ATI Fundamentals Proctored Practice

Tagging in Mass Causality incident

1. Red flag: immediate threat to life a. Breathing issue, hemorrhaging wound, major burns 2. Yellow tag: major injury that requires prompt attention a. Bone fracture 3. Green tag: minor injury not immediate attention a. Abrasion, cut, or sprain 4. Black: expected and allowed to die a. Penetrating head wound, chest/crush injury 5. Nursing actions a. Tornadoes: close shades, move Pt's away from windows and into the hallways, place blankets on bedbound patients b. Chemical exposure: undress and irrigate profusely with water i. Dry chemical: brush chemical off skin and clothing c. Hazardous material: locate safety data sheet i. Water is the universal antidote d. Bomb threat: keep caller on phone, listen for background noise or clues

Cain

2 points of support at all times o Cain on stronger side of body o Support body weight on both legs o Move Cain forward 6-12 inches, move weaker leg forward, then stronger leg past cain

33 coping

3 stages of general adaptation syndrome o 1: alarm, reaction: fight or flight, HR and BP increased, cortisol released, boost of adrenalin o 2: resistance: normalize hormones and vitals o 3: exhaustion: prolonged stress resulting in body no longer being able to respond to stressor Fatigue, depression - Ask what coping skills you have used in the past

Pharmacokinetic

Absorption: location of admin bloodstream o Distribution: bloodstream site of action Circulation issues, permeability at destination site, and protein binding (albumin) o Metabolism: inactivation of a medication by enzymes. Primary done in the liver Affected by age (infants and elderly have lower), 1st pass effect o Excretion: leaving the body through the liver, lungs, and intestines Kidney probs - Therapeutic index: minimum effective concentration for the drug to the level of toxicity - Half-life: amount of time it takes a medication to be reduced by 50% - Agonist: activates a receptor in the body; morphine - Antagonist: blocks the receptor in the body; naloxone

Refusal of treatment

Allowed if competent o AMA: tell provider, tell of risks, and have sign document

Nursing Process

Assessment and date collection o Subjective data (symptoms): pain level, how they're feeling o Objective data (signs): temp, BP, capillary refill - Analysis and more data collection o Cluster collected date, ID patterns and trends, compare data to expected values o Forms picture of Pt condition and identifies trends o primary source: what they Pt tells you and what you see yourself o Secondary source: what others tell the nurse about the patient Can come from the medical record - Planning: o Prioritize interventions o Identify measurable outcomes: time limited, not vague Vague: hopefully they will breathe better tomorrow Not vague: Pt will not complain of dyspnea tomorrow - Implementation: o Perform actual nursing care using your interventions o Document Pt response to those interventions - Evaluation: o Compare results with planned outcomes and determine where you go from there

Ch. 3 nursing ethical principles

Autonomy: Pt has a right to make his/her decision even it is not in their best interest o Ex. Going AMA - Beneficence: doing good and best for the patient o Providing medications, helping the patient, doing the right thing - Fidelity: keeping your promise o If you say you're going to find out, then find out - Justice: providing fairness in care in the allocation of resources o You are not giving one Pt more resources than another - Nonmaleficence: do no harm o Catching an incorrect prescription dose - Veracity: telling the truth o If the Pt asks their diagnosis, tell them their diagnosis

First aid principles

Bleeding: Direct pressure to the wound Don't remove the impaled object—stabilize it Fractures: apply a splint then do neuro checks below level of injury Sprain: RICE Frostbite: warm effected area in water that is between 98.6 and 100.8 degrees. Then administer tetanus vaccine Burns: remove the agent that causes it, elevate extremity, administer fluids, administer tetanus vaccine

Head and Neck

CN 1. Olfactory-S 2. Optic-S; Snellen 3. Oculomotor-M; PERRLA, move fingers 4. Trochlear-M; in, down, and laterally 5. Trigeminal-B; chewing and face sensation 6. Abducens-M; lateral movement 7. Facial-B; taste of anterior 2/3 tongue, salivary and lacrimal gland 8. Vestibulocochlear-S; hearing and balance 9. Glossopharyngeal-B; parotid gland and gag reflux and taste of posterior 1/3 tongue 10. Vagus-B; pharyngeal and laryngeal muscles, voice, gag reflux, speech, and thoracic and abdominal viscera 11. Accessory-M; sternocleidomastoid and trapezius 12. Hypoglossal-M; controls tongue movement - Assessing thyroid gland o Have Pt hyperextend neck or have them sip a glass of water - Inspection of the eyes o Snellen: stand 20 feet away Myopia: impaired far vision 20/40: someone has to come 20 feet to a letter where a normal person could see 40 feet away o Rosembaum: tests for presbyopia (impaired near vision) Hold 14 inches away o Ichihara: color vision o Extraocular movement of eyes Corneal light reflection: check for symmetry in light of cornea Cover/uncover test: tests for strabismus—lazy eye 6 cardinal positions PERRLA 3-7 mm of pupils Artery/vein ratio Ophthalmoscope: 2 arteries per every 3 veins - Hearing o Whisper test: 1-2 feet away o Rinne: tuning fork against mastoid bone against ear canal Tests for conductive VS sensorineural hearing loss o Weber: compares left to right side o Check alignment Top of auricle should be at same position as inner canthus of eyes o Insert otoscope: 1-1.5 cm into ear canal without touching the ear canal o Light reflex: 5 o'clock in the right, 7 o'clock in the left, in cone shape o Cerumen (ear wax) is expected finding - Changes in older adult o Decreased vision o Yellowing of lenses in the eye o Issues with glair and darkness o Hearing loss is common—but not expected o Thickening of mucous membrane o Decreased sense of taste, gum disease and tooth loss is common o Decreased salivation and paler gums o Increased vocal pitch o Decreased sense of smell

injury prevention

Carbon monoxide (reduces oxygen supply to bodies tissues) o Need detectors for this o Need proper ventilation when using gas stoves or fireplaces o Poisoning: N/V, HA, loss of consciousness - Food poisoning o Frequent hand hygiene o Refrigerate perishable products within 2 hours Or 1 hour if temperature is 90 degrees or more o Prevent cross contamination: handling raw and fresh food separately o Cook food to recommended temps o Immune compromised PT's should only consume pasteurized dairy products - ABCDE o Airway: ensure patient airway, stabilize cervical spine o Breathing o Circulation: HR, BP, cap refull o D: disability; LOC o E: exposure: trauma and exposure to heat or cold

Chain of infection

Causative agent: bacteria or toxin o Reservoir: where the causative agent lives Human, soil o Portal of exit: how that pathogen leaves the host Blood, respiratory tract o Mode of transmission Contact, droplet, airborne o Portal of entry How that pathogen enters the host o Susceptible host

Self Concept and Sexuality

Certain procedures and medical conditions can result in impaired body image o Amputation, spinal cord injury, hysterectomy, and mastectomy

considerations of med-admin

Children o Decreased gastric secretion, gastric emptying time, first pass effect, o Increased absorption of topical medications o Lower BP, higher body-water content o Decreased protein-binding sites - Older-adults o Increased gastric pH o decreased GI emptying time, decreased blood flow and kidney function o decreased protein binding and lower albumin o decreased body water and muscle mass, increased fat content o greater likelihood of polypharmacy

learning domains

Cognitive: thinking, knowledge, comprehension - Affective: feeling, ideas, beliefs, and values - Psychomotor: physical coordination, movement, and manipulation - Education: o Assessment: identify needs, learning style (auditory, visual), evaluate abilities and resource available o Planning: with the patient o Implementation: avoid use of medical jargon, reading at 6th grade level or lower o Evaluation: ask Pt to explain learning or teaching or to perform action

screening and assessment

Colorectal: starts at age 50 o Fecal occult yearly o Sigmoidoscopy every 5 years o Colonoscopy every 10 years - Papst smear o Every 3 years beginning age 21 or more frequently - Mammogram: annually at 40 - Testicular exam: starting age 20, routine - PSA and digital rectal exam: annually at age 50 - Types of prevention o Primary: prevents initial occurrence of disease Education, immunization o Secondary: early detection and limiting worsening Screening, control outbreak o Tertiary: maximize recovery after illness occurs Rehab, PT/OT, support groups

- Risk factors for developing an infection

Compromised immunity o Chronic or acute injury o Poor hygiene o Crowded living o IV drug use o Unprotected sex o Poor sanitation

Bowel Elimination

Constipation o Increase fluid2-3L/d, increase fiber to 25-30 g, and increase activity—stimulates peristalsis o No non term laxative use - FOB test (fecal occult blood test) o 3 sample from 3 different BM o Contaminants: water or urine o Blue: positive result - Edema: o Warm it o Position in sims (left side, right foot flexed) o Lube the tip, insert 7.5-10 cm (3-4 inches) o Open clamp with the bag level with the patient's hip o Raise the bag slowly—12 to 18 inches above the anus o Slow flow if cramping occurs by lowering the bag - Changing the ostomy o Remove the pouch carefully with a washcloth soaped with water o Inspect the stoma: pink/red and moist—not purple or pale o Skin surrounding should be intact o Clin skin with mild soap in water o Dry thoroughly—no moisturizer o Cut a hole in barrier that is slightly lower than the stoma (no more than 1/8th inch larger than the stoma) o Apply skin barrier and pouch—may use barrier paste - Valsalva maneuver: occurs when Pt bears down and strains o Results in bradycardia, hypotension, and syncope - Diarrhea o Symptoms: increased pulse, hypotension, poor turgor, elevated temp, and dry mucous membranes o Use zinc oxide ointment to prevent breakdown

Fluid volume deficit

Deficit: tachycardia, tachypnea, hypotension, weak pulses, fatigue, weakness, thirst, dry mucous membranes GI upset, oliguria, decreased turgor and capillary refill, flattened neck veins, diaphoresis o labs: increased Hct, serum Osm, hypernatremia o urine: increased specific gravity (over 1.03) o nursing care: weigh daily, provide fluid replacement, report UOP less than 30 mL/hr, assist with ambulation - overload: can be d/t CHF or kidney failure; tachycardia, tachypnea, hypertension, bounding pulse, weight gain, dyspnea, edema, crackles, jugular vein distention, o labs: blood is diluted, decreased Hct, decreased Osm, decreased electrolytes, BUN, creatinine, decreased urine specific gravity (under 1.01) o nursing care: restrict fluids and Na, administer O2 and diuretics, and prevent skin breakdown

Foot care

Diabetic: decreased sensation in feet, can even walk around with a nail in the foot o Inspect feet daily using mirror o Test water temperature before getting in using their hands or elbow o Dry feet thoroughly—moist areas feet to maturation and fungus o Apply moisturizer to feet but not between the toes o Wear cotton socks—not synthetic o Cut nails straight across o Check shoes for objects that cause injury o See pediatrist regularly o Do not apply heating pads to the feet - Oral hygiene with unconscious patient s o Have suction available o Do not put fingers in their mouth o Position Pt on their side o Denture care: upper (down and out) lower (up and out) Store dentures in water

Ch. 2 Interprofessional Team

Dietician: assist with NTR needs - Lab tech: blood draws - Pharmacy: reviews meds, put in MAR - PT: mobility - OT: helps Pt regain ability to perform ADL's - Provider: can be the doctor or advanced practiced nurses or PA - Social workers: identifies and coordinates community resources, medical equipment, and other needs of the Pt to be discharged from acute care - Speech/language pathologist: help with speech and swallowing assessments o Dysphagia and difficulty swallowing

Skin and peripheral vascular system

Discoloration o Pallor: circulation issue or anemia o Blue: cyanosis d/t hypoxia—emergency o Jaundice: hepatic or liver dysfunction or high rbc destruction o Erythema: inflammation, sunburn, or rash o Brown: venous insufficiency - Capillary refill: within 2 seconds - Skin turgor: over sternum or forearm o Tenting: dehydrated, or old age - Edema: compress skin for 5 seconds over bony prominence o 2 mm immediately rebound: scant; 1+ o 4 mm, 15 seconds; mild; 2+ o 6 mm, 30 seconds; moderate; 3+ o 8 mm; 30+ seconds; 4+ - Primary and secondary lesions o Macule: flat area of discoloration less than 1 cm wide, freckle o Patch: discoloration over 1 cm; birthmark Not raised o Papule: elevated solid lesion under 1 cm, mole o Plaque: elevated solid over 1 cm; psoriasis o Vesicle: elevated serous filled lesion under 1 cm; herpes or varicella o Boa: over 1 cm o Nodule: firm, deep lesion 1-2 cm wide, wart o Tumor: solid mass that is also deep that is over 2 cm; neoplasm o Pustule: pus filled vesicle, under 1 cm (acne) o Wheal: transient elevated irregular border, edematous lesion (itchy, red)—insect bite - Secondary o Crust: slightly elevated lesion composed of dried blood, wound exudate, or pus o Erosion: loss of the epidermis that is moist (popped blister) o Scale: flaky skin and exema o Fissure: linear break in skin surface from being too dry or too moisten o Ulcer: damage to epidermis and dermis from pressure - Skin changes with age o Thinner, translucent o Loss of elasticity o Hair thins o Decreased sweating and oil production o Decreased subcutaneous tissue over bone o Larger pigmented spots—normal o BV become more fragile resulting in bruising and bleeding

Crutches

Do not adjust after fitting o 3 finger width between axilla and top of crutch o Support weight on hand grips—not axilla o Elbows flexed at 30 degrees o Non weight bearing on 1 leg Tripod: advance both crutches and injured leg together, then unaffected leg beyond crutch o Sitting or rising Position crutches on unaffected side o Going up stairs: hold on rail with one hand, crutches with the other, step up with the unaffected leg, then bring the crutches and affective leg up beside the o Going down: place crutches and affected foot on stair below and bring unaffected leg down

Delegation

Do not delegate o Pt information (initial teaching) o Any task that require nursing judgement or nursing assessment - Can be delegated to LVN (practical nurse) o Medication admin o Enteral feedings o Suctioning o Tracheostomy care o Reinforce patient teaching - Can be delegated to CAN o Bathing, dressing, ambulating, toileting, feeding Pt's who do not have swallowing difficulties (if Pt has dysphagia, you need to do it), positioning, taking vitals, collecting specimens, reporting I/O - 5 rights of delegation o Right task: repetitive, relatively non-invasive, and doesn't require supervision o Right circumstance: never assign an unstable Pt to an LVN, right person o Right direction and communication: timeline, expected result, and follow-up communication (such as if vitals are abnormal) o Right supervision and evaluation: may need to intervene or provide feedback

Walker

Do not use to stand up o Flex elbows 20 to 30 degrees o Advance 12 inches, the affected then unaffected leg

Admission

Document advanced directive status: DNR or full code o Collect vitals, height and weight, allergies o Head to toe assessment, health history, spiritual/cultural considerations o Assess for swallowing issues: do they have r/f aspiration If yes: need evaluation from speech pathologist o Safety assessment: r/f falls o Inventory Pt belongings o Put valuables in facility safe or have family take it home o Medication reconciliation: compare home meds to providers prescriptions o Discharge planning starts at admission****

Medicare

Eligibility: 65+ , on disability for 2 years, or diagnosed with ALS and end state renal failure and on dialysis o Four parts A: inpatient, limited skill nursing care, home health B: outpatient care: diagnostics services, and OT/PT C: combines A and B and provided through private insurance companies D: prescription drug coverage

Medicaid

Eligible: low socioeconomic status, no insurance, dependent on size of household

AE of medications

Extrapyramidal; dystonia, Parkinson's, akathisia (restless), TD o AC effects: photophobia, and tachycardia Increased fluid and fiber and wear sunglasses o Orthostatic hypotension o Bleeding: coffee ground emesis (blood in emesis), tarry stools, bruising, petechiae, bleeding gums, and oozing o Foods that affect meds: Grapefruit juice (especially statins), foods high in vit K, high protein foods (levodopa—Parkinson's), tyramine (cause HTN crisis in MAOI), K rich foods (cantaloupe, oranges—cause toxicity in ace inhibitors and K sparing diuretics), dairy interacts with tetracycline

More Precautions

Fall prevention o Regular toileting for those that require assistance o Skid proof socks o r/f falls: place close to the nurse's station o hourly rounding o make sure frequently used objects are within reach - seizure o during: lower Pt to floor or bed, turn them on their side, loosen restrictive clothing, do not restrain Pt or put anything in their mouth note onset and duration o after: check vitals, perform neuro checks, re-orient the patient, identify the trigger, and implement seizure precaution - restraints o physical: vest, belt, or mittens o chemical: sedative or antipsychotic o alternative: re-orientating, have a sitter, give diversion o rules: in an emergency: nurse can place them, but order must be placed within 1 hour worn up to 4 hours for adults every 2 hours: remove restrains, 1 at a time, to assess for skin integrity to do neuro and skin checks, and to provide ROM least restrictive: mittens 2 fingers fit between restraint and skin Quick release not

Sensory Perception

Hearing: you can write down - Aphasia: slowly, clearly, and 1 person at a time - Conductive o Packed cerumen, tympanic membrane damage (ear infections), old age (otosclerosis) o Findings: Rinne: BC > AC Weber: lateralize to affected ear - Sensorineural o Inner ear or damage to CN8 o Causes: ototoxic medications, excess exposure to loud sounds, and old age o Findings Rinne: AC > BC Weber: unaffected ear - Ear care o Carmelitic solution to clean ears o Turn off hearing aid, keep it dry and clean with soap and water o Blow 1 nostril at a time

Oxygen Safety

Increases r/f combustion o No smoking sign at entry of home o Make sure electrical equipment is grounded and in good shape o Cotton bedding and clothes No synthetic or wool o Keep flammable objects away, including nail polish

Stages of infection

Incubation: when the pathogen enters the body to the first symptom o Prodromal: onset of general symptoms (malaise, fatigue, fever) to specific symptoms o Illness: when specific symptoms occur o Convalescence: symptoms disappear to complete recovery

injury prevention by age group

Infants and toddlers o Choking hazards: popcorn, raisons, grapes, hot dogs, celery, PB, peanuts, candy and tough meat o Place infants on their back to prevent SIDS o Nothing in the crib—not even blankets o Make sure crib slats are less than 2 and 3/8 inches apart o Keep plastic bags, houseplants, and cleaning agents out of reach o Lock up medications o Rear facing car seat until age 2 with 5 point harness in back seat of car o Close bathroom doors and close toilet lids - School age o Booster seat if less than 40 lbs or 4'9" o Backseat until 12 years old o Protective hear with sports o Water temperature heater to less than 120 degrees Fahrenheit to prevent burns o Enclose pools with locked fence - Adolescence o Educate on risky substances and risky sex o Educate on distracted driving and seatbelts o Monitor for mental health issues - Older adults: o Remove trip hazards from the home—such as scatter rugs and lose carpets o Place electrical cords behind furniture

Advanced directives

Living will: communicates wishes if becomes incapacitated - DPOA (durable power of attorney): individual that the Pt designates as their Proxy - Providers order for DNR or AND (allow natural death) - Mandatory reporting o If you suspect abuse: you must report that o Communicable reporting mandated by the state o Impaired coworker Do not gather more info or talk to her directly—tell the manager

Mixing insulins—clear before cloudy

Long acting is by itself o Regular (clear) NPH (cloudy) Do not administer a cloudy insulin 1. Inject air in longer acting NPH 2. Inject air in shorter acting (regular) 3. Draw up shorter acting insulin 4. Draw up longer acting insulin o Insulin suspensions Gently rotate vial in hands - Types of prescriptions o Routine/standard: timed drug, can be given within 30 minutes of order o Single/1 time o Stat: immediate o Now: 1x within 90 minutes o PRN: dose, frequency, and conditions it must be administered o Standing: specific circumstances on specific units

Nutrition

Macronutrients o Carbs: main source of energy (45-65%): Glycogen is stored carbs in liver and muscle, released between meals to maintain glucose levels o Protein: tissue building, immune function, muscle building Wound healing 10-35% o Fat: stored energy, padding and insulation, hormone production, and absorption of fatsoluble vitamins 20-35% - Vitamins o Water: C and B-complex o Fat soluble: DEKA - Newborns o Breastmilk of formula for 1st year o Solid foods at 4-6 months o No cow's milk or honey until 1 year old - Older adults o Fewer calories o Decreased thirst sensation o Need Ca and vit D supplements to decrease r/f osteoporosis - BMI o Calculated: weight kg/height in m2 o BMI Underweight: under 18.5 Healthy: 18.5-24.9 Over: 25-29.9 Obese: 30+ - Dysphagia o Sit in fowlers or high fowlers o 1 medication at a time o Lightly stroke throat to promotes swallowing o Thicken, thin liquids as prescribed o Swallow evaluation by speech pathologist—makes recommendation on thickness of liquids o Check for food pockets before eating o Tuck chin when swallowing—do not extend back o Monitor during meals—have suction available o Avoid straws - Diets o NPO: pre-procedure, blockage o Clear liquid: water, tea, coffee, broth, clear juices, ginger ale, gelatin o Full liquid: milk, pudding, soup, ice-cream, fruit juice, vegetable juice, sherbet, pudding, o Soft diet: no raw fruits or veggies, nothing that causes gas, no coarse grains or cereals o Normal diet o Pureed diet: oral/facial surgery, wired jaw Foods and liquids that are pureed to liquid form o Mechanical soft: chewing difficulties and no teeth Minimal chewing: ground meat, cooked veggies, ground food o Low residue: GI disorders like IBS Low in fiber and easy to digest Milk products and eggs

IV care

Maintain patency by flushing every 8-12 hours when Pt isn't recieving continuous IV infusion o Chance sites according to facility policy (about every 3 days) o Replace tubing according to policy (every 24 to 48 hours) o Wipe all ports with alcohol or anesthetic o Picc line or central line: special blue caps on port to keep clean - DC an IV o Elevate the arm and hold pressure at the site for 2-3 minutes o When removed: make sure the catheter tip is in tact

Grief, loss, and palliative care

Maturational: expected with normal life transition o Child going off to college - Situational: unexpected, external event o Car accident, tornado, fire - Anticipatory - Complicated grief o Prolonged, severe, and interferes with normal functioning after 6 months - Stages o Denial, anger, bargaining (if only), depression, acceptance - Palliative care: o Focus on symptom relief—used at the same time as treatment or end of life - Hospice: for Pt's with terminal illness not expected to live longer than 6 months o No treatment—just treating symptoms - Signs of impending death o Abnormal breathing (chain stokes), apnea, or death rattle o Decreased LOC, muscle tone, moddling of skin and extremities are cool o Pt will have decreased pulse and BP o Incontinence, decreased UOP, decreased secretion o Hearing acuity is not decreased - Postmortem care o Remove tubes and personal belongings o Lay body supine with head on pillow, dentures inserted o Equipment removed, lights dimmed o Family enters

Thorax, heart, and abdomen

Monthly breast exam after period is complete o Circular, wedge, or stripe pattern - Lung: should hear resonance o Dullness: tumor or pneumonia o Hyperresonance: pneumothorax or emphysema - Heart o S1: mitral and tricuspid close o S2: aortic and pulmonic closing o Thrills: associated with murmurs and other abnormalities Heard over AV fistula (expected) o Bruit: narrowed artery, obstructed blood flow o Point of maximal impulse (apical): left midclavicular line, 5th intercostal space - Abdomen o High pitched clicking and gurgling o Abnormal: loud growling o Must listen for 5 minutes before determined absent BS o Tympany in abdomen, dullness over liver Liver should be between 6 and 12 cm o Palpation: palpate tender area last - Changes in aging: o Breast: pendeloques, atrophy of glands, smaller or inverted nipples o Lungs: barrel chest, decreased alveoli, kyphosis o CV: increased systolic BP, thickening and hardening o Abdomen: increased adipose tissue, decreased secretion, and decreased bowel motility

NG intubation and enteral feedings

NG insertion o Place Pt in high fowlers—prior, agree on a signal for if the Pt is feeling distress o Lay towel across patient's chest o Use water-based lubricant on the tip of the NG tube o Have Pt sip water while you're inserting it & withdrawal slightly if they gag or choke and then keep going o Check placement by checking pH, confirm placement with x-ray - Enteral feeding o Verify placement before 1st feeding and presence of BS and gastric contents ph should be between 0 and 4 o Discard bags and tubing every 24 hours o Measure residual every 4-6 hours, return residual o Hold feeding if residual is above policy (500 mL) & will likely hold feeding o Flush feeding tubes with 300 mL of water every 4 hours o Feeding solution should be at room temp o During feeding: elevate head during and for 30-60 minutes after feeding o Cover and label any unused formula with Pt info, and can refrigerate up to 24 hours o Only fill feeding bags with up to 4 hours with of formula to prevent bacterial contamination o Slowly increase volume and rate to desired level, then gradually decreased when weaning off

Sleep and Rest

NREM sleep and REM sleep 1. Stage 1: light sleep, vitals and metabolism decrease, only a few minutes 2. Stage 2: deeper sleep, vitals and metabolism decrease, lasts about 10-20 minutes 3. Stage 3: deeper, difficult to awaken, lasts 15-30 minutes 4. Stage 4: deepest, physiologic rest and restoration ,vitals are low, sleep walking and talking take place 15-30 minutes 5. REM sleep: cognitive restoration, vivid dreaming, very difficult to awaken, vitals vary—20 minutes a. Gets longer each cycle Sleep hygiene - Exercise regularly, not within 2 hours of bedtime - Avoid caffeine, nicotine, and alcohol within 4 hours - Fluids limited - Engage in muscle relaxation - Have light carb snack before bedtime - No TV or screen time Sleep apnea - Greater than 5 incidences of breathing cessation each hour—10 seconds or more - Need CPAP mask

electrolytes imbalances

Na: 136-145 o Function: helps maintain fluid balance, nerve and muscle function o Hyponatremia: Causes: GI loss, diuretics, skin loss like sweat, SIADH, edema, hyperglycemia Symptoms: tachycardia, hypotension, confusion, fatigue, N/V, and HA o Hypernatremia: Causes: water deprivation, excess sodium, kidney failure, and Cushing's Symptoms: tachycardia, muscle twitching and weakness, GI upset, and edema - K: 3.5-5 o Function: maintains intercellular fluid balance, nerve function, muscle and heart contraction o Hypokalemia Cause: GI loss, diuretics, skin loss, and metabolic alkalosis Symptoms: dysrhythmias, muscle weakness and cramps, constipation (ileus), and hypotension o Hyperkalemia Cause: uncontrolled diabetes or diabetic ketoacidosis, metabolic acidosis, salt substitutes, kidney failure Symptoms: dysrhythmias, muscle weakness, numbness and tingling, diarrhea, and confusion Ca 9 and 10.5 o Function: bone and teeth formation, nerve and muscle function, and clotting o Hypo Cause: diarrhea, Vit D deficiency, hypoparathyroidism Symptoms: positive Chvostek's or Trousseau sign, muscle spasms, numbness and tingling in lips and fingers, and GI upset o Hyper Cause: hyperparathyroidism, long term steroid use, bone cancer Symptoms: constipation, decreased DTR, kidney stones, and lethargy - Mg 1.3-2.1 o Function: nerve and muscle function, bone formation, and critical for many biochemical reactions Hypo GI loss, diuretics, malnourishment, and alcohol abuse Symptoms: dysrhythmias, tachycardia, HTN, tremors, seizures, and increased DTR Hyper Causes: kidney disease and laxatives that contain Mg Symptoms: hypotension, muscle weakness, lethargy, and respiratory and cardiac arrest

Safe med admin and error reduction

Name, date/time, name of med, strength/dose, route, time/frequency, quantity, # refils, provider signature - 10 rights o Patient o Med o Dose o Time o Route o Documentation o Pt education o Right to refuse o Right assessment before and after o Right evaluation - Error prone abbreviations—NEVER USE o MS, MSO4 for morphine o MgSO4 for Mg sulfate o No decimals without leading zero o No trailing zero o No U or IU o QD orq, qod o SQ, SC, or SBQ - Identify allergies prior to admin - Always question unclear or inappropriate doses: multiple vials, multiple pills - Prepare meds for 1 pt at a time - Only administer meds that you prepare - Always double check high alert meds with another rn: like heparin and insulin - Complete incident report for med error—not in the chart!!!

Information Technology

Nursing documentation o Both objective and subjective data Objective: see, hear, feel, or smell—no interpretation Subjective: direct quotes or identify as information provided by the patient o Never leave blank spaces, never corrections, never scratch or black out, always include name and title o Incident reports: accident of some kind or an unusual event (medication error or fall) Do not: refer to incident report in Pt charting, NOT IN THE MEDICAL RECORD - Telephone order o Have 2nd RN on call o Read back prescription order o Have provider sign this within 24 hours - HIPPA/information security o In place to ensure confidentiality of health information o Only persons responsible for Pt care are allowed to read record o Communication about Pt must be in private or at the nurses station o Password protect electronic records, don't share records o Don't share information with unauthorized people Such as the people in the room o Code system can be used: like a number—family can get info if they tell you the code

Data Collection and Physical Examination

Older adults o Assessments should be gathered in multiple shorter sessions rather than 1 longer session o Allow more time for response o Allow time for position replacements o Make sure aids are in place o Reduce environmental noise o All PT to use restroom before examination - Physical assessment o Inspection o Palpation: assess most tender areas last. Dorsal surface of hand for temperature, palmar surface of hand for vibration o Percussion o Auscultation - Abdomen o Inspect o Auscultate o Percuss o Palpate - General survey o Physical appearance: age, race, gender, LOC, s/s of substance abuse or distress o Body structure: height, weight, NTR status, posture, obvious abnormalities o Mobility: gait, ROM and movement o Behavior: mood, speech, grooming o Vitals

Cultural and spiritual nursing care

Orthodox Judaism: kosher kitchens, do not eat meat with dairy, no pork or shellfish - Islam: no alcohol or pork, fast during ramada, same sex provider, pray 5x day - Jehovah's witness: no blood product—right to autonomy - Mormans: caffeine, alcohol - Catholics: fast during lent - Ethnocentrism: belief that one's own culture is superior - Interpreter o Do not: use Pt's friend or family member o Do: use certified medical interpreter—either in person or over phone o Direct questions at patient or family o Ask 1 question at a time o Use laymen's terms o Do not supplement gestures with words

Iv complication

Phlebitis: erythema, pain, warmth, edema, indurated cor cord like veins (hard), or red streak o DC IV, elevate extremity, apply warm compress, obtain culture - Infiltration: swelling, edema, coolness, dampness, and slowed rate of infusion o DC med, elevate arm, and use warm or cold compress - Catheter embolus: missing cath tip, severe pain with migration o Place tourniquet, prepare for removal of tip using x-ray or surgery - Fluid overload o Increased BP, jugular distention, tachy, SOB, crackles, edema HF at high risk o Stop infusion, raise head of bed, monitor O2 status, decrease infusion rate, admin diuretics - Cellulitis: pain, warmth, edema, induration (harness), red streak, fever, chills, and malaise o Stop infusion, remove IV, elevate extremity, obtain warm compress, obtain specimen o Admin antibiotics, analgesics, and antipyretics

Nasopharyngeal and nasotracheal suctioning

Place Pt in fowlers or high fowlers o Lube distal 6-8 cm with water-soluble lubricant o Insert during inhalation and insert the distance from the tip of the nose to the base of the earlobe o Apply suctioning intermittently while withdrawing the catheter, rotating it at the same time for 10-15 seconds o Can do up to 2 passes, waiting 1 minute between each pass

Endotracheal suctioning

Place Pt in fowlers or high fowlers position o Catheter diameter: less than or equal to half the diameter of the endotracheal tube o Hyper oxygenate Pt with 100% O2 prior to, and in-between suctioning o Use suction pressure between 120 and 150 mmHg o Advance catheter until resistance is met, then pull back 1 cm above the carina prior to suctioning o Apply intermittent suctioning while withdrawing the catheter and rotate it for a max of 10-15 seconds o Never re-use catheter

Discharge

Pt receives pamphlet with instructions Diet/activity restrictions Instructions for home procedures: wound care Instructions and supply Meds: what to take, when to take, and precautions s/s of complications and when to seek medical attention ex. If they spike a fever or have increased erythema follow up appointment provide names and numbers of providers and community resources

- Fire safety

RACE Rescue: move pt's to a safe location: first horizontal evacuation and then a lateral or vertical evacuation Alarm Contain: close doors and windows, turn off oxygen Extinguish using PASS Pull the pin Aim at the fire Squeeze the handle Sweep side to side

JCHO

Regulations for health care facilities

MS and MS

Spine o concave cervical o convex thorax kyphosis o concave lumbar lordosis: pregnancy and toddlers o convex sacral - LOC o Alert: responsive, open eyes spontaneously, answer Q's o Lethargic: fall asleep easily but can answer questions o Obtunded: responds to light shaking but slow to response o Stupor: barely responds to painful stimuli o Comatose: Abnormal posturing Decorticate arms internally rotated, legs extended and internally rotated Decerebrate: head arched back, arms and legs extended o Worse, more brain damage - Glasgow coma scale: between 3 and 15 o Less than 8: severe head injury/coma o 9-12: moderate head injury o Eye opening—4 Spontaneous: 4 Voice: 3 Pain: 2 Don't open: 1 o Verbal response—5 Coherent and oriented: 5 Incoherent and disoriented: 4 Inappropriate words: 3 Making sounds but unable to talk: 2 No vocalization: 1 o Motor response—6 Follow commands: 6 Local reaction to pain: 5 Withdrawal to pain: 4 Decorticut: 4 Deseribrit: 2 No movement: 1 - Neurosensory assessment o Romberg test: stand still for 5 seconds o Heel to toe walk o Stereognosis: put familiar object in Pt's hand and have them ID it o Graphesthesia: trace number in Pts hand o Deep tendon reflex: 4+ brisk 3+ above average 2+ normal response 1+ diminished 0 no response - Changes with age o Decreased muscle mass and bone mass—r/f osteoporosis o Joint degeneration—osteoarthritis o Decreased ROM o Decreased reaction time, decreased senses, ability to feel pain is diminished

body mechanics

Spread feet, lower center of gravity - Distribute weight between major muscle groups of arms and legs - When lifting: old as close to the body as possible - Avoid twisting and bending at the waste - Get help when repositioning a patient - Moving patients o Gurney to bed: Bed slightly lower than gurney Lower head of bed Touch head to chin, cross arms, slide them across o Food drop: toes point downward Place board to keep feet in flexed position Against soles of feet - Bed position o Semi-fowlers: 15 to 45 degrees Prevents aspiriation, promotes ventilation o Fowlers: 45 to 60 Good for suctioning and improved ventilation o High fowlers: 60 to 90 For severe dyspnea and during meals o Supine o Prone Helpful for lower extremity amputation—helps prevent hip flexion contractures Pt should be prone several times a day for 30 minutes o Orthopneic Breathing position o Sims Left side, left hip and lower extremity straight, right hip and lower knee bent Used for enemas and rectal exams o Trendelenburg: head lower than feet Promotes venous return o Reverse Trendelenburg Promotes gastric emptying (GERD), prevents reflux o Modified Trendelenburg Flat, legs elevated above heart For hypovolemia, and hypovolemic shock

Pressure ulcers, wounds

Stages of wound healing o Inflammatory: 3-6 days; vasoconstriction, clot formation, hemostasis, and phagocytosis o Proliferative: 3-24 days; replacement of loss tissue with granulation and collagen, wound contraction (smaller), wound resurfacing (new epithelial cells form across surface) o Maturation: 1+ years, remodeling and strengthening of collagen tissue - Wound healing o Primary intention: wound edges are approximated and are sutured and stapled Repair is faster and with minimal scarring o Secondary: wound edges apart and with increased r/f infection scarring, longer healing time o tertiary: wound left open to address infection concerns, close at later time - factors that affect wound healing o age o decreased immune function o impaired nutrition: need protein! o Decreased perfusion o Smoking - Appearance: o Red is healthy o Yellow: indicates slough or pus—wound needs to be cleaned o Black: indicates presence of eschar, wound needs to be debrided - Drainage o Serous: pale or clear/yellow and watery o Sanguineous: bloody. Contains serum and rbc o Serosanguinous: blood tinged and watery o Purulent: yellow, fowl odor, infection is present - Removing sutures o Grasp knot with forceps o Cut suture close to skin, pull suture in 1 piece - Cleaning a wound o Clean from least to most contaminated - Irrigate: 30-60 mL syringe o 5-8 psi of pressure - Dehiscence - Evisceration o Place saline-soaked sterile dressing over wound and organ—never re-insert o Place PT in supine position with hips and knees bent o Keep Pt NPO in prep for surgery - Stages of pressure injuries o 1: skin is intact, red, and no blanchable o 2: damage to epidermis or dermis Very shallow ulcer that is red, pink, and moist. No slough visible o 3: enters SQ tissue. No muscle, bone or tendon o 4: muscle, bone or tendon o Unstageable: base is covered in eschar and slough so you cannot visualize how deep the wound is - How to prevent pressure injuries o Turn every 2 hours o Limit chair or wheelchair sitting to 1 hour—shift weight every 15 minutes or use pressure reducing device o Ensure Pt is getting proper nutrition and hydration—especially protein o Elevate head of bed at 30 degrees or less o Raise heels off bed with boots o Lift—not pull patients up in bed o Do not massage bony prominences—do not used powder or corn starch—this causes

Precautions

Standard: used for all Pt's regardless of infection o Hand hygiene—alcohol based antiseptic unless hands are visibly soiled o Used face masks when splashing of bodily fluids may take place o Wear clean gloves o Moisture resistant bag for soiled items o Use sharps container - Airborne—MTV o Measles, varicella, and TB o Private room on negative airflow o All caregivers and visitors will need to wear N95 - Droplet o Influenza, pneumonia, pertussis, mumps, sepsis, rubella, and bacterial meningitis o Private room or roomed with someone with exact infection o Everyone wears masks - Contact o Impetigo, scabies, rabies, MRSA, C. dif, other enteric infections, RSV, and wound infections o Private or same infection room o Gown and gloves - Herpes zoster aka shingles o Reactivation of varicella zoster virus (chickenpox) o Risk factors: compromised immune system o Symptoms: painful unilateral rash that runs along the dermatome o Rash is vesicular, pustular, or crusting o Low grade fever o Paresthesia: sharp, tingling, pins and needles o Nursing care: isolate pt until vesicles have crusted over, they should avoid contact with people who are risk for chickenpox, admin acyclovir and analgesics o Complications: post herpetic neuralgia (pain that persists 1 month after pain is gone) o Prevention: shingles vaccine (recommended for Pts over 60)

Urinary Elimination

Stress incontinence: small amount of urine leak d/t abdominal pressure - Urge: inability to reach the bathroom in time d/t an overactive detrusor muscle - Pt teaching: encourage toileting schedule - Kegel exercises, reduce caffeine and alcohol, vaginal cone therapy for stress incontinence, and weight reduction for stress - 24 hour collection: discard 1st o Make sure there's no stool o Put it in ice - Foley care: o Soap and water 3X day or after BM - UTI's o Female gender, Foley's, uncircumcised males, menopause, and frequent sexual intercourse

Vitals

Temp o Oral: 36-38, avg 37 Eating, drinking, smoking all affect temp (wait 30 minutes) o Rectal: 36.5-38.5 o Axillary: 35.5-37.5 o Temporal: 36.5-38.5 o Things that impact temp Newborn: 36.5-37.5 Older adults: 36 o Increased temp Menstruation, menopause Exercise, dehydration - How to take temps o Rectal: sims, use lubricate, insert 1-1.5 inches Don't take for less than 3 months old or r/f bleeding o Tympanic: pull up and back, back and down for children under 3 o Temporal: slide across forehead to hairline, then soft depression behind ear - Hyperthermia over 39 o Need blood cultures and other specimens o Administer antibiotics and antipyretics o Administer fluids o Prevent shivering: blankets - Hypothermia under 35 o Warm blankets o Warm IV fluids o Keep Pt's head covered - Pulses o Rate: 60-100; infants between 120-160 o Rhythm o Equality o Strength: 0-4+ o Radial: thumb side of the wrist o Apical: 5th IC space, midclavicular line If Pt is on cardiac medications, take pulse for full minute rather than 30 seconds o Pulse deficit: difference between apical and radial Normal finding: 0 - Tachycardia o Fever, exercise, medications, pain, hyperthyroidism, hypovolemia, and stress - Bradycardia o Medication, an athlete, hypothyroidism, hyperthermia - Respirations o Infants: 35 to 40 o School age: 20 to 30 o Assess rate and depth (shallow or deep) o Rhythm o Chemoreceptors detect when CO2 levels rise in the blood, increasing RR o Taking RR: semi-fowlers, hand on abdomen Count for 30 sec Irregular: 1 minute o Ventilation: exchange of O2 and CO2 between environment and lungs o Diffusion: exchange of O2 and CO2 between alveoli and rbc o Perfusion: rbc and body tissues o Increased RR: Anxiety, smoking, illness, anemia, high altitude o Decreased RR: Opioids, sedatives, old age o O2 sat: 95-100 COPD: low 90's - BP o Hypotension: systolic less than 90 o Normal: 120/80 o Pre: 120-129/80-89 o 1: 140-159/90-99 o 2: 160+/100+ o Diagnosis of HTN BP must be + 3x over a number of weeks o Orthostatic hypotension: Take BP when supine Wait 2-3 minutes, take it again Stand up, wait a few minutes, take it again If systolic changes 20, or diastolic 10 with a 10-20% increase in HR, this indicates orthostatic hypotension o Things to know about BP Pulse pressure: systolic - diastolic If elevated increase r/f CHD Proper sizing Width: 40% arm circumference Bladder: 80% Too large: falsely low Too small: falsely high Never take BP in arm where Infusion is running, mastectomy, AV shunt or fistula, Auscultating BP Palpate radial pulse Pump up until pulse is absent Pump 30 mmHg Note when pulse is palpable again

Garlic, ginger, and ginseng

Thin the blood

IV therapy

Trauma: 16g d/t mass quantity of fluids - Surgery/blood donation: 18-20g - Other Pt's: 22-24 o Typical Pt gets a 20g - Best practice o Place arm in dependent position o Apply tourniquet 4-6 inches above insertion site Don't use for older adults—use a BP cuff instead o Choose distal veins on the non-dominant hands instead o Avoid varicose veins, veins near valves, veins in flexion areas like the AC fossa o Do not ever place IV on same side as mastectomy or AV fistula Need sign above head if this is the case o Use sterile needle per attempt o Never insert sillette into catheter o Insert at 10-30 angle with bevel up

preventing respiratory complications

Turn, cough and breathe every 1-2 hours while awake - Incentive spirometer - Increase fluids to 2L/d - Reposition every 1-2 hours to mobilize secretion - Pulmonary embolism o Dyspnea, chest pain, increased HR, decreased BP, bloody sputum o Notify provider o Place in high fowlers, administer O2, monitor vitals o Get ABG's o Give thrombolytics and anticoagulants

CI for PO

Unconscious, lack of gag reflex, dysphagia, and vomiting o Place in high fowler's position o Never crush enteric coating and extended release - Liquid: o Base of the meniscus should be at the ordered dose level - Sublingual o Under tongue - Buccal: check and gum o Do not eat or drink until fully dissolved - Transdermal o Watch skin with soap and water and dry thoroughly o Place on a hairless area of skin o Rotate sites o Use gloves when applying the patch - Optic o Rest dominant hand on Pt's forehead o Drop drops into conjunctival sac w/o touching eye with dropper o Apply gentle pressure to the nasolacrimal duct for about 1 minute o Wait 5 minutes between different eye drops - Otis o Lay on unaffected side o Pull auricle up and back (down and back for children under 3) o Hold dropper 1 cm above ear canal o Apply gentle pressure to tragus o Lay on side for 2-3 minutes - Inhalers o Metered dose: shake first o Dry powder: do not shake o Put mouth around inhaler, inhale slowly, hold for 10 seconds, take out of mouth, exhale slowly o Steroid: rinse mouth afterwards to avoid getting a fungal infection - NG/G tube o Verify tube placement: get x-ray o Dissolve tablets in 15-30 mL o Flush before and after admins with 15-30 mL - IM o Use a 1-1.5 inch needle that is 18 to 27 gauge VL: infnats less than 1 year VG: volumes over 2 Deltoid: volumes up to 1 o Inject at 90 degree angle and make sure to Z-track - Intradermal o Tb syringe that is 26-27 gauge o 0.01-.1 mL o Insert bevel up at 10 degree angle o Observe for small bubble - SQ o 3/8-5/8 imch, 27 gauge o Use insulin syringe: 28-31 gauge o Inject volumes up to 1.5 areas in fatty areas o 45-90 degree angle

DVT's

Unilateral edema, pain, swelling, warmth, and erythema o Sometimes groin pain or calf pain o Notify provider o Elevate leg—provide anticoagulants o Prevention: increase activity o Ant embolic activities q2 hours o Avoid putting pillows under knees, wearing restrictive clothing o SCD's o Ant embolic stockings: remove q8 hours to assess skin

Torts

Unintentional tort o Negligence: Pt is at high risk for falls and you didn't set their bed alarm, and they fell o Malpractice: medication error - Intentional tort o Assault: threatening o Battery: following through with a threat o False imprisonment: inappropriately restrain or administering a sedative

Transfer

Use SBAR

Chest physiotherapy

Use of percussion, vibration, and postural drainage to release secretions o Schedule treatment 1 hour before or 2 hours after meals to avoid vomiting o Admin bronchodilator/nebulizer 30 minutes prior to open airways o Collecting sputum sample: early in morning and through coughing rather than suctioning

Labs for infection

Wbc count: between 5,000 and 10,000 o Left shift: when immature wbc are released bc the body is overwhelmed by infection o ESR (erythrocyte sedimentation rate): indicated inflammation in the body o CRP: c-reactive protein indicated inflammation o + culture result o Blood culture, sputum culture Get the culture before starting antibiotics - Diagnostic procedures o Gallium scan: identifies hot spot of wbc in the body o X-ray, CT, and MRI o Biopsy

Therapeutic Communication

Wrong o Never "why" o Never offer your opinion o Never give false reassurance o Never ask closed ended questions. Rather, get the patient talking more o Never change the subject o Never minimize the Pts feelings - Right o Open-ended questions that start with "tell me more" o Offering of self: personal information. However, turn discussion back towards Pt as quickly as possible

Virulence

ability of a pathogen to produce a disease

Best practices for taking blood glucose

clean finger with warm water and soap—no alcohol - use warm, moist towel to increase circulation - place hand in dependent position - pierce outer-edge of finger & hold lancet perpendicular to skin - wipe 1st drop of blood - hold test strip next to drop of blood—do not smear - when taking glucose o over 200: hyperglycemia o under 70: hypoglycemia o high stress: test for ketones in urine if glucose above 240+

symptoms of hypoxemia

early: restlessness and irritability, tachypnea, tachycardia, increase BP, pallor, and abnormal breathing (accessory muscles, nasal flaring, adventitious lung sounds) o late: decreased LOC, bradycardia, dysrhythmias, bradypnea, decreased BP, and cyanosis - O2: between 95 and 100 o COPD: 89-90 o When giving: use lowest amount - O2 delivery vehicles o Nasal canula: between 1-6; 4+ use humidification o Simple face mask: 5-8 o Partial rebreather: 6-10—ensure reservoir bag is 1/3-1/2 full on inspiration o Nonrebreather: 10-15—keep reservoir bag 2/3 full—assess hourly o Venturi: 4-12—offer most precise O2 delivery o Aerosol/face tent: facial trauma or burns, provides high humidification - Symptoms of O2 toxicity: o Non-productive cough o Substernal pain o Nasal congestion, N/V, fatigue, HA, and sore throat - Avoid combustion o No-smoking signs o Avoid synthetic or wool fabrics—wear cotton instead o Wear flammable products away from )2 equipment o Make sure electrical devices are in good, working order and grounded—no extension cords. o Keep 8 ft or more away from heat sources

Local Infection

edema, pain, erythema, warmth in one part of the body

Ssytemic Infection

fever, chills, malaise, fatigue, increased RR, increased pulse, enlarged lymph nodes

medical and surgical asepsis

hand hygiene: o alcohol based: used between 3 and 5 mL of the product rub hands until dry o antimicrobial soap and water: visibly soiled, before eating, after using the restroom, and contact with bodily fluids scrub for 15 seconds dry hands before turning off the faucet - preventing spread of microorganisms o stand at least 3 feet away from those coughing or have them wear a mask o never use artificial nails or gel polish o remove jewelry from hands or wrist before washing o clear least soiled area first - setting up a sterile field o top, right, left, close flap o sterile solution: remove bottle cap and place it facing up on a sterile surface place label against palm waste 1-2 mL don't touch bottle to site you're pouring it on o don't talk over a sterile field o above the chest is not sterile o drop 6 inches above field

State board of nursing

laws and regulations that govern nursing in their state o Ensure the state hospitals are complying with regulations o Issue and revoke nursing license Nurses must have license in every state they practice in

Inflammation

local response to injury or infection o 1 st stage: erythema, warmth, edema and pain o 2 nd stage: wbc come to kill the organism and exudate and dead tissue cells form Types of exudate Serous: clear Sanguineous: bloody Serosanguineous: pink or red streaked Purulent: indicates an infection, contains leukocytes and bacteria o 3 rd stage: scar tissue forms

Informed consent

necessary for all procedures o Provider: communicating purpose, giving Pt a complete description of procedure in the Pt's primary language, explains R v. B and alternatives to the procedure o RN: make sure the provider did everything they were supposed to, make sure the pt was competent to make the decision (not mentally impaired), have Pt sign consent document, and notify provider if Pt has any more questions o Who can give informed consent? DPOA: durable power of attorney (Pt gave this person the right to make decisions) Emancipated minors

Immunities

nonspecific innate o out body's barriers that respond to all antigens o skin, mucous membranes, stomach acid - Specific adaptive o Body produces B and T lymphocytes for specific immunity o More efficient and effective once immunity is developed - Active natural o Body produces antibodies from exposure to live antigen o Example, getting the cold - Active artificial o Antibodies produced in response to vaccine - Passive natural o Mom to baby through breastmilk or placenta - Passive artificial o Immunoglobins administered after being exposure to a pathogen

Trach care

o Give oral care every 2 hours and trach care every 8 hours o Suction as needed—not routinely o Apply oxygen loosely if Pt's O2 decreases during the procedure o Use surgical asepsis to remove and clean the inner canula o Use slit gauze dressing under the tracheostomy plate—never cut the gauze o Replace ties as needed, secure new ties before removing old ones o Home care: clean with NS using medical asepsis and cover the tracheostomy when they go outside