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NURS 206 Final Exam Study Guide

by: Lindsay Mirrione

NURS 206 Final Exam Study Guide NURS 206

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NURS 206 Final Exam Study Guide
Fundamentals of Nursing
N. Lischke
Study Guide
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This 41 page Study Guide was uploaded by Lindsay Mirrione on Saturday August 20, 2016. The Study Guide belongs to NURS 206 at San Diego State University taught by N. Lischke in Fall 2016. Since its upload, it has received 5 views. For similar materials see Fundamentals of Nursing in NURSING at San Diego State University.

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Date Created: 08/20/16
Prof. N. Lischke Nursing 206 Fall, 2015 N 206 FINAL EXAM STUDY GUIDE (6 pages) Final: THURSDAY, Dec 17 from 1030-1230 Arrival Time 1010 -optional Adams Humanities 2108 PARSCORE Bring your half parscore (red). Do not crease the parscore. Complete the parscore ahead of time: otherwise you lose exam time.  Name: Print last and first name  Subject: Print last name of your clinical instructor  Hour/Day: Put day of the week of clinical lab  I.D. Number: USE YOUR RED ID and bubble in  Test Form: Bubble in A BLACKBOARD Final Exam Grades will be posted by FRIDAY early evening Dec 18 on Blackboard  Follow the point guidelines in your course syllabus on page 3.  Blackboard will give you a point total in the last column  Calculate your own course grade: Total Points are 650  You need 350 points from the 4 exams to pass the course.  If you did not achieve 350 points, look at your total points anyway to figure out your course grade a. If you fell within the C point range for total points, but did not receive 350 points on your exams alone, your grade will be a C-(minus) b. Otherwise, + and - scores are not given in the course  If you do not pass N 206 and are considering staying in the nursing program, please consult with the Undergraduate Advisor - Mr. Jason Ramirez – as soon as possible.  Possible course letter grades: A, B, C, C-, D, F 1. Grades are determined by points; not a percentage. 2. There is no option for extra credit. 3. Regardless of clinical “success,” it is not a determining factor in passing or a higher letter grade. 4. Do not inquire about “borderline” grades as many opportunities for points have been provided in this course beyond the 4 exams to succeed. Lecture notes are the official reference in case there is any discrepancy in information presented by other resources. Major resources: Lecture/campus lab notes and lecture reading assignments. REVIEW OF FINAL There will be no designated sessions to review the Final Exam like there were for the first 3 exams. FINAL EXAM: 100 questions worth 200 points  50% of the Final Exam will cover new material and 50% will be review. Lischke Final Exam Study Guide N 206 1  Read over all your notes. The following study guide lists the major areas of concentration for questions. Do not familiarize yourself with just these areas. Have a thorough understanding of the lecture concepts and their application. Professional Nursing o Review Code of Ethics (main points)  ANA, goals and values of nursing. o Review components of critical thinking  -Based on science  -Examine all available situations for a problem  -NOT SPECIFIC TO NURSING  -Judgements based on facts  -Thinking through strategies  -Devising a number of scenarios  -Determining a number of possible outcomes o What are Standards of Professional Performance?  -define competent levels of behavior  -performance/growth  -how do we expect nurses to behave Mobility/Immobility o Psychological and physiological benefits of mobility  Promotes well-being  Maintains health of pt  Ensures proper body functioning of the: integument, musculoskeletal, cardiovascular/respiratory, metabolic/gastrointestinal, urinary, and psychological health (page 19) o Therapeutic effects of bed rest  Reduces pain and need for larger dose of pain med  Promotes healing of injured tissues  Oxygen needs of body are decreased due to decreased physical activity  Provides rests for pts  Prevents migration of disease (organisms through body circulations) o Interventions to prevent/minimize complications of immobility on the integumentary and musculoskeletal systems  INTEGUMENTARY  Risk assessment--> assessment tool=Braden scale where lower the score the higher the risk  Turning schedule of q2hrs  Pt hygiene; encourage them to bath because it promotes circulation and can move them for exercise and to relieve pressure points  Hydration/nutrition  Treatment of ulcers  MUSCULOSKELETAL  ROM, PT  Positioning, alignment and support  Pain control and motivation (to move)  Assistive devices Lischke Final Exam Study Guide N 206 2  Nutrition; Adequate intake of Ca/vitamin d (which draws CA in), protein, calories, fluids (water), and fiber (keeps GI system working) o What is osteoporosis and how to prevent?  Loss of bone Ca++ -> Ca++ goes back to circulation -> porous, brittle bones, Ca++ in blood increases  Prevention: Need to put stress on bone!! Weight bearing causes osteoblasts to form from stress on bone o How to evaluate body alignment on a patient in bed o Dietary needs of the immobile patient o Vital sign parameters when mobilizing a patient  SBP drop of 20-25mm  DBP drop of 10mm  Pulse increase of 20 or more o Venous return devices: TEDS, PAS - nursing management  TEDS; Compresses vein -> causes blood from superficial vein -> deep vein -> femoral vein –This prevents venous pooling/prevents dilation of vein/injury of vein  SCDs/PAS/Leg squeezers; Increases velocity of blood, increases fiberonlisis (break down of clot), stimulates release of NO which inhibits platelets aggregation. (don’t need if pt is ambulating 3x a day)  FOR BOTH—take off 1hr every 8hrs o Factors (advancing) thrombi and emboli and medical management; lab test?  Factors: 1) VENOUS STASIS; when you are not walking around, veins are not contracting so blood pools, no dilation in veins causing it to tear which can lead to blood clots 2) INCREASED BLOOD COAGULABILITY; Hypovolemia (decrease in blood volume) of immobilization causes the plasma portion to decrease to a greater extent than red cell mass so blood gets THICKER and slows; blood pools in leg veins 3) DAMAGE TO VEIN WALL’S INTIMA (lining in vein wall); improper body alignment, immobility, pooling from “knee gatch” position (pillow underneath need) --> platelets cover defect in wall resulting in plaque  Medical management: PREVENTION = heparin, lovenox injections, ASA, elastic hose and compression stockings (TED&SCD)  Lab test??? o Major musculoskeletal physiologic responses to prolonged immobility  DISUSE ATROPHY; disuse of muscles causes them to become smaller and muscle mass decreases leading to decrease muscle strength  DECREASED MUSCLE STRENGTH AND ENDURANCE; Lose 3% of muscle strength a day  DISUSE OSTEOPOROSIS; decrease weight bearing/stress on bones lead to loss of bone ca -> porous, brittle bones, increase calcium in blood  JOINT CONTRACTURE; fixation of the joint caused by disuse, atrophy, shortening of muscle fibers. Can be a food drop, wrist drop, external hip rotation, back aches. o How to minimize problems associated with valsalva maneuver  Pt teaching  Avoid situations that cause vasovagal stimulation (coughing, vomiting, gagging, constipation)  -Stool softeners  Give fluids/fibers  Medication for nausea to avoid vomiting or gagging Lischke Final Exam Study Guide N 206 3 o Positions: supine, prone, lateral, Sims  SUPINE: resting on back. Position with the greatest number of pressure ulcer problems in the occipital region of head, vertebrae, coccyx, elbows, heels  PRONE: Face/chest down. Studies shown that prone reduces risk of pressure ulcers (but it is impractical)  LATERAL: side-lying; a 30 degree lateral is recommended for pt who are at risk for pressure ulcers  SIMS: between prone/lateral (impractical) Medication Administration and IV Therapy Review drug calculation problems and know the conversions o Anatomical location of injection sites  INTRAMUSCLAR SITES  DON’T USE DORSOGLUTEAL SITE  DELTOID o Find Acomion process and go two figner widths below o Draw line from axilla across arm o Site is w/in triangle, axilla = apex  VASTUS LATERALS (good for infants) o Hand width below greater trochanter o Hand width above knee o Choose MIDDLE THIRD LATERALLY o DO NOT inject into the rectus femoris which is the anterior thigh  VENTROGLUTEAL (gluteus medius muscle) o Use hand opposite of pt’s hip o Put palm on greater trochanter and finger on anterior superior iliac spine o Inject into the center of the V  SUBCUTANEOUS INJECTIONS  Outer posterior portion of upper arms  Abdomen below costal margin to iliac crest  Anterior thighs  Back  INTRADERMAL INJECTIONS  Inner forearm  Upper back  Upper chest o Needle gauge/length for IM & subcutaneous injections  INTRAMUSCULAR  Deltoid o 5/8 – 1 inch; gauge 22-25  Vastus Lateralis o 1 to 1 ½ inch; gauge 20-23  Ventrogluteal (gluteus medius muscle) o 1 to 1 ½ inch; gauge 20-23  SUBCUTANEOUS  ½ to 5/8 inch; gauge 25-29  Preferred needle is ½ of the width of the skin fold o Critical thinking: safety measures and nursing judgment in administration and Lischke Final Exam Study Guide N 206 4  recording drug-related information  Adhere to sterile technique guidelines  Use engineered sharps (safety devices) whenever possible  Use one handed recap for a sterile needle  Plan safe handling and disposal of needles before beginning procedure  Always wear gloves when giving an injection  Never recap a dirty needle  Dispose of sharps, engineered sharps, syringes into sharps disposals  Recording drug-related information? o Medication routes: advantages/disadvantages  ORAL  Advantages: o Reduced cost o Safe because doesn’t violate skin/mucous membranes o Convenient; easy to administer  Disadvantages: o Cant give to pt who is: unconscious, NPO, or N&V o Unpleasant taste o Gastric side effects o Altered absorption in the absence/presence of food  SUBLINGUAL  Advantages: o Absorbed by blood vessels under the tongue w/in a short time and is not altered by digestion  Buccal (buckle)  Advantages: o Table held in mouth against cheek until it dissolves and acts locally on the mucous membrane of mouth or systematically  Topical  Advantages o Applied to a certain surface area = usually a local effect  Inhalations  Advantages  Disadvantages  Parenteral Administration (injecting a medication into a body tissue – SUBQ, IM, INTRADERMAL, IV)  Advantages: o Rapid, systemic, and total dosage usually absorbed o Good for pt who cant take drugs orally o Used for drugs that become inactive by GI tract (insulin) or are poorly absorbed/irritating o Good route for emergencies due to rapid, predictable absorption  Disadvantage o Infection, air embolism, tissue damage o Rapid onset of allergic reactions Lischke Final Exam Study Guide N 206 5 o Possible pain and anxiety in receiving the medication o Routes: clean or sterile technique  Clean: oral, topical (skin/mucous membrane/ear drops/nose drops/vaginal suppositories/rectal suppositories)  Sterile: eye, parenteral o What are reasons for IV therapy? (i.e. maintenance, replacement, etc)  REPLACEMENT THERAPY:  Pt experiencing significant loss of fluid o Active loss (surgery) o NPO for a number of days o Drains into surgical area o Burns o Trauma (hemorrhage/high fever) o Nasogastric tubes??? o GI unable to take in fluid  MAINTENANCE LINE:  To sustain normal balance when pt at risk for losing fluid (have not lost any yet) o Geriatric pt o Pt that refuses to eat/drink o Pt comatose or at risk for aspiration o Pt going into surgery o GI upset (N&V)  NUTRITION: TPN/PN/HYPERALIMENTATION  Complete nutrition  Given through a CENTRAL line  If NPO for 5-9 days then fat/protein stores break down so PN is given to pts w/non-functional GI tract or NPO longer 5 days  IV MEDICATIONS  EMERGENCY  Don’t necessarily need it, but just incase (NS usually used) o Volumetric pumps: when to use  For really FAST rates  Rates less than 50 mls/hr and greater than 150 mls/hr  Fluid restrictions where fluid intake is critical and need to be monitored accurately  All DRIP solutions that have concentrated additives (i.e heparin drip, insulin drip, morphine drip, etc)  Central lines, midlines, port-a-caths, arterial lines o Factors influencing gravity flow IVs  When pt’s move it affects iv by slowing/speeding pump  Needs pressure difference o IV fluids hypotonic, hypertonic, isotonic and how do they work in the body?  Water moves from less solute concentration to greater solute concentration (low osmolarity -> high osmolarity)  HYPOTONIC (less osmolarity then plasma/more dilute then serum)  D5W, 1/2NS (0.45 NS), D50.2NS  Shifts fluid and electrolytes out of intravascular compartment and hydrates intracellular and interstitial compartments where osmolarity is higher Lischke Final Exam Study Guide N 206 6  Swells the cell  Use for… o Hydration of pt such as when they are dehydrated or pt experiencing fluid loss post op o Diabetic ketoacidosis is a high concentration of sugar in blood streams so cells are dehydrated because water going into intravascular fluid instead of inside cells (intracellular). Giving hypotonic solution (1/2NS) helps hydrate cells  DON’T USE FOR o Pt with increase ICP; D5W is dangerous because it automatically goes to brain cells and causes it to swell rd o 3 spacing; fluid leaks into body compartments that are unusable (fluid accumulates into dead space)  ISOTONIC (blood plasma is the isotonic standard 0.9%)  NS (0.9NS), LR, D5NS, D10W, D5LR  No change in fluid/electrolyte concentration of plasma  Increasing intravascular compartment to expanding blood volume  PT THERAPY o Shock/hypovolemic o Dehydration  DON’T USE FOR o Pt w/high blood pressure  HYPERTONIC (greater osmolarity then plasma )  D10NS, D20W, TPN, 3%NS (anything greater then 0.9%)  Draws fluid and electrolytes intro intravascular compartment while dehydrating intracellular/interstitial compartments  Cells shrink (decrease intracellular volume)  Osmolarity of blood stream increases (increase intravascular volume)  PT THERAPY o Low blood sugar (need to give concentrated sugar, but make sure cells hydrated) o Hyponatremia  DON’T GIVE TO o Dehydrated pt o Impaired kidney function o Critical thinking concerning IV rates  TKO/KVO = 20-30ml/hr  Slow = 50-75 ml/hr  Intermediate = 100-125 ml/hr  Fast = 150 mls/hr +  Ahead: check rate and readjust to correct rate (if faster then it should be then slow it down)  Behind: check rate and readjust to correct rate  DON’T try to catch up  IVPB = primary solution stops until it is done  Trouble shoot for complications or problems in the IV delivery system o IV complications peripheral and central lines Lischke Final Exam Study Guide N 206 7  Peripheral:  Infiltration: nonvesicant solution leaked into surrounding tissue o Edema, pain, pallor, coolness  Extravasation: vesicant solution leaked into surrounding tissue  Phlebitis: inflammation of the vein with possible clots (chemical/bacterial/mechanical) o Edema, pain, erythema, warmth over vein, possible a red streak  Air embolism  Speed shock – rapid infusion, increased drug concentration  Tape/catheter allergy  Occlusion (not flushing)  Hematoma; missed attempts, improper removal – raised bump, painful, bleeding underneath skin (put pressure on skin until stops)  Infection  Central:  Pneumothorax (accumulation of air in the pleural space) – upon insertion  Danger of bleeding from superior vena cava if IV tubing becomes disconnected from IV catheter  Air Embolism (upon insertion, removal, tubing change)  Catheter sepsis: endocarditis (infection/inflammation of the heart valves/lining of the heart) o Break in sterile technique, poor insertion technique, multiple lumens, stopcocks o Auto infection (rate of infection related to skill level and “dwell time” of catheter  Dysrhythmias  Thrombus – blood clot forms outside catheter but in vein and can collapse the wall of the catheter and occlude the vein  Occlusion (clotted blood): incompatibles, TPN, lipid deposits  Infiltration & Extravasation o Advantages of a central line  Long-term therapy  Irritating medications  Chemotherapy  Hypertonic solutions (TPN)  Large volumes  Major surgeries  Needing CVP monitoring o How long does an IV solution last once the seal is broken?  All IV solutions expire 24 hours after seal is broke o Principles behind saline/heparin flushes  Central  Short term (1-2 weeks) o Unused ports = flush q8hrs or after use w/dilute heparin  Long term (weeks to months to years) Lischke Final Exam Study Guide N 206 8 o Hickman (open?) = flush with dilute Heparin solution q8hrs and after use o Groshong (valve?) = 10ml NS after use  PICC o Open = heparin q8hr o Groshong (valve) = NS after use  PERIPHERAL LINES (SALINE)  Q8hrs o After IVPBS o Immediately after primary tubing disconnected (lock in place)  CENTRAL LINES (HEPARIN  One a shift minimum  After IVPBS  Immediately after primary tubing disconnected (if lock already in place)  Groshong (VALVE) = saline o Insulins:  Aspart/Novolog (SQ)  Onset of action: 15-30 min  Peak: 30-60 min  Regular  Onset of action: 30 min  Peak: 2.5 – 5 hours o I & O records:  What do you record?  ?  What is the rationale for I & O?  Indicator of pt who is at risk/experiencing fluid/electrolyte imbalance/problems  Keep routinely for pts that are: post-op, unstable condition, elevated temp, fluid restrictions, receiving diuretic therapy, IV therapy Wounds and Pressure Ulcers o Principles of sterile asepsis (at the back of the Wound Lecture notes)  All objects on a sterile field must be sterile  Sterile objects become unsterile when touched by unsterile objects  KEEP HANDS IN VIEW, ABOVE WAIST-> Sterile items that are out of the field of vision or held below the level of the waist are considered contaminated o Describe the 3 types of surgical wound healing  PRIMARY INTENTION  Assess outer skin only (staples/glue) because cannot see inside the wound since the incision is CLEAN, STRAIGHT LINE with all layers APPROXIMATED by suturing  Majority of surgical wounds  There is not much granulation because tissue loss is little  Acute inflammatory response occurs immediately o Tissue layers are interwoven with collagen fibers o Surface of wound is closed by migration of epithelial cells Lischke Final Exam Study Guide N 206 9 o Collagen helps strengthen the edges  Healing is QUICK, Inflammation is MINIMAL, Epithelialization occurs RAPIDLY, Tissue loss is MINIMAL, Scarring is MINIMAL  SECONDARY INTENTION  It is an OPEN WOUND and can see inside so assess color, depth, exudate  Includes wounds occurring from trauma, ulceration, and infection o Ulcers -> pressure sores with edges that CANT be approximated o A surgical wound that is open and has a lot of tissue loss o Wound that is infected in surgery so is LEFT OPEN due to large amount of EXUDATE o A reopened infected wound  Involves GRANULATION since tissue loss is GREAT and collagen cannot form enough. Granulation is bright red and composed of new capillaries. It is also a type of connective tissue that is more vascular and not as strong as collagen becoming scar tissue -> scar is larger then primary  There is more INFLAMMATION then primary  DEBRIS and NECROTIC tissue may be present  The risk of infection is INCREASED  TERTIARY INTENTION  Basically a delayed primary and at one phase it was a secondary wound  Examples include.. o A contaminated wound that was left open and then sutured after infection was controlled o A primary wound that was infected, opened, allowed to granulate, and then sutured.  Involves delayed suturing of wound with two layers of granulation that are sutured together o Purpose of dressings?  Bacteriological protection  Physical protection  Maintains a moist environment  Protects against injury  Absorbs exudate  Debrides wound (only OPEN WOUNDS=SECONDARY)  Allows wound healing by secondary intention to heal BOTTOM -> UP and SIDES -> IN  Stops bleeding  Applies pressure  Covers topical meds (i.e ointments)  Seals off wounds (by clinging to hem) o How to assess wound healing (appearance of normal/infected wound)  INFECTION  Local heat  Redness  Edema  Pain Lischke Final Exam Study Guide N 206 10  Wound edges are indurated (abnormal firmness)  NORMAL  Incision o Slightly elevated o Depressed/pink  Surrounding skin o Warm and slightly edematous  Wound edges o Well-approximated, well-defined o State the influence of moisture, oxygen, and temperature on wound healing  MOISTURE  Provides for cell migration and mitosis  OXYGEN  Increases local resistance to infection and enhances collagen formation  TEMPERATURE  Wounds heal better at body temp o What roles do Vitamins A and C, zinc, iron, and protein play in wound healing?  VITAMIN A  Epithelialization (migration to close top of wound)  Collagen synthesis  VITAMIN C/ZINC  Collagen synthesis  IRON  RBC production  PROTEIN  Tissue repair; collagen and capillary synthesis  Positive nitrogen balance needed to ensure adequate protein o What are differences between red, yellow, and black wounds? Give an example of each  THESE ARE ALL TYPES OF SECONDARY WOUNDS  RED o This is good, this is clean. o Examples include:  Skin tears  Pressure necrosis sores (Partial Thickness-Stage 2)  Partial thickness or Second Degree burns  Partial Thickness = tissue destruction through EPIDERMIS but NOT through the dermis  Wounds created surgically to heal by secondary intention o Appearance  Serosanguineous drainage  Clean, pink to bright or dark red healing with granulation  YELLOW o Examples include:  Surgical or traumatic injuries  Wounds where eschar is REMOVED  Eschar = thick necrotic tissue o Appearance Lischke Final Exam Study Guide N 206 11  Presence of slough or soft necrotic tissue  Slough = dead matter separated from living tissue  Liquid to semiliquid slough with creamy ivory to yellow-green exudate  BLACK o Examples include  Full thickness or third degree burns  Full thickness = Destruction is through the DERMIS to involve SUB-Q and possible MUSCLE AND BONE  Pressure necrosis sores (Stage 3 or 4)  Gangrenous ulcers o Appearance  COVERED with THICK necrotic tissue  BLACK, GRAY, or BROWN necrotic tissue  Possible presence of PUS o Staging of pressure sores  PARTIAL THICKNESS  Stage 1 o NO BREAK IN SKIN o Nonblanchable erythema of INTACT SKIN (abnormal reactive hyperemia) o Individuals with darker skin = discoloration, warmth, edema, induration  Stage 2 (can be reversed) o Skin loss involving epidermis, dermis or both (BUT DOES NOT GO TRHOUGH DERMIS) o Ulcer is SUPERFICIAL and presents as an abrasion, blister, or SHALLOW crater (NO eschar NO slough)  FULL THICKNESS  Stage 3 (heal by scarring that is permanent. May get again at same spot o Skin loss involving damage to or necrosis of SUBQ tissue (damage goes through dermal layer) o May extend down to but NOT THROUGH underlying fascia o Ulcer prevents as DEEP CRATER o May/May not have undermining of adjacent tissue  Stage 4 o Skin loss with extensive destruction, tissue necrosis, or damage to MUSCLE, BONE, SUPPORTING STRUCTURES (tendons, joint capsules) o MOST LIKELY may have UNDERMINING and SINUS TRACTS.  SUSPECTED DEEP TISSUE INJURY  PURPLE localized area of discolored INTACT skin or blood- filled blister that rapidly exposes additional layers of injured tissue  UNSTAGEABLE PRESSURE ULCER  Full-thickness loss in which the base is covered by slough or eschar that interferes with staging (CANT STAGE WITH SLOUGH/ESCHAR – MUST REMOVE BEFORE STAGING) Lischke Final Exam Study Guide N 206 12 o How do pressure sores form?  Pressure sores form as a result of PRESSURE in combination with SHEAR or FRICTION  Forces of compression and shearing cause an interruption of blood supply to due unrelieved pressure  COMPRESSION PRESSURE o Pressure is high enough to close capillaries (it interrupts blood supply to tissues) o Unrelieved pressure -> pressure ulcer  Pressure over larger area < localized pressure (more damage)  Low pressure over long periods of time causes as much damage as high pressure over short period of time  Turning schedule (usually q2hrs)  For a healthy person to develop an ulcer 6-12 hrs o Reactive hyperemia  Abnormal reactive hyperemia - excessive vasodilation and localized edema  SHEARING FROCE o Separating force (stretches BV, pulls muscle) o Commonly occurs in semi-fowlers o Friction is a part of shearing force  Three elements of pressure sore formation  Intensity of pressure and capillary closing pressure  Duration of pressure  Tissue tolerance – skin and subq tissue can tolerate some pressure o Pressure sore myths  All pressure sores are preventable  Pressure ulcers are the result of poor nursing care  Massage of skin and tissues over bony prominences prevents pressure ulcers (MASSAGING INCREASES FRICTION, MAKES IT WORSE) o Preventative measures for pressure sores  Assess risk of development using a risk assessment scale (lower score = higher risk for skin breakdown)  Identify “suspected” areas (redden areas)  Initiate a SKIN FLOW SHEET  Educate pt about the risks of pressure ulcers and how to prevent them  Shift weight  Lean forward when sitting; stand every half hour  Isometric exercises of gluteal calf muscles to stimulate circulation  Pain control (so they are willing to move)  Basic hygiene for skin  Rinse soap well (soap can alter the effectiveness of skin)  No astringents  Frequent bed changing and skin care  Reduce friction on bed when moving pt  LIFT don’t slide  Pull sheets Lischke Final Exam Study Guide N 206 13  Keep bed dry  Turning schedule (min q2hr) o Tissue load: positioning and support surfaces  GOAL is to create an environment that enhances SOFT TISSUE GROWTH and PROMOTES HEALING OF PRESSURE ULCERS  Tissue load = distribution of pressure, friction, shear on tissue (give tissue change to grow and ulcer a chance to heal)  POSITIONING  Stay off ulcer  Avoid DONUT-TYPE devices  Frequent REPOSITIONING SCHEDULE/WRITTEN SCHEDULE q2hrs  Use pillows, use wedges to relieve pressure on heels and raise off bed  Maintain HOB at LOWEST DEGREE consistent with medical condition to MINIMIZE SHEAR FORCE of sliding down in bed  SUPPORT SURFACES  Special mattresses, cushions, beds to reduce pressures o STATIC: air mattress, thick eggcrate, foam  PRESSURE REDUCING (just reduce)  Don’t use on completely immobile pt, use on one that can move w/o bearing weight on pressure ulcer  Check for bottoming out and see if you can feel pt’s body through overlay (you shouldn’t feel this) o DYNAMIC: air fluidized beads/air channel beds  PRESSURE RELIEVING (completely relieve)  For immobile pt, pt cant move  If pt fully compresses the static support??  If pressure ulcer doesn’t show evidence of healing w/in 2-4 weeks  AIR FLUIDIZED BEAD BEDS (CLINTRON)- clinically effective o Soft, sand like beads that absorb secretions through a polyster sheet o “floating in space” o less than capillary filing pressure so CAN LIE DIRECTLY ON WOUNDS  AIR CHANNEL OR AIR CUSHION BEDS o Series of cushions w/different pressure o Can lie directly on wounds o Clinically effective o Common irrigation solutions (NS and half-strength H 2 2: purpose & precaution  Normal saline  Any wound and those showing epithialization (fresh tissue growth)  H2O2 Lischke Final Exam Study Guide N 206 14  Doesn’t prevent/treat infections -> kills fibroblasts necessary for repairing wound, AVOID THIS SOLUTION, DON’T USE IN WOUND o State the concern when using Dakins solution  Antiseptics; It is cytotoxic  Moderate anti-infective property; protect wound edges o Local effects of heat and cold (Wound Campus Lab Notes)  HEAT  Muscle strain (muscle pull), low back pain, localized joint pain  Increased blood flow by vasodilation and brings nutrients and oxygen to area of injury  COLD  Sprains (injury to muscles, tendons, ligaments), spasms, fractures  Decreases edema and inflammation during acute phase of injury  Causes vasoconstriction Oxygenation o Normal ABG: pH, PaO , PaCO , HCO , O saturation values 2 2 3 2  pH: 7.35-7.45  PaO2: 80-100 mmHg  PaCO2: 35-45 mmHg  HCO3: 22-26 mEq/L  O2 sat (SaO2): 95-100% o What happens in metabolic acidosis & alkalosis, respiratory acidosis and alkalosis (only to the extent discussed in lecture)?  Metabolic acidosis  Diabetic ketoacidosis, diarrhea (HCO3/BASE-Bicarb decreases)  Metabolic alkalosis  NG suction (HCO3/Base increases)  Respiratory acidosis  Chronic bronchitis, emphysema (Increase PaCO2/acid -> COP pt)  Respiratory alkalosis  Hypermetabolic states (fever) o What is hypoxemia in terms of a blood gas parameter?  Amount of O2 in arterial blood is less than normal  Normal PaO2 is 80-100 mmHg  MILD to MOD = PaO2 60-80 mmHg  SEVERE HYPOXEMIA: PaO2 less then 60 mmHg  Can lead to hypoxia o What is surfactant? What does it do?  Detergent-like phospholipid, decreases surface tension and aids ventilation  Expands alveoli by reducing tension of fluid lining o Discuss factors that influence ventilation: compliance, airway resistance, etc.  COMPLIANCE  How elastic are the lungs? Does it need a lot of effort to expand?  Normal breathing should be effortless Lischke Final Exam Study Guide N 206 15  Stiff lung problems: diseases causing fibrosis of lungs such as pulmonary fibrosis and emphysema: normal changes associated with aging o Stiff noncompliant lung o Surfactant helps in non-compliant lung  RESISTANCE  Anything that makes it difficult to have air get in. o Obstruction from..  Foreign substances  Secretions  Tumors  Lying positions  Artificial airways-if not aligned properly (tracheostomy/incubation tube)  Lower airway problems o Asthma (bronchioles constrict in episodes; reaction to various stimuli), bronchitis (copd, narrowed bronchioles; resistance to airflow, increase mucous production- infection can follow)  ACCESSORY MUSCLES  Air movement is possible with muscular effort o COPD PT  Frequent use of accessory muscle, need excess muscle to increase lung volume o Muscle of the abdomen, neck, and back (scalene, SCM, trapezius) o Nursing interventions for promoting oxygenation (positioning, breathing exercises, etc.)  AIRWAY MANAGEMENT  Position o High fowler’s o Ambulation or a frequent change in position  Alignment o Keeps oxygenation tubes midline: tracheostomy, intubation  Hydration/Humidification o Thins and loosens secretions, important for circulating blood volume for O2 delivery, dilutes toxins  BREATHING EXERCISES: purpose is ..  Look in notes o Nasal cannula: advantages/disadvantages; care of the patient with a cannula  Advantages:  Comfortable, can eat with a nasal cannula  Disadvantages:  Dislodged by restlessness  Mouth breathers don’t receive full amount  Nasal passage must be patent o Identify oxygen delivery devices and state what flow/percentage they deliver  Low Flow Oxygen Delivery Devices Nasal Cannula : 1-6 LPM (24-44%) o Uncomplicated post-op, COPD pts, pneumonia, chronically debilitated Simple face mask: 5-10 LMP (40-60%) Lischke Final Exam Study Guide N 206 16 o Pt w/difficulty breathing such as emergencies Non-rebreather: 10-15 LPM (90-100%) o Dying pts/respiratory crisis/emergency trauma  High Flow Oxygen Delivery Devices Venturi mask- exact O2 delivery, can give low % up to 60% precisely o Pt w/irregular breathing patterns o Advantages and disadvantages of pulse oximetry  Advantages  Alerts us to hypoxemia  Inexpensive  Easy  Reliable  Disadvantages  Can tell difference between arterial pulsations and other strong pulsations  CO molecules have a greater affinity for hemoglobin molecule  Anemia (does not inform of hemoglobin concentration)  Ambient light (lamps, sunlight) cover sensor with towel when reading o What is the chemical stimulus for controlling respiratory rate and depth?  Increased CO2 in blood is the chemical stimulus for controlling the respiratory rate/depth o Explain the normal curve for oxyhemoglobin dissociation curve  Relationship between hemoglobin and PaO2  ??? o Chest tube drainage: nursing considerations in managing a pt with chest tubes  Keep below pt’s chest level  CDB?  Don’t clamp properly functioning chest tubes  Pt positioning  Drainage unit positioning  Avoid kinks/obstructions in tubing  Milk but never strip clots from tubing  Reinforce dressings (don’t replace)  Respiratory assessments  Serial CXRs Pharmacology o Name factors that affect drug absorption  Blood flow, pain, stress, hunger, fasting, food types, pH, gastric motility o What is hepatic first-pass?  When drugs do not immediately enter systematic circulation after oral absorption, instead it passes from intestinal lumen to the liver by the portal vein. The liver alters or modifies the drug (metabolism/biotransformation) o What happens in biotransformation? (drug metabolism)  Process of the body altering/modifying the chemical structure of drugs  Done in the liver  Amnt of active drug is USUALLY reduced Lischke Final Exam Study Guide N 206 17  Not all drugs are metabolized to the same extent  Some drugs arent metabolized and are excreted unchanged  Most drugs converted to metabolites by liver enzymes o Some more active then original drug o Large percentage of drugs are lipid soluble so the liver metabolizes them to water soluble form for renal excretion o Sometimes metabolites prolong the drug action o What is bioavailability? What factors affect it?  Bioavailability is the percent of drug dose reaching systematic circulation  Oral route o w/ first pass = 20-40% bioavailability  IV route o 100%  Liver disease increases bioavailability  Cardiac, hepatic, renal disease caused prolonged metabolism leading to a cumulative drug effect which is an excessive response to an ordinary dose  Rapid absorption increases bioavailability and can cause drug toxicity o What is the implication of low serum protein levels concerning protein binding? What factors might cause a low serum protein?  Low serum protein level = decrease in protein-binding sites = increase in the amnt of drug in plasma  Decrease amnt of protein = increase potency of drug  Increase amnt of protein = decrease potency of drug  LOW SERUM PROTEIN  Liver/kidney disease/malnourished o What is an agonist/antagonist?  Agonist = drug that produces a response  Antagonist = drug that blocks a response o What is a loading dose?  Speed up minimal desired action  Large initial dose of drug to achieve rapid MEC o What is a half-life?  Time for half of the drug concentration to be eliminated  Determines how often drugs should be given  Tells us when to expect a response from drug o What are onset, peak, and duration of drug actions?  ONSET  The time it takes for drug to reach MEC to start seeing a change in a pt  PEAK  The time it takes for a drug to reach highest effective concentration  DURATION  The length of time the drug has a pharmacologic effect  Determined by rates of absorption and elimination o What is creatinine clearance and its importance in drug dosing?  A test to see how much creatinine is cleared by the kidney  Used to determine kidney function (renal function) o Difference between allergic and anaphylactic reactions Lischke Final Exam Study Guide N 206 18  Allergic response is a hypersensitivity reaction to intrinsically harmless antigens. Body perceives drug as a foreign substance (antigen)  Anaphylactic reaction is a severe form of allergic reaction. It is LIFE THREATENING. Can cause SOB, respiratory arrest and possible cardiac arrest o What is a therapeutic index?  The therapeutic index measures the margin of safety of a drug. We want it between the minimum effective concentration and the minimum toxic concentration. The closer the TI is closer to 1, the greater danger of toxicity  A low TI = narrow margin of safety  A high TI = high margin of safety and less danger of producing toxic effects o What is a normal PTT and the desired PTT for Heparin therapy?  Normal PTT  23 – 35 sec  Desired PTT  60 – 90 sec o Indications for PT and PTT  Protime (PT)  Lab value used to monitor oral Coumadin therapy  Partial thromboplastin time (PTT)  Lab value used to monitor IV heparin therapy o Digoxin: nursing considerations in administration of  Apical pulse <60 bpm  Hypokalemia  Hypomagnesemia o Define additive, synergistic, idiosyncratic, side effect, adverse reaction  Additive  2 drugs with the same effect  enhances effect of two drugs that equal the combined effects of both  i.e drug A = x effect, drug B = y effect, therefore additive effect is X + Y  Synergistic  Multiplied effect  Most DANGEROUS effect because the combined effects of the two drugs are multiplied  Drug A has the effect of 1; Drug B has the effect of 1 = synergistic effect is 3 not 2  Idiosyncratic  Unusual and unexpected reaction resulting from genetic difference unique to that pt (cant predict)  Side effect  SECONDARY EFFECT  Physiological effects not related to desired drug effect  All drugs (even w/correct dosage)  Drugs lacking specificity (urecholine)  Some side effects may be desirable  Adverse reaction  NOT WANTED  More severe than side effects (a harmful side effect) Lischke Final Exam Study Guide N 206 19  Untoward (unintended) at normal dosing range causing mild to severe side effects including anaphylaxis shock Nursing Process and Teaching Learning o What are the components of a diagnostic statement  Three part statement: actual problems  Problem (NANDA)  Etiology (related to) o Cant imply liability/be judgmental o Can use medical diagnosis  Defining Characteristic (as evidenced by) o S&S  Two part statement: risk problems  Problem  Etiology (related to)  No defining characteristics o What are the formulas for writing goals and outcomes  GOALS  A general statement with a time element (long term or short term)  OUTCOMES  Time statement + Main idea + Verb + End Behaviors o What is the goal of the teaching process for hospitalized patients?  Goal must have personal meaning to the pt o How do you motivate your patient to learn  o Recognize general ways to increase retention  Involve multiple senses and use active learning (cognitive/audio visual)  Repeat facts/skills; encourage questions  Minimize time between learning and using knowledge/skill; give pt opportunity to apply info  Present easier material first and proceed to more complex  Or begin with the known and proceed to unknown  Teach anxiety provoking material first  Provide immediate feedback  Decide on formal or informal sessions  Teach on a continuous basis (modify lifestyle)  Try not to make teaching solely a part of discharge  Focus on life-style modifications, not complete change  Provide supplemental teaching materials: pamphlets; audio tapes, video tapes, charts, close-circuit tv, diagrams o How are cognitive knowledge, psychomotor skills, and affective needs taught?  Cognitive  Thinking, understanding  Taught by discussion w/written material  Audiovisual aids  Passive learning  Psychomotor Lischke Final Exam Study Guide N 206 20  Demonstrate, practice, discussion, reinforcement  Active learning  Affective needs (attitudes, feelings)  Group sessions  Encourage acceptance Infection Control – all from your notes o Define nosocomial (health care associated infection)  Infection pt received bc they were in hospital (did not have before they entered hospital)  Any encounter that pt has with health care delivery system.  Develop illness after 48 hours!!!!! –if enter hospitals w/o symptoms and develop BEFORE/less then 48 hours then it is COMMUNITY ASSOCIATED INFECTION o Define colonization,  Organism there, but no S&S  Don’t know if pt is affected o Define iatrogenic  Type of noscomial infection resulting from a diagnostic or therapeutic procedure (i.e foley catheter, not changing something w/sterile technque) –something we did to patient  “assigns” blame –don’t place blame just recognized it happened o Define exogenous  Something we did to pt. (i.e instruments weren’t sterilized)  Associated w/devices and procedures  Microorganisms external to the individual that do not exist as normal flora  Preventable 1/3 o Define endogenous  The pts own flora that is altered and overgrowth/infection results  2/3 not preventable o What is meant by direct and indirect modes of transmission  Indirect: more common in health care environment (more worrisome in health care facilities); less efficient; intermediate object (needle stick or hands of health care worker)  Direct: how microorganisms transfer from person to person (biting, touching, kissing, sexual intercourse, blood through a cut) –portal of exit direct contact to portal of entry o What are major categories of nosocomial infections that are preventable?  EXOGENOUS 1/3  Associated with devices and procedures; “managing the devices” o What are the major differences between airborne, droplet, and contact precautions?  AIRBORNE:  TB control = ventilation; negative-pressure isolation room (room sucks in air) w/door closed; air exchanges  Mask (PER95 or HEPA filter respirator)  Surgical mask on pt when leaving the room (they need 3 AFB sputums that are negative)  Sign on door stating “airborne precautions”  DROPLET:  Private room or same disease  Wear surgical mask when w/in 3 feet Lischke Final Exam Study Guide N 206 21  Have pt wear mask when leaving room  Best protection is vaccination  CONTACT:  Private room or those with same diagnosis in room  Wash hands/wear gloves/gown  Dedicated equipment  Appropriate barriers for pt when out of room  Staff education  MRSA, VRE, HEP A, CDIFF o What is a “reservoir” in the chain of infection?  Source  Commonly the human body but can be food or water ? o Recognize basic nursing actions to prevent the spread of infection from the “reservoir”  Changing dressing  Proper disposal of anything that is a body substance (body substance control) o What are the “research principles” of Body Substance Isolation?  We interact with patient in hospital in terms of isolation procedures NOT because they have diagnosis –not waiting for diagnosis first!!!!  It is how we interact w/pt. Our behavior is INTERACTION DRIVEN. However we interact with patient tells us what to do (i.e if touching some of their body substances we are going to put on barriers)  Barriers -> interaction driven (add them as interact w/pt) <- theory behind standard precautions  DO standard 1 precautions automatically regardless of their diagnosis o What is the best way to control MRSA?  Gown/Glove, take off in proper way  Ha


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