Nursing 301- Exam 4

Things to ask/observe during assessment of pt with cognitive issues

-significant other/partner? -religious preferences -nutrition -motor ability (tremors, nail biting, arthritis, shuffling, etc.) -Speech patterns (able to communicate and at what level) -Educate with words that fit the pt's level

Affect

-the behavioral expression of emotion -how you express your moods -congruent with situation (crying at death) -good insight vs. poor insight

Supplies needed for NG tube

-tubing -lube -tape/securement device -safety pin -suction (20-40) -anti-reflux valve -syringe

what is the second leading cause of death in people ages 15-24?

suicide

screenings for suicidal patient

-PHQ-2 and PHQ-9 (situational) -C-SSRS -question based

characteristics of altered cognition

-confused -disoriented -altered speech

NG tube admin pill medications

-flush with 30mL of sterile water -no swabbing needed -crush pills and add 5-10mL of sterile water (mixing) -draw up into syringe and administer into tube (no time limit) **if giving more meds, flush with 5mL of sterile water, **if done giving meds, flush with 30mL of sterile water -Keep tubing clamped for 30mins before reattaching suction

NG tube admin liquid medications

-flush with 30mL sterile water -draw up amount into syringe and administer into tubing **if giving more meds, flush with 5mL of sterile water, **if done giving meds, flush with 30mL of sterile water -Keep tubing clamped for 30 mins before reattaching suction

NG tube drainage

-mark drainage every 4 hours in the suction cup -add a solidifying factor into drainage to make foamy and stiff -discard into garbage or biohazard bag if bloody

Seizure precautions

-padded bedrails -take away stimulus in environment (tables, toys, etc.) -make sure easy IV access -don't restrain the patient -administer Lorazepam during the active seizure -have suction and O2 ready at the bedside

Altered affect

-poor insight (laughing at death) -inappropriate (not congruent) -constricted/blunted (diminish range in intensity) -flat (absence of emotion)

Administration steps of NG tubes

-prepare suction -measure tubing -lube tubing -put tube as far as possible into the nasopharynx -Then have pt sip water and continue inserting tube when they swallow -mark tubing and get abdominal x-ray -secure tube with tape and SAFETY PIN to gown -attach tubing to suction

Use of suction with NG tubes

-prepare suction before tube -start at regular setting, keep between 20-40, then switch to intermittent -if suction is higher than 40, it could cause internal hickey

risk factors of postpartum depression

-previous episodes -social factors (lack of coping skills, lack of support, financial burdens)

Extraction Collar

-put on immediately upon pt arrival in ER or ambulance -leave on pt until provider orders -cut off within 6 hours of getting to the hospital

interventions to help with delirium

-repeat -personal belongings in room -CARE BOARDS and CLOCKS (very helpful for pt) -re-orient pt frequently -hearing aids/glasses -Try to not restrain pt or allow them to rest all day

How long can cervical tongs be in place?

-short term relief (if no neuro surgeon is present and there is swelling in cervical vertebrae) -can be used for 2 days max

what are some ways to help increase cognition?

-stimulate mind of pt (puzzles, sudoku, etc.) -consistency (routines and schedules) -fluid and electrolyte balance -encourage "normal" actions (walking, bathing, etc.)

Common skin breakdown areas

-under the chin -upper shoulders -neck -padded areas

Important lab data for patient with cognitive issues

-underlying problems (eg. UTI is physical that can lead to psychological) -metabolic problems (electrolyte imbalance) -side effects of meds -Cortisol: primary stress hormone (affects sleep, appetite, and concentration)

Removal of NG tubes

-unpin from gown -flush tube with 30mL of air -remove tube while pt hold breath -give pt tissues in case nose runs -discard tubing in garbage

Stryker drain (blood conservation system)

-used most commonly for pts with leg or hip surgery -during first 6 hours, collect blood and readmin to pt (through IV) -anything after 6 hours should be put in biohazard bag -humming noise when working and red button suction down -pt can have for up to 48 hours (if continuous drainage)

Word salad

A group of words that are put together in a random fashion without any logical connection

Flight of ideas

A symptom common in bipolar manic episodes in which the individual's thoughts are racing and they rapidly switch topics when communicating

What are expected side effects after administration of a nebulizer treatment?

Circumoral cyanosis and tachycardia

A nurse is teaching the family of a client who has a new diagnosis of epilepsy about actions to take if the client experiences a seizure. Which of the following instructions should the nurse include in the teaching?

"Do not allow the client to swim while unattended."

Ventilator standards of care (vent bundle)

-HOB elevated 30 degrees -Inline suction -Pre-oxygenate at 100% O2 for 3 minutes when suctioning -Check securement device, mouth/lip assessments, and reposition the ETT from side to side -Monitor sedation: versed, ativan, propofol

What is the med given during a seizure?

-Lorazepam (Ativan) given during active seizure -Antidote: Flumazenil (Romazicon)

NG tubing ports

-NEVER put liquid into the air vent port (blue tubing) -anti-reflux valve is inserted blue to blue -ALWAYS clamp tubing if ambulating and for 30 mins after med admin -Use syringe to block end of tube when preparing other meds to prevent leakage onto bed/pt

What should be used to complete cervical tong pin care?

-Normal saline -Half % hydrogen peroxide

interventions for a violently escalating pt

-PRN oral medications -De-escalation techniques (including debriefing w/ pt after event occurs) -show of support -physical hold -injection of psychotropic drugs -mechanical restraints -Behavioral Case Manager Consult

antidepressant pharmacology

-SSRIs -SSNIs -Heterocyclic -MAOIs -doesn't work instantly-> take around 4-6 for full effect

signs and symptoms of delirium

-acute onset -fluctuating day to day (ex: sun-downing) -inattention/disorganized thinking -altered level of consciousness -CAM assessment (completed every 8-12 hrs depending on pt status)

characteristics of altered mood

-anxiety -stress -improper coping strategies -lying (non-verbals, fidgeting, etc.)

interventions for pt with cognitive issues

-assessment -referral/consult -meds needed? -fix pt problems (use stress techniques, etc.) -therapy (relaxation, etc.) -cognitive behavioral therapy (CBT)

characteristics of healthy cognition

-awareness -logic -reasoning power -effective thought pattern/process

dressing for JP drains

-change dressing daily (or more if needed) -use drain sponge or tegaderm -use 1 piece of tape and cover the slit area

NG tube securement

-change the strip securement every 72 hours -before finalizing securement, get abdominal x-ray for pt to make sure not going into lungs -after x-ray is approved, use sharpie to measure placement in pt (DRAW ON TUBE, NOT THE TAPE)

mentally healthy person

-copes with stress -realizes abilities -ask for help -process emotions -able to share emotions with others

Miami Collar

-covers soft spot on head -no skin breakdown is the goal -no plastic should be touching the skin (may need to shift the bottom layer of foam when putting on)

Signs/symptoms of mild postpartum depression

-depressed mood -varies from day to day -anxiety -impaired cognition -begins 48 hours after delivery -peaks 3-5 days and lasts about 2 weeks -fairly normal for most women to experience the "blues"

symptoms of delirium

-disoriented -rapid onset (lasts for a brief duration; 1 week-1 month) -restlessness/agitation -low attention/concentration -disrupted sleep cycles -altered speech -decreased memory -distracted/disruption in awareness

Cervical Tongs

-drill pins into skull to prevent vertebrae from spreading apart and stabilize the spine -Use Lidocaine to numb the area before pins (may need to sedate if pt is cooperating) -Make sure to be checking ROM on pt -NEVER raise the head of the bed -NEVER move the weights or let touch the floor (will snap vertebrae)

reasons for delirium

-electrolyte imbalance / malnutrition -medication side effects or interactions (Ativan is likely to cause delirium if given too much) -head trauma -decreased O2 (hypoxia) -infection -sleep deprivation -seizures/strokes -COPD

characteristics of healthy mood

-emotions -inner feelings -emotional tones -behavioral personality -perception

How often should you empty a JP drain?

-empty every 8 hours

examples of anxiety responses

-fear -worry -SOB -restlessness -increased HR -tense -feeling like you're not in control

what are some interventions if someone is in metabolic acidosis?

-fix infection (ex: antibiotic) -give bicarb (baking soda in water or tablets) -drive CO2 to alkalosis to compensate -if pt has brain injury, allow pH to fluctuate (good for the brain)

what are some interventions if someone is in respiratory acidosis?

-give Narcan -put on O2 -if ventilated, increase rate of ventilation (volume and frequency) -intubate if needed

what are some interventions if someone is in respiratory alkalosis?

-give acidic increasers -encourage deep breathing -give analgesics/opioids (help with both pain and activate breathing center)

impact of delirium on pt

-increased risk of falls (costs to facility and longer pt stay) -increased risk of death -decrease in function/cognition -post op delirium associated with negative pt outcomes (increased cost, length in hospital, function, mortality rate, etc.)

How do you know if JP drain is working effectively?

-it will be compressed or dimpled -drainage is observed -if blood clots or chunks in tube, strip or milk the tubing to move it along into the base

examples of stress triggers

-job change or loss -marriage -birth of a child -death of close friend or family member -graduation from school -starting college

situational depression

-less than 6 months in duration -triggered by stressful life events -screenings (PHQ-2, PHQ-9)

How long can a patient have a Halo device?

-long term use -up to 6 months

What could cause a pt to be disoriented?

-look at med list and affects -look at lab values -ask questions/observe -vital signs -reason for admission -baseline values and what is "normal" behavior for them

Synchronized Intermittent Mandatory Ventilation (SIMV)

-machine breaths are given at a present rate and present volume -allows pt to breathe at own rate and tidal volume (pt volume can vary at each breath)

What is important regarding Invasive Mechanical Intubation?

-make sure not in esophagus, balloon should be in trachea -get x-ray to see if in the lungs -document what number the tube is at when inserted (teeth or lips)

outcomes and interventions for situational or MDD

-medications -norepinephrine -serotonin -dopamine -therapy -group -CBT -family -individual -meditation -journaling -light therapy -ask about plan (if suicidal) -inpatient or outpatient

Positive End Expiratory Pressure (PEEP)

-minimum present pressure maintained in lungs at expiration -does not allow total exhalation -may decrease cardiac output and BP

signs/symptoms of moderate postpartum depression

-more bad days than good -worse feeling at night -fatigue -irritability -loss of appetite -decreased libido -sleep disturbances -lasts weeks to months -can impact ability to care for child

Alterations of mood

-not enough sleep -anxiety -appetite change -chronic illness -loneliness -functional impairment (social and motor) -pain -psychosis -death/suicide thoughts (*PRIORITY: pt feels hopeless or helpless) -social isolation -substance misuse -weight change

Pressure Support Ventilation (PSV)

-often used with SIMV -patient triggered breaths are given mechanical support at present pressure -spontaneous breathing -used for weaning from the ventilator

characteristics of people experiencing suicidal ideations

-older than 50 yrs -males -access to firearms -50-80% people who commit suicide have had a previous attempt

Risk factors of impaired cognition

-older than 60 yrs -altered sleep/cognitive function -dehydration and electrolyte imbalances -hx of stroke -dementia -impaired metabolic factors (increased BUN/creatinine, decreased Hgb) -impaired mobility -infection -malnutrition -pain -pharmaceutical agents (meds and how it impacts the pt) -sensory issues -substance abuse -urinary retention

What are the interventions used to prevent ventilator associated pneumonia (VAP)?

-oral care (brushing teeth and subglottic suction) -HOB 30 degrees -Sedation vacation (minimal/no sedation 2 times a day) -hand hygiene -NG tube on low intermittent suction (no reflux)

common Post-Ictal signs/symptoms

-sleepiness -obstructed airway (may begin to appear/sound like they are snoring) -confusion -restlessness -headache -soreness

How to measure NG tube

-start at tip of nose -go to back of ear -then down to the xiphoid process

Halo Device

-used to allow bone regrowth -4 screws in the head -clean with NS or 1/2 % HP -aligns cervical spine -Make sure to keep wrench on HOB for easy access if needed to alter the device -NEVER take off without order -NEVER grab the rails to move a pt

Aspen Collar

-usually first choice after the initial extraction collar -most common -clean skin every 6 hours to prevent skin breakdown

JP drain

-very common -purpose is to drain extra fluid to avoid collection in abdomen that could lead to infection ***ALWAYS safety pin to pt gown when finished changing dressing or drain

4 characteristics of acute delirium

1. disturbance of consciousness and shifts in attention and ability to concentrate 2. change in cognition or development of disturbance that has not been accounted for by a preexisting dementia 3. develops over a short period of time and fluctuates throughout the day 4. evidence suggests it is caused by a physical condition such as mental, substance, or medication side effects

Steps when changing a JP drain

1. take cap off and empty 2. alcohol swab outlet AND plug 3. recompress drain 4. put the cap on

Do you need to check compatibility between Fentanyl and Zosyn?

No, they enter the body at different sites.

How can complications of self-extubation be prevented?

Weaning from the vent ASAP as well as using restraints and sedation

How will you decide if the PCA continuous rate should be increased or decreased?

ask patient about pain and adjust, and look for a possible order from the provider

How would patient with cervical tongs use the bathroom?

catheter or bedpan

A patient with second-degree burns has been receiving morphine through patient-controlled analgesia (PCA) for a week. The patient wakes up frequently during the night reporting severe pain. The most appropriate action by the nurse is to...

consult with the health care provider about using a different treatment protocol to control the patient's pain.

How often should oral care be done?

every 2 hours

How often should subglottic suction be done on pt during oral care?

every 6 hours

secondary prevention

*early symptoms -anxiety, post partem depression, substance abuse

Top priorities for assessment information

1. Sleep 2. Appetite 3. Concentration -goal: oriented 24 hrs after onset of disorientation (person, place, time, situation) -all 3 affected by the Cortisol hormone

What is a racemic epinephrine?

1:1 mixture of the dextrorotatory and levorotatory isomers of epinephrine

What is the difference between CPAP and BiPAP?

CPAP: has 1 pressure, continuous positive pressure *PEEP* BiPAP: 2 pressures (both at inhalation and exhalation)

suicide risk assessment tools

CSSR -if patient answers "yes" for either of the first 2 questions, continue on, but if answer "no" for both, don't need to

The nurse assesses a client who has fentanyl infusing at 50mcg per hour in an epidural and notices that the epidural dressing and bed sheets are wet. Which of the following actions should the nurse take first?

Call the physician to remove the catheter.

T/F: A patient with an endotracheal tube can speak

False

What happens if patient with Halo device goes into cardiac arrest?

Pull up the white middle part of the device before starting CPR

A client with a morphine sulfate PCA is drowsy, has a RR of 12, SpO2 of 89% on 2L of O2 (via nasal cannula) and ETCO2 of 43. Which of the following interventions should the nurse complete first?

Raise head of the bed and try to wake/arouse the client

How do you know when the nebulizer treatment is completed?

The fluid in the chamber is empty and no more aerosol comes out

When caring for a patient who is receiving epidural morphine, which information obtained by the nurse indicates that the patient may be experiencing a side effect of the medication?

The patient has not voided for over 10 hours.

What are the potential complications of self-extubation?

Vocal cord/larynx damage and aspiration

pathological anxiety

affects day to day activities (such as unable to attend work because of anxiety)

referral for suicidal patients

treatments or therapy

What is the normal range for ETCO2 (end tidal)?

35-45 (if elevated, it means hypoventilation or oversedation)

What is the purpose of a sedation vacation?

ensure the min. amount of sedation is being used

A client with a cervical vertebrae injury is admitted to the hospital with a cervical collar in place. Which of the following actions is the nurse responsible for when caring for this client? Select all that apply

-Changing the extrication collar to an Aspen Vista collar -Washing the skin under the collar

Cervical Collars

-DONT move pt head when taking on/off (someone hold to keep stable) -skin begins to breakdown after 6 hours (need an order to change collars) -complete cares every 8 hours -make sure pt can swallow -may need to sedate if pt isn't cooperating

Seizure care priorities

*#1 PRIORITY IS SAFETY* -administer med -suction -O2 (non rebreather) -position pt on their left side

primary prevention

*before anything has happened -immunizations up to date, altering lifestyle (bad sleep to good sleep), hand hygiene

tertiary prevention

*prevent sickness/disease from getting worse -bipolar, PTSD, ADD, Schizophrenia

Supplies for Lorazepam administration

-3mL syringe (dilute with equal parts of med and saline) -Smart tip -draw up Lorazepam vile first (1mL) -draw up Normal saline second (1mL) -Alcohol swab closest port to pt -Push over 30 seconds and discard is garbage

What is post-partum depression?

-50-85% blues (no reason, but allow to relive the birth) -10-20% moderate depression -1% severe psychosis

warning signs of suicide

-8 out of 10 people give cues -cries for help -most occur within 3 months after the beginning of improvement -suicide of close family members increase risk -threats

How does the nurse decide when the pt is ready to be extubated from the vent?

-ABGS -Low sedation -Able to switch from SIMV and AC -Nurse and respiratory therapist are present when extubating

Outcomes when caring for pt with cognitive issues

-Alert and oriented after 24 hrs of initial symptoms -discuss 2 applicable coping strategies -decreased VS -decreased stress levels

Assist Control (AC) mode of ventilation

-All machine and pt initiated breaths are at present tidal volume -Ventilator senses the pt attempt at inhalation by detecting negative airway pressure (inspiratory flow) -The machine helps pt by making the breath a complete tidal volume (programmed into machine)

Which vent mode would be appropriate for a pt who has no spontaneous breathing?

AC

A patient asks if she may lay on her side while the nebulizer is running, how do you respond?

Ask to wait until to neb is finished or reposition her in a way that allows the neb to be upright

What do you have to determine before diagnosing someone with depression?

DSM5 criteria -determines what type of symptoms or depression someone has, to help with a more specific treatment plan

A nurse is caring for a client who has a postoperative illeus and an NG tube that has drained 2,500 mL in the past 6 hr. Which of the following electrolyte imbalances should the nurse monitor the client for?

Decreased potassium level

What test is used to measure seizure activity?

EEG

You walk into your patient's room and come to find they self-extubated. How do you respond?

First, assess their respiratory status. Assure that they can maintain their airway and have adequate effort. If they can, monitor them and notify the physician if they can NOT, use an ambu to provide respiratory support and plan to reintubate the patient emergently

How do you determine how far to insert the suction catheter?

Insert until you meet resistance/patient coughs, pull back slightly, then press the button and pull back

When a sedation vacation finished, what is the resumed dose?

It is restarted at 25% of the previous dose

What are the benefits of using an endotracheal securement device?

It makes it easier to reposition the tube to prevent skin breakdown

The RN determines that a student nurse shows a good understanding of nasogastric tube (NG) standards of care when the student is observed:

Securing the tube to the client's nose with tape.

What is the best position to be in while using a neb?

Sitting upright (high fowlers), it allows the lungs to expand and more medication to be inhaled

stress vs. anxiety

Stress: external pressure that triggers a response of anxiety Anxiety: emotional response to a stressor (feelings of uncertainty and hopelessness)

Tangentiality

The inability to get to the point of a story, the patient introduces many unrelated topics until the original topic of discussion is lost Often associated with schizophrenia

The nurse assesses a postoperative patient who is receiving morphine through patient-controlled analgesia (PCA). Which information is most important to report to the health care provider?

The patient's respiratory rate is 6 breaths/minute.

The patient's spouse is afraid the patient might overdose with the PCA. What could you say as a response?

There are safety precautions and a lock on the pump which prevents it from administering too quickly. Every 10 minutes, but nurse should still have Narcan nearby because we cannot ensure the patient wont overdose.

A nurse is caring for a client who has a Jackson-Pratt (JP) drain in place after surgery for an open reduction and internal fixation. The nurse should understand that the JP drain was placed for which of the following purposes?

To prevent fluid from accumulating in the wound

Echolalia

meaningless repetition of another person's spoken words as a symptom of psychiatric disorder A parrot-like repetition, by an individual with loose ego boundaries of the words spoken by another

situational anxiety

occurs in new or unfamiliar situations -test taking -medical diagnoses

Why is it important to perform oral care every 2 hours?

prevents infection (along with HOB 30 degrees and sedation vacation)

what are some interventions if someone is in metabolic alkalosis?

take away the offending agent

Why is it important to give a pt who is being weaned from the vent period of less vent support alternated with period of more vent support before extubating?

to exercise respiratory muscles and prepare PT for breathing independently

How often should pt teeth be brushed?

twice a day