patient stands *within the walker, not behind it* so when the walker goes forward they are not leaning far forward & the center of gravity isn't shifting too far forward causing the patient to fall. -the walker should ideally be lifted & not scooted, lifted then stepped into. -Tennis balls/wheels on walkers have the advantage of decreasing friction & work but the disadvantage is an increase in fall risk. Braces support ____ - answer-joints and muscles that cannot independently support the body's weight. -Most commonly used in lower extremities. nursing responsibilities: assisting the patient into and out of the brace and monitoring the condition of the skin under the brace Crutches - answer--The crutch should not hit the axilla, *it should be three finger widths below the axilla* -The hand grip must be at a position that there is enough flexion there that you can push a little bit with it. -If you have to teach a client to go up stairs or up a curb, they must go up with the uninjured leg, then they bring the crutch & injured extremity. When you go down, go down with the crutch & injured leg first. *Up with the good & down with the bad.* -When leaning on the crutch, they are at risk for damaging their nerves & cutting off their circulation in their arms. Restraints are a _____ resort - answer-LAST Use restraints to - answer-1. reduce fall risk 2. prevent interruption of therapy 3. maintain life support 4. reduce risk to others DO NOT use restraints just because it's easier for the nurse. 2 types of restraints - answer-1. physical 2. chemical Physical restraints - answer-ANY manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. Chemical restraints - answer-medications that are used to restraint (sedates or calms anxiety) Restraints are a ___ intervention - answer-dependent needs to happen *face to face*. provider must come & look at the patient How often should an order for restraints be renewed? - answer-order should never last more than 24 hrs. when you hit that mark, the patient needs to be reassessed by the provider Never accept an order for restraints ___ - answer-PRN (as necessary) Alternatives used to maintain a restraint-free environment (8) - answer-1. treat the cause 2. distraction 3. relaxation techniques 4. physical activity 5. frequent assessment 6. anticipate needs 7. modify the environment 8. provide consistency Assessment of the restrained patient - answer-1. reassess- constantly reassess that the behavior that triggered the need for the restraint is still there. Remove restraints if the need is gone. 2. Neurovascular assessment- -check distal pulse -color & temperature of the extremity -Check capillary refill & for tingling/numbness. *Document on application & every hour to two hours* How often do you want to remove restraints to relieve pressure? - answer-at least every 2 hours *remove one at a time* -always want to assess circulation What is the most commonly used restraint? - answer-rails. Forms of restraints - answer-1. limb- goes around wrist or ankle 2. mitten- a patient who is trying to escape from soft wrist restraints; person who is scratching a lot 3. belt- allows patient to turn while being restrained 4. vest Measures to prevent injury & risk of complications in clients who are restrained - answer-Assess for: 1. pressure ulcers 2. pneumonia 3. constipation 4. emotional harm How many fingers should you be able to get under a restraint? - answer-1-2 fingers to keep it from restricting circulation Documentation for a restrained client - answer-1. all nursing interventions that were done to eliminate the need for restraints 2. reason for placing the restraint 3. the initial restraint placement, location, circulation, & skin integrity 4. the teaching session with the patient & family members 5. circulation checks, & restraint removal per agency protocol. 6. entries on fall risk assessment sheet, restraint flowsheet, and nursing notes according to agency policy Culture & sensory function - answer-people of different cultural backgrounds tend to prefer differing amounts of eye contact, personal space, & physical touch Illness & sensory function - answer-1. neurological disorders such as MS slow the transmission of nerve impulses 2. diseases that affect circulation may impair function of the sensory receptors and the brain, altering perception & response. 3. reduced or lack of oxygen harms & even destroys cells, causing widespread damage to the neurological system Medications & sensory function - answer-medications that cross the blood brain barrier affect neurologic or sensory function by damaging or killing brain cells Stress & sensory function - answer-stress can cause too much stimulation. stressors may lead to stimulation overload-- more stimuli than the person can handle Personality/lifestyle & sensory function - answer-clients are at risk for sensory alterations if their previous level of stimuli does not match their current level Kinesthesia - answer-muscle sense. a complex process involving proprioceptors that detect stretch in muscles to create a mental picture of how the body is positioned Stuporous - answer-requires vigorous stimulation before responding Obtunded - answer-dull the sensitivity of Myopia - answer-nearsightedness, means that the patient is able to see close objects well but not distant objects Presbyopia - answer-a change in vision associated with aging. the lens becomes less elastic & less able to accommodate to near objects Glaucoma - answer-vision loss caused by increased pressure in the anterior cavity of the eyeball that distorts the shape of the cornea & shifts the position of the lens, resulting in loss of peripheral vision Macular degeneration - answer-loss of central vision due to damage to the central portion of the retina Vision assessment - answer-1. age- around 40 can assume near vision will diminish 2. medical history- diabetes affects vision, ask for recent changes 3. assistive devices- glasses or contacts 4. ability to perform self-care- can the pt read expiration dates? 5. snellen chart 6. read a sample if snellen chart not available 7. identify colors to look for color blindness 8. observation- note if pt is rubbing eyes, squinting. repositioning Vision deficit implementations - answer-1. speak before approaching & inform of departure 2. communicate when you leave 3. stay in visual field 4. provide large print or magnifier to read 5. use audio tools to teach 6. light up the room well & eliminate clutter 7. assist with ambulation 8. identify locations. verbally confirm to the client where things are 9. keep bed in low position Vision health promotion - answer-1. encourage pt to start getting vision screenings around 40 & every 3-5 years after that 2. check pressures in eye/intraocular pressure to screen for glaucoma 3. screen pregnant patients for any history that can cause problems like loss of vision during pregnancy & delivery 4. teach pt to wear goggles if landscape worker 5. teach pt to wear sunglasses 6. sports equipment- make sure kids wear protective gear Presbycusis - answer-progressive sensorineural loss associated with aging. It results from deterioration of the hair cells in the cochlea. leads to diminished ability to hear high-pitched sounds and to distinguish sounds in a noisy environment. Tinnitus - answer-ringing in the ears Impacted cerumen - answer-condition in which earwax becomes tightly packed in the ear canal, blocking the canal. Congenital hearing deficit - answer-patient is born with it Illness/trauma causing hearing deficit - answer-trauma to ear or tympanic membrane can cause hearing loss. ask the patient about medications (aspirin causes tinnitus, lasix causes hearing loss, aminoglycosides are ototoxic) Auditory assessment - answer-1. age- 30 year olds see hearing loss 2. medical history- frequent ear infections or any trauma 3. environment- ask client about noise exposure 4. assistive devices- hearing aids 5. ability to perform self care- can they do this safely? 6. patient behaviors that show they do not hear well 7. perform the whisper test 8. perform audiometry (hearing testing) Auditory deficit implementations - answer-1. use written tools 2. legally you have to have an interpreter when someone does not speak the same language. for deficits, you will use someone who knows sign language 3. encourage client to use their hearing aid if they have one. Make sure they have a good fit & know how to handle it correctly. Gustatory deficits - answer-loss of taste -around age 50 you start to have decreased sense of taste -assess nutritional status since they are not eating -perform a taste test. give pt something salty, sour, bitter & see if they can correctly identify the taste Impaired taste most commonly results from ____ - answer-xerostomia (excessively dry mouth) which may be caused by meds, decreased saliva production, inadequate fluid intake, poor nutrition, or poor oral hygiene. Other causes of taste deficits include: - answer-1. common cold 2. infections of the nose, sinuses, mouth, or salivary glands 3. smoking 4. vit. b12 or zinc deficiency 5. dental fillings 6. dementia 7. injury to the nose, mouth, head 8. metallic taste can occur during pregnancy due to hormonal fluctuations or from cancer, peptic ulcer & kidney disease Gustatory deficit implementations - answer-1. assess nutritional status 2. oral hygiene- can correct dry mouth & enhance sense of taste 3. presentation of food- serve food how its supposed to be served. concentrate on visual appeal of the meal 4. food safety- have them read expiration dates & teach them to use their sense of smell to test if food has gone bad Amnosia - answer-sense of smell is lost Olfactory deficits - answer-1. age 50 you lose the sense of smell 2. medical history- brain trauma, zinc deficiency, smoking 3. identify odors- have patient close eyes & see if they can correctly identify smells Olfactory deficit implementations - answer-1. assess nutritional status 2. have gas appliances regularly inspected & maintained to prevent gas leaks 3. check smoke detectors & replace batteries regularly 4. promote food safety by teaching them to read labels for expiration dates Tactile deficits - answer-inability to feel. -can be caused by a cerebrovascular accident (stroke), brain or spinal tumor or injury, or peripheral nerve damage caused by diabetes, guillain-barre syndrome, or chronic alcoholism -ask patient if they have any numbness or tingling -observe function. frequently dropping things, lack of coordination in fine motor activities For tactile deficits, test _____ - answer-Two point discrimination- the ability to perceive as 2 close but separate points pressed against the skin Stereognosis - answer-when you can identify what you are touching by the shape Tactile deficit implementations - answer-1. teach visual assessment 2. use bath thermometer to monitor water temp. & prevent burns 3. change position frequently to relieve pressure on bony prominences 4. use properly fitting shoes & socks 5. immediately report any signs of circulatory impairment 6. inspect daily for open areas, cuts, abrasions, or areas of redness. Speech deficit/aphasia - answer-aphasia- patient has difficulty with words medical history- strokes, head injuries Expressive aphasia - answer-patient can understand, but can't produce words to speak Receptive aphasia - answer-patient can't understand the language Global aphasia - answer-patient can't understand language or produce words Speech/aphasia implementations - answer-1. speech techniques- introduce yourself & speak clearly/politely. give full info to client. use short sentences 2. ask yes/ no questions. 3. give them time to answer- pause between questions. do not rush client to answer. 4. use tools like a picture chart Sensory deprivation - answer-lack of meaningful stimuli Causes for sensory deprivation - answer-1. impaired sensory reception (neuro injury, dementia, depression, meds) 2. inability to transmit or process stimuli 3. restricted mobility 4. sensory deficits 5. nonstimulating monotonous environment 6. being from a different culture & unable to interpret received cues Sensory deprivation CMs - answer-1. yawning & sleeping 2. preoccupied with somatic complaints 3. decreased attention span 4. difficulty concentrating, problem solving, remembering 5. disorientation or confusion 6. hallucinations 7. tearful, easily annoyed, depressed Sensory deprivation nursing interventions - answer-1. keep client oriented 2. adapt communication- be conversational 3. maximize environmental input- turn on music, open shades 4. encourage social interaction 5. encourage use of devices (hearing aids) 6. provide mental stimulation- tv, games, crossword puzzles Sensory overload - answer-environmental or internal stimuli or combination of both exceed a higher level than the patient's sensory system can effectively process Causes of sensory overload - answer-1. hospitalized pts- combination of physical discomfort, anxiety, separation from loved ones, & being in an unfamiliar hospital environment 2. medications that stimulate the CNS 3. mental health conditions are exacerbated by high intensity noise & light in the environment Sensory overload CMs - answer-1. fatigue & sleeplessness 2. irritability or anxiety 3. reduced ability to problem-solve 4. scattered attention, racing thoughts 5. disorientation 6. delirium 7. dementia 8. confusion Delirium - answer-acute, reversible state of confusion caused by medications & a variety of physiological processes. Dementia - answer-chronic & progressive deterioration in mental function caused by physical changes in the brain & is not associated with changing levels of consciousness Sensory overload nursing interventions - answer-1. provide orientation 2. communicate simply 3. minimize environmental stimuli 4. consider limiting visitors 5. pain management 6. encourage rest/sleep 7. use stress-reducing techniques Seizure assessment - answer-1. assess the cause: do they have history of seizures, brain tumor, head injury? what meds are they on? what is their blood sugar? 2. history- find out when it started & how long its lasting. What to do while patient is having a seizure - answer-1. airway can be blocked by secretions or tongue. never put anything in their mouth. set up suction 2. position pt on side in case they vomit 3. client may need oxygen during & after seizure 4. call for help. if pt is at risk for falling, help them to a safe place. 5. protect pt from injury (hitting head) 6. pad bed 7. bed low & locked, side rails up 8. provide privacy- pt may have been incontinent 9. administer meds 10. check glucometer and for injuries from the fall 11. watch for adequate breathing. pt may have amnesia 12. tonic clonic seizures last no more than 5 min. if longer, pt has status epilepticus. this is a true medical emergency Cutaneous/superficial pain - answer-arises in the skin or the subcutaneous tissue. injury is superficial, may cause significant short-term pain Visceral pain - answer-caused by the stimulation of deep internal pain receptors. it is most often experienced in the abdominal cavity, cranium, or thorax. not well localized & can be described as tight, pressure, or crampy pain Deep somatic pain - answer-originates in the ligaments, tendons, nerves, blood vessels, and bones. localized & can be described as achy or tender Radiating pain - answer-starts at the origin but extends to other locations Referred pain - answer-occurs in an area that is distant from the original site Phantom pain - answer-pain that is perceived to originate from an area that has been surgically removed. Psychogenic pain - answer-refers to pain that is believed to arise from the mind Nociceptive pain - answer-most common type of pain experienced. it occurs when pain receptors (nociceptors) respond to stimuli that are potentially damaging. may occur as result of trauma, surgery, or inflammation. 2 types of nociceptive pain - answer-1. visceral pain (pain originating from internal organs) 2. somatic pain (pain originating from skin, muscles, bones, connective tissue) Neuropathic pain - answer-complex and often chronic pain that arises when injury to one or more nerves results in repeated transmission of pain signals even in the absence of painful stimuli. Acute vs. chronic pain - answer-1. acute- short duration, generally rapid in onset 2. chronic- pain that has lasted 6 months or longer and often interferes with daily activities. Words patients use to describe pain - answer-sharp or dull, aching, throbbing, stabbing, burning, ripping, searing, or tingling What is the 5th vital sign? - answer-pain scale. pain is whatever the patient says it is & exists when the patient says it exists. PQRST - answer-P- provokes the pain, palliates the pain (makes it better), pattern Q- quality R- radiation, referred pain S- severity, pain scale. assess before & after every intervention T- timing, onset, duration Factors that influence pain - answer-emotions: 1. fear- if fears remain unresolved, a pts pain can be prolonged or increase 2. confusion & helplessness 3. anxiety & depression- anxiety is most often associated with acute pain, but the anticipation of pain may also trigger anxiety. Depression is most often linked with chronic pain. 4. previous pain experience- patients who have had numerous painful experiences are more anxious about the prospect of experiencing pain & are more sensitive to pain. 5. sociocultural- some cultures expect not to express pain. When to assess pain - answer-1. on admission 2. before & after each potentially painful procedure or treatment 3. when the pt is at rest, as well as when involved in a nursing activity 4. before you implement a pain management intervention, and 30 minutes after the intervention 5. with each check of vital signs, if the pain is an actual or potential problem 6. when the patient complains of pain How to assess pain if patient is not able to tell you clearly - answer-when using a pain scale for cognitively impaired patients, you must allow sufficient time for the patient to respond. nonverbal signs of pain: 1. vocalization- moaning, screaming, crying, grasping, grunting 2. facial expression- grimacing, frowning, biting, clenching teeth, biting lips 3. body movement- clenched fist, tension, shifting, moving a lot 4. social interactions- irritable, withdrawn, angry 5. unable to perform ADLs How the body reacts to pain - answer-1. endocrine- ongoing pain triggers release of hormones. can result in weight loss, tachycardia, fever, increased RR, & even death 2. CV system- unrelieved pain leads to hypercoagulation & an increase in heart rate, BP, cardiac workload, & oxygen demand. may lead to chest pain, thrombosis, & heart attack 3. musculoskeletal- unrelieved pain causes impaired muscle function, fatigue & immobility. poorly controlled pain can prevent pt from performing ADLs 4. respiratory system- pts in pain tend to breath shallowly. these changes can lead to pneumonia, atelectasis, underventilation, & resp. acidosis 5. GU- hormones lead to decreased urinary output, retention, fluid overload, hypokalemia, HTN, & increased cardiac output 6. GI- intestinal secretions & smooth muscle tone increase, & gastric emptying & motility decrease. Nonpharmacological pain relief measures - answer-exercise, meditation, visualization, and music therapy can prompt the release of endogenous opioids. *they offer an alternative for people with mild pain* who do not wish to take potent drugs for pain relief. *they should be used as an adjunct to pharmacological therapies for pts with moderate to severe pain* Nonpharmacological cutaneous stimulation: TENS units - answer-transcutaneous electrical nerve stimulator -worn externally -consist of electrode pads, connecting wire, & stimulator. -pads are applied directly to painful area. once activated, the unit stimulates A-delta sensory fibers Nonpharmacological cutaneous stimulation: acupuncture - answer-application of extremely fine needles to specific sites in the body to relieve pain Nonpharmacological cutaneous stimulation: acupressure - answer-stimulates specific sites in body. instead of needles, fingertips provide firm, gentle pressure over the various pressure points. provides a calming effect through release of endorphins Other cutaneous stimulation - answer-1. massage 2. application of heat & cold 3. contralateral stimulation- stimulating the skin in area opposite to the painful site. Cutaneous stimulation works best on pain that is _____ - answer-localized and not diffuse Distraction for pain - answer-1. visual tactics such as watching TV 2. auditory such as music 3. tactile such as massage, holding a pet, hugging a loved one 4. intellectual such as crossword puzzles or a challenging game Progressive relaxation - answer-the person sits comfortably & tenses a group of muscles for 15 seconds and then relaxes the muscle while breathing out. Guided imagery - answer-uses auditory and imaginary processes to affect emotions and help calm, divert, and relax Diaphragmatic breathing - answer-effective measure to invoke relaxation and improve tissue oxygenation for pain management. goal is to train patients to intentionally take slow, even breaths using the diaphragm to inhale & exhale at the same rate for 5 to 8 breaths per minute. Analgesics - answer-classified into 3 groups: nonopioids, opioids, & adjuvants Choice of treatment is based on _____ of pain the patient is experiencing - answer-the level Pain levels & analgesics administered - answer-1. pain persisting or increasing- nonopioid & adjuvant 2. pain persisting or increasing- opioid for mild to moderate pain, nonopioid, & adjuvant 3. freedom from cancer pain- opioid for moderate to severe pain, nonopioid & adjuvant Around the clock (ATC) dosing - answer-prevents the patient from experiencing severe pain several times a day & is believed to be better than prn (as needed) dosing for pain. explain to the pt that ATC dosing will keep pain at an acceptable level throughout the day & allow them to function at an optimal level. Nonopioid - answer-relieve mild to moderate pain. may also reduce inflammation & fever. ex: acetaminophen, aspirin, ibuprofen (NSAIDs) Adjuvant analgesics - answer-reduce the amount of opioid the patient requires. they may be used as a primary therapy for mild pain or in conjunction with opioids for moderate to severe pain. ex: anticonvulsants, antidepressants, local anesthetics, muscle relaxants, corticosteroids Opioid analgesics: mu agonists - answer-stimulate mu receptors & are used for acute, chronic, & cancer pain. excellent medications for breakthrough pain (pain that breaks through relief) no maximum daily dose. you can steadily increase the dose to relieve pain. ex: codeine, morphine, dilaudid, fentanyl, methadone, & oxycodone Common side effects of opioid analgesics & treatment - answer-1. constipation- add more fruits, vegetables, fiber to diet. increase oral fluid intake to 8oz glasses of water. administer stool softeners or a mild laxative 2. NV- reduce opioid dose by combing nonopioid or adjuvant drugs. premedicate or medicate with antiemetic 3. pruritus- reduce dose by combining. use cool packs, lotion, or topical anesthetics. administer antihistamines. 4. respiratory depression- assess resp. status before administering & frequently afterward. reduce dose by 25% when you observe signs of oversedation. if pt is nonresponsive, stop the opioid and administer an antagonist. 5. drowsiness- teach pt drowsiness will subside. during daytime, offer stimulants such as caffeine. offer a lower dose more frequently Patient controlled analgesia (PCA) - answer-PCA pumps are an effective & safe way to deliver opioids. they provide excellent pain relief & give pt a sense of control. most PCA pumps can be programmed with 1 or 4 hour maximum lockout interval to prevent overdosing. if the pt reaches the set limit, the pump will trigger a "lockout" even if the pt keeps pressing the button PCA by proxy - answer-someone other than the patient presses the button to inject a dose of pain medication into the patient When you begin the PCA infusion, you will have another _____ check dosage calculations & confirm the settings on the pump - answer-nurse Chemical pain relief measures: types of regional anesthesia - answer-nerve blocks & epidural injection anesthetic agent is injected into or around the nerve that supplies sensation to a specific part of the body Nerve blocks may be used for - answer-short term pain relief after surgical procedures or long term management of chronic pain Local anesthesia - answer-injection of local anesthetics into body tissues. lidocaine or marcaine may be used. local anesthetics are injected into subcutaneous tissue for minor surgical procedures. they may also be injected into joints & muscles for pain relief Topical anesthesia - answer-involves applying an agent that contains cocaine, lidocaine, or benzocaine directly to the skin, mucous membranes, wounds or burns. it is quickly absorbed & provides pain relief for mild to moderate pain Addiction - answer-state of psychological dependence in which a person uses a drug compulsively & will engage in self-destructive behavior to obtain the drug Drug tolerance - answer-tolerance to opioids can occur, but increasing the dose or changing the route of administration can correct the problem Physical dependence - answer-leads to withdrawal symptoms when the medication is stopped abruptly; it can be prevented by decreasing the dose slowly over time. Behaviors that may indicate addiction - answer-1. repeated requests for injections of an opioid or atypical high dosing when pain should normally be diminishing 2. refusal to try oral meds for pain relief 3. "doctor shopping" 4. "pharmacy shopping" Placebo - answer-contain inactive substances that dont chemically provide analgesia Acid-base regulation: 3 ways our bodies respond to abnormal pH - answer-1. buffers- buffer system prevent wide swings in pH. a buffer system consists of a weak acid and a weak base. buffer molecules keep strong acids or bases from altering the pH either by absorbing or releasing free hydrogen ions. 2. Excretion of acid & base by the lungs (rescue faster by increasing & decreasing rate & depth of breathing 3. excretion of acid & base by the kidneys (rescue slower but are still effective) ABG analysis measures: - answer-pH, partial pressure of oxygen (Po2), partial pressure of carbon dioxide (PCo2), saturation of oxygen (SaO2), and bicarbonate (HCo3) level. Normal pH - answer-7.35-7.45 *indicates acidosis, alkalosis, or normal acid-base balance* Normal PaCO2 - answer-35-45 mmHg carbon dioxide ("acid") *signals respiratory causes* Normal HCO3 (bicarb) - answer-21-28 mEq/L sodium bicarbonate ("base") *signals metabolic cause* Normal PaO2 (arterial) - answer-80-100 mmHg Normal SaO2 saturation - answer-95% Acidosis - answer-occurs when the serum pH is below 7.35 Alkalosis - answer-occurs when the serum pH increases above 7.45 Respiratory acidosis - answer-may be caused by conditions or medications that impair gas exchange at the alveolar-capillary membrane, depressed respiratory rate and depth, or injury to the respiratory center in the brain. *pH down, PaCO2 up, HCO3 normal* Respiratory acidosis acute CM - answer-1. increased pulse & RR 2. headache, dizziness 3. confusion, decreased LOC 4. muscle twitching Respiratory acidosis chronic CM - answer-1. weakness 2. headache Respiratory acidosis interventions - answer-1. provide pulmonary hygiene 2. institute measures to improve gas exchange, such as chest physiotherapy, bronchodilators, antibiotics possible. 3. provide supplemental oxygen 4. maintain hydration Respiratory alkalosis - answer-may be caused by hyperventilation resulting from anxiety, fever, sepsis, thyrotoxicosis, lesion in the respiratory center in the brain, or excessive ventilation with a mechanical ventilator *pH up, PaCO2 down, HCO3 normal* Respiratory alkalosis CM - answer-1. confusion, difficulty focusing 2. headache 3. tingling 4. palpitations 5. tremors Respiratory alkalosis interventions - answer-1. if caused by anxiety, encourage the pt to relax & breathe slowly 2. for other causes: identify & treat the underlying disorder. Metabolic acidosis - answer-may be caused by retained acids in the blood resulting from renal impairment, poorly controlled diabetes mellitus, or starvation conditions that decrease bicarbonate, such as excessive GI loss, will also trigger metabolic acidosis may be caused by excessive intake of acids, which may occur with aspirin poisoning, or by prolonged infusion of chloride containing IV fluids *pH down, PaCO2 normal, HCO3 down* Metabolic acidosis CM - answer-1. headache 2. confusion, drowsiness 3. weakness 4. peripheral vasodilation 5. NV 6. kussmaul's breathing (rapid & deep) 7. frequently associated with hyperkalemia Metabolic acidosis interventions - answer-1. treatment is directed at correcting the underlying problem 2. bicarbonate may be ordered Metabolic alkalosis - answer-may be caused by excessive acid loss due to vomiting or gastric suction, use of potassium-wasting diuretics, hypokalemia, excess bicarbonate intake, or hyperaldosteronism *pH up, PaCO2 normal, HCO3 up* Metabolic alkalosis CM - answer-1. dizziness 2. tingling of extremities 3. hypertonic muscles 4. decreased respiratory rate & depth Metabolic alkalosis interventions - answer-1. treatment is directed at correcting the underlying problem 2. treatment often includes administration of NaCl-rich fluids. Stroke volume - answer-Volume of blood pumped from the left ventricle per beat Cardiac output - answer-total quantity of blood pumped per minute. cardiac output= stroke volume x pulse rate Normal cardiac output - answer-4.6 LPM at rest Factors that influence the pulse rate - answer-1. developmental level- newborns have a rapid pulse rate. the rate stabilizes in childhood & gradually slows through old age 2. gender- adult woman have a slightly more rapid pulse 3. exercise 4. food- ingestion of food causes a slight increase 5. stress- pulse rate & stroke volume increases 6. fever- pulse increase about 10 bpm for each degree of temp elevation 7. disease 8. blood loss 9. position changes- standing & sitting cause a temporary increase in pulse rate 10. medications Nutrition & cardiac health - answer-a diet high in saturated fat predisposes to the development of atherosclerosis, coronary artery disease & HTN all of which can compromise circulation & oxygenation. a low fat, low cholesterol, low sodium diet is considered heart healthy. vitamins & minerals & proteins are important to prevent anemia, which reduces blood oxygen carrying compacity Obesity & cardiac health - answer-obesity increases the risk of developing atherosclerosis & HTN. excess fat stores in & around the heart itself reduce its effectiveness as a pump. the workload of the heart is increased by the need to perfuse the excess body tissues Exercise & cardiac health - answer-exercise improves blood circulation & delivery of oxygen to tissues & cells. it also increases metabolic demands. the body responds by increasing the heart rate & rate & depth of breathing. Tobacco use/substance abuse & cardiac health - answer-tobacco use is a major risk factor in several chronic CV conditions. Alcohol abuse causes fatty infiltration of the heart muscle, thrombi in the coronary arteries, heart enlargement & dysrhythmias Levels of prevention - answer-1. primary prevention- activities are designed to prevent or slow onset of disease. ex: eating healthy, exercising 2. secondary prevention- involves screening activities & education for detecting illnesses in the early stages. ex: breast self exam 3. tertiary prevention- focuses on stopping the disease from progressing & returning the individual to the pre-illness stage. ex: rehab Conditions that increase cardiac output by increasing stroke volume include: - answer-1. increased blood volume (as occurs during pregnancy) 2. more forceful contraction of the ventricles (as occurs during exercise) Conditions that decrease cardiac output by decreasing stroke volume include: - answer-1. dehydration 2. active bleeding 3. damage to the heart (heart attack) Up to a point, an increase in heart rate increases cardiac output. However, a very rapid heart rate limits the time allotted for the ventricles to fill resulting in _____ - answer-decreased stroke volume & decreased cardiac output Heart failure - answer-the heart becomes an inefficient pump & is unable to meet the body's demands impaired circulation leads to systemic & pulmonary edema which further impairs gas exchange. Cardiomyopathy - answer-heart muscle disorder that results in heart enlargement & impaired cardiac contractility Dysrhythmias - answer-alterations in heart rate or rhythm. can lower cardiac output, decrease tissue oxygenation, & increase risk of stroke Heart valve abnormalities - answer-create turbulent flow, leading to a decrease in cardiac output & compromised tissue oxygenation. P wave - answer-represents the firing of the SA node & conduction of the impulse through the atria. in the healthy heart, this leads to atrial contraction. QRS complex - answer-represents ventricular depolarization & leads to ventricular contraction T wave - answer-represents the return of the ventricles to an electrical resting state so they can be stimulated again (ventricular repolarization). U wave - answer-not always seen on the ECG, but may be detected with an electrolyte imbalance such as hypokalemia or hypercalcemia. U waves sometimes occur in response to certain meds Inverted U wave may occur with ischemia to the cardiac muscle Normal sinus rhythm - answer-60-100, regular rhythm Tachydysrhythmias - answer-rates 100 beats/min Bradydysrhythmias - answer-rates 60 beats/min Ectopy - answer-extra beats Supraventricular - answer-above the ventricles Junctional - answer-within the AV node Ventricular - answer-in the ventricles All dysrhythmias have the potential to _____ cardiac output - answer-decrease Cardiac diagnostic testing - answer-labs- lipid profile, carry fats in blood stream; LDL- low density, bad cholesterol. elevated cholesterol is highly associated with CV problems. *want cholesterol to be less than 200 mg/dL* 3 lab values that indicate cardiac muscle damage - answer-1. troponin- very specific to cardiac damage. low troponin indicate there has been a blockage in the muscle that is releasing this protein. will go up if pt is having a heart attack. 2. creatinine kinase (CK)- CKMB levels will rise with heart damage. 3. myoglobin- protein released from heart muscles when there is damage. Cardiac screening - answer-1. CXR- basic chest xray tells us the silhouette/outline of heart 2. cardiac monitoring- noninvasive. 3. 12 lead EKG 4. hoitor monitor- a long term rhythm strip we use in hope to catch a change intermittently 5. echocardiogram- ultrasound. gives info about stroke volume & valves & how its functioning Nursing diagnoses related to circulation & perfusion - answer-1. decreased cardiac output 2. activity intolerance 3. impaired gas exchange 4. fatigue 5. ineffective health maintenance 6. risk for imbalanced fluid volume Preload - answer-the pressure that the blood is placing on the muscle fibers in the ventricles at the end of diastole. increased preload- pregnancy decreased- fluid volume loss Afterload - answer-Pressure in the wall of the left ventricle during ejection increase afterload- hypertension, anything that causes vasoconstriction decrease- anything that reduces resistance. Cardiac interventions - answer-1. manage anxiety 2. promote circulation- promote venous return -elevate patients legs above level of the heart -avoid sitting with legs crossed -encourage & support ambulation -provide ROM exercises -apply compression devices -quit using tobacco bc smoking restricts blood flow -take good care of feet & prevent injury to feet. -regular exercise improves circulation & oxygen delivery 3. prevent clot formation -turn pts frequently -promote adequate hydration -promote smoking cessation IV therapy - answer-administration of fluids, electrolytes, medications, or nutrients by the venous route. IV fluids are used to: - answer-1. expand intravascular volume 2. correct an underlying imbalance in fluids or electrolytes 3. compensate for an ongoing problem that is affecting either fluid or electrolytes Isotonic fluids remain in the _____ - answer-intravascular compartment Hypotonic fluids pull body water _____ of the intravascular compartment - answer-out Hypertonic fluids pull body water ______ the intravascular compartment - answer-into Isotonic fluids - answer-normal blood serum osmolality is 275-295 mOsm/kg. Isotonic solutions have similar tonicity (250 to 375 mOsm/L). Therefore when infused, *they remain inside the blood vessels.* Isotonic fluids are useful for clients with _____ - answer-hypotension or hypovolemia Commonly prescribed isotonic solutions - answer-1. 0.9% sodium chloride (0.9% NaCl) also called normal saline 2. Lactated ringers (LR) Isotonic fluid precautions - answer-Clients who have congestive heart failure must be closely monitored when they receive isotonic fluid replacement, bc they may easily develop fluid overload Hypotonic fluids - answer-the osmolality of a hypotonic solution is less than that of serum (less than 250 mOsm/L) therefore when infused, these solutions *pull body water from the intravascular compartment into the interstitial fluid compartment*. Expand volume & rehydrate cells Hypotonic fluid is used for: - answer-hyperglycemic conditions, such as diabetic ketoacidosis, in which high serum glucose draws fluids out of the cells and into the vascular & interstitial compartments Examples of hypotonic fluids - answer-1. 5% dextrose in water (d5w) 2. 0.45% NaCl (1/2 normal saline) 3. 0.33% NaCl 4. 0.2% NaCl Hypotonic fluid precautions - answer-administer carefully to prevent sudden fluid shift from the intravascular space to the cells. never give to patients at risk for increased intracranial pressure because they can cause or worsen cerebral edema. Hypertonic fluids - answer-the osmolality of hypertonic fluids is higher than that of serum. When administered, *they pull fluids and electrolytes from the intracellular & interstitial compartments into the intravascular compartment* Hypertonic fluids can help: - answer-stabilize blood pressure, increase urine output, and reduce edema. volume expanders are hypertonic, & used to increase blood volume Examples of hypertonic fluids - answer-1. D3 0.9% NaCl (D5NS) 2. D5 0.45 % NaCl 3. D5 Lactated ringers 4. 10% dextrose in water (d10w) Over the needle catheters - answer-also called angiocaths. a polyurethane or teflon catheter is threaded over a metal needle. you pierce the skin & vein with the needle, advance the catheter into the vein, & remove the metal needle. *this is ideal for brief therapy* Inside the needle catheters - answer-this type of catheter is similar to the over the needle catheter; however, the polyurethane or teflon catheter lies inside the metal needle. after you advance the catheter into the vein, you withdraw the needle Butterfly needle - answer-short, beveled metal needle with flexible plastic flaps attached to the shaft. Butterfly needle is commonly used for - answer-intermittent or short term therapy for children & infants for single dose medications & drawing blood Butterfly needle disadvantages - answer-bc the inflexible metal needle remains in the vein, a butterfly needle is more likely to infiltrate (damage the vein & allow fluid to leak into the interstitial spaces) than a flexible plastic catheter. Midline peripheral catheter - answer-a peripherally inserted flexible IV catheter typically inserted into the antecubital fossa & then advanced into the larger vessels of the upper arm for greater hemodilution. Midline peripheral catheter is left inserted for how long? - answer-typically 1-4 weeks. A midline peripheral catheter should be changed only when _____ - answer-there is a specific indicator (swelling, pain) A midline peripheral catheter is easily confused with - answer-a peripherally placed central line (PICC) Peripheral intravenous lock - answer-also called a saline lock, a prn adapter, & sometimes a heparin lock establishes a venous route as a precautionary measure for clients whose condition may change rapidly or who may require intermittent infusion therapy. How is the patency of a peripheral intravenous lock maintained? - answer-by injecting normal saline or a dilute heparin solution Central venous access device (CVAD) - answer-intravenous line inserted into a major vein. typically, the subclavian or internal jugular vein is used. CVADs are used to: - answer-administer large volumes of fluid or highly irritating medications, when peripheral sites are unavailable, for monitoring central venous pressure, & for frequent blood draws. Advantages of central lines - answer-1. accommodates highly irritating solutions 2. central veins are accessible even if the pt is experiencing fluid depletion 3. can be left in longer than peripheral IVs 4. nutrition can be given parenterally 5. phlebitis, extravasation, & infiltration less likely to occur Disadvantages of central lines - answer-1. practitioners must have specialized training to insert 2. must obtain patients consent 3. placement must be confirmed by radiography 4. placement treated as minor surgical procedure 5. dressing changes require strict sterile technique 6. risk the catheter will float into the right side of the heart 7. greater risk for embolus & infection 8. risk for sepsis is higher 9. costs are greater Preventing central-line associated bloodstream infections - answer-1. education & training- encourage pts to report any changes or new discomfort in their catheter site 2. hand hygiene 3. maximal barrier precautions for insertion 4. chorhexidine skin antisepsis 5. optimal catheter site selection- subclavian vein has the lowest rate of infection. avoid femoral vein 6. type of catheter- the catheter with the fewest number of ports or lumens is best 7. daily review of lines- should be removed as soon as it is no longer necessary 4 types of CVADs - answer-1. PICC lines 2. nontunneled central venous catheters 3. tunneled central venous catheters 4. implanted ports PICC lines - answer-long, soft, flexible catheters inserted at the antecubital fossa through the basilic or cephalic vein of the arm. the catheter is then advanced into the superior vena cava. A physician or specially trained RN performs the insertion. Most commonly used for prolonged IV antibiotic therapy, parenteral nutrition, & chemo Intended for intermediate to long term use & does not need to be replaced Nontunneled CVC - answer-inserted by a physician, specially trained nurse practitioner, or physician assistant through the skin into the jugular, subclavian & occasionally femoral veins. they are sutured into place. intended for shorter use than a PICC line (less than 6 weeks) dont routinely replace Tunneled CVC - answer-intended for long term use. the catheter is inserted by a surgeon through a 3-6 in subcutaneous tunnel in the chest wall & then into the jugular or subclavian vein, risk of infection is less with their use than it is with PICCs or nontunneled central lines. Implanted port - answer-the catheter enters the internal jugular vein in the neck, & it may be tunneled or untunneled to a completely implanted port in the upper chest. placed by surgeons & only specially trained nurses are allowed to access an implanted port bc of risk of infiltration into the tissue if the needle placement is not correct. intended for long term use Intraosseous devices - answer-designed for immediate access (within seconds) and short term use (less than 24 hrs) used to administer fluids when a peripheral catheter cannot be inserted or when a central line insertion is not advisable, but especially in emergency situations. placed into the matrix of a bone most common access site is the proximal tibia in both children & adults. sternum & head of humerus can also be used in adults osteomyelitis is a rare complication. How does a nurse choose the size of the IV catheter? - answer-select the smallest diameter and the shortest length catheter that will accommodate the prescribed therapy. nurses commonly use a 20-22 gauge catheter for adult peripheral infusions. a 20 gauge will accommodate adult blood transfusions you will need the larger 16-18 gauge for rapid infusions, thick fluids, or surgical/trauma patients. the smaller 24 gauge is used in geriatric & neonates Macrodrip vs microdrip tubing - answer-1. macrodrip delivers 10-20 drops per ml of solution; select a macrodrip for most adult infusions 2. microdrip delivers 60 drops per ml; use for very slow infusion rates or for infants & children How many times should you attempt to initiate an IV? - answer-twice. do not make more than 2 attempts Selecting a peripheral IV site - answer-1. age- for adults, you will use veins in hands or arm; for infants veins in the scalp or foot 2. type of solution- for irritating solutions, choose a large vein 3. speed of infusion- the faster the rate, the larger the vein and the larger the IV catheter you will need 4. duration- some recommend changing every 72-96 hours 5. avoid areas with scarring or impaired circulation IV complications & interventions: hematoma - answer-localized mass of blood outside the blood vessel causes: nicking the vein during unsuccessful insertion, discontinuing IV line without holding pressure over the site, or applying a tourniquet too tightly signs & symptoms: ecchymosis, localized mass, discomfort -Interventions: be gentle with venipuncture -apply pressure when discontinuing IV complications & interventions: infiltration - answer-seepage of novesicant solution or medication into surrounding tissues causes: iv catheter dislodges or the tip penetrates the vessel wall signs & symptoms: slowed or stopped flow, swelling, tenderness, pallor, hardness and coolness at the site. pt may report a burnt sensation -stop immediately -restart in a different vein, higher in extremity or another extremity IV complications & interventions: extravasation - answer-seepage of a vesicant substance into the tissues (vesicant- causes blisters) iv catheter dislodges or tip penetrates vessel wall signs & symptoms: slowed or stopped flow, pain burning & swelling at site, blanching & coolness. blistering is a late sign. if extravasation resulted from vasoconstricting medication may see necrosis of dermis -treatment depends on severity -stop immediately -administer antidote -apply cold compress,