Session 11:

Ayyy oh! This is the last lecture for the fundamentals course! I’m super excited that I have finished this class with all of you and hope that this momentum will carry over well into the future.

The topics for today are quality improvement and team work. Important things to remember are that there are topics covered that are basically lists and should be understood, but may not need to be memorized.

Teamwork and collaboration

QSEN – shared decision making respect, communication, respect, to achieve quality patient centered care.

  • there is shared power with the LIP  
  • work together as a team
  • respect the unique attributes that each team member has

Stages of team development (not necessarily linear, more fluid)

  1. Forming – excitement, anticipation, the beginning
  2. Storming – resistance, confusion, frustration, changing roles or positions
  3. Norming – acceptance of role and membership.
  4. Performing – interdependence, recognize strengths.
  5. Adjourning – end of the work, pride.

CRM – crew resource management

  • from aviation industry
  • addresses authority gradients
    • how to have a level of communication to allow people with lower power to be able to add their thoughts on the process, and recognizing the adverse situations.

Group think: restricts the flow of information and able to see all viewpoints of the scenario

disruptive behavior

  • verbal abuse, physical,

Learning from the leonard article

  • quality and safety
  • looking for team dysfunction related to culture
  • what we can learn from aviation to standardize communication
  • Power distance

Quality improvement

  • use data to monitor and improve outcomes and methods in the healthcare systems
  • completely dependent on data
    • how do I measure it?
    • what gets measured gets managed
  • florence nightingale – one of the first people to gather data and regulate hand washing
  • Never events
    • will not receive reimbursement
    • air embolism, CAUTI, DVT, Pressure ulcers, Falls, surgical site infections, MRSA during hospital stay.
  • Core measures – one consensus list, help determine what is done well and what needs improvement for people in the healthcare system
    • admittance, meds and time frame, interventions and diagnosis, can be improved to improve outcomes
  • PDSA – plan, do, study, act
    • system to improve systems
  • control chart is a chart that has a range that is “in control” ie. # of patients, the range is 4-6 patients and the actual data is added over the range
  • Gawande’s article
    • nurses needed to remind a provider to do missed steps
    • nurse is given the responsibility to make sure all the team members are following through the 5 steps
  1. wash hands
  2. clean pt’s skin
  3. sterile dressing
  4. wear a sterile mask, hat, gown, and gloves
  5. Place a sterile dressing over the catheter site

Fundamentals session 10:

Here is session 10 already, and this is the second to last class before the final! In this session we focused on care plans, nursing diagnosis, as well as communication. There are common sense tactics for communication, and the care plans will be a skill that improves with time as more and more a written. Happy studying!

-Peter

Session 10:

Nursing process and Diagnosis

the nursing process has changed over the years

1950’s care cure and core: assessment decision and nursing action

1967 APIE – assessment, planning, implementation, evaluation

  • Discover, delve, decide, do, discriminate

1970 nursing diagnosis is a separate step

APIE additions – Nursing diagnosis, and outcome identification

  • assessment, Nursing diagnosis, and outcome identification, planning, implementation, evaluation
  • discrete 6 step process
  • You will need to be able to verbalize this to your preceptor

assessment

  • the initial assessment is very important and sets the baseline of that patient
  • it directs care, and will set the goal for discharge

outcome identification – the goal for discharge

  • realistic client focused goals that are measurable
    • activity or VS goals
  • can be the patient’s goal, said by the patient

Planning – five column plan of care (one problem per plan)

  • Assessment Data
  • Goals
  • Interventions
  • Rational
  • outcome/ replanning

Implementation

  • it’s what you do to the patient

Evaluation

  • how did the implementation go?
  • Should be measurable

Diagnosis

  • Identifies the plan of care
  • a nursing diagnosis provides the basis for selection of nursing interventions
    • pressure ulcer
    • fall risk
  • types
    • Actual – human response to a health problem that is happening right now
      • 1. Diagnostic label must be NANDA approved
      • 2. Related factors – what contributes to the problem
        • Related to…
      • 3. Defining characteristics – observable cues that are related to the problem Dx
        • as evidenced by….
      • EX: impaired physical mobility R/T hip replacement as evidenced by inability to ambulate w/ walker
    • Risk – problems that may develop
    • wellness – we didn’t really go over this
    • possible – or this but may be tested on the NCLEX

Communication in Healthcare Communication on teams

Reporting from nurse to nurse is an art and needs to be practiced

  • develop good habits around the end of shift reports
  • “I don’t know” is not acceptable

reporting to provider

  • make it specific to the person that you are talking to
  • always see and assess the patient before making the call to the physician
  • know the notes associated to the patient

Any information that the patient give to you needs to be shared with the patient

circle of confidentiality is inside the care team

SBAR – know the tool and be comfortable

document read back – RB*1

Team STEPPS

  • we will be trained in all of these
  • improves patient safety
  • optimises team
  • every voice is heard and empowers everyone on the team
  • focused on the care plan
  • checklists, huddle
  • support team members
  • the Brief is important and comes first
  • huddle can happen at any time, is a specific time sensitive issue
  • debrief after care, what we did well, and what can be improved on

two challenge rule

  • tell the person at least twice before moving up the chain of command

Closed loop communication is crucial

Handoffs

  • this is a area when error can occur at a higher rate
  • clarify and ask questions

Charting

  • make sure charting is top notch when the care is not going as planned or there are questions that you are unsure about.
  • watch out for copy forwarding there is a huge chance to make errors
  • use military time
  • avoid vague descriptions
  • be concise, and objective. not subjective

theory of interpersonal relationships

  • do things with the patient, not for the patient
  • positive regard for patient ie, warmth, trust, positive attitude

Nonverbal communication is a huge % of total communication, about 90% or as low as 75%

OARS style motivational interviewing

  • Open ended q’s
  • Affirm
    • make it genuine and your own style
  • Restate
  • Summarize

clarity, going over the big picture

Fundamentals session 9:

Today we talked briefly about dosage calculations, then moved on to the main part which covered safety and pain management. In pain management there was a focus on the PCA and self titrating the medication. Happy studying!

-Peter

Dosing review topics

Pediatric dosing

calculate weight in lbs into kg

  • round to the first decimal place

Calculate the max daily dose by taking the dose amount times the amount of times that it is given

concentration of medication

  • 25,000u/500ml is twice as concentrated as: 25,000u/250ml
  • this means that the drip rate for #2 would be half as fast as #1

Safety

risk factors

  • bad systems
  • lack of communication systems
  • lack of standardization
  • fear of punishment for reporting

Culture of safety

  • cannot be a blame culture
  • focus on what went wrong, not the person
  • promote safety through education and training
  • cannot just “try harder” to stop errors
  • periodic assessment of the culture and relationship between the culture, and quality and safety

AHRQ

    • Measures culture of safety
  • reliable valid tools to measure culture of safety

Latent failure (blunt end of care)

  • affect the organizational policies

Active error (sharp end of care)

  • directly contacts the patient

NPSG – (national patient safety goals)

  • yearly update of the foci of the patient safety goals

Work safety

  • Make a “Brain” to make patient notes, to avoid relying on safety
  • work hours and, ratios, and under staffing
  • Using a checklist
  • team training
  • involve patients in care
  • Anticipate problems
  • Recovery – systems set up to improve errors once they occur
  • improving access to accurate information

Human factors

  • relationship between humans and technology
  • always a system contribution to the problem
  • Mindfulness – internal environment

Patients want an honest apology, know exactly what went wrong, and to have the system fixed.

the smetzer article

  • OB setting,
  • nurse thinking ahead but switching the antibiotic medication with the epidural
  • there are many system that added to this error
    • the mom died, but the baby made it.
  • Definitions to remember
    • hindsight bias – remembering differently than it actually happened
    • perceptual blindness – you see what you expect to see, no what is actually there.

Pain management

“Pain is whatever the experiencing person says it is, existing whenever they say it is” – M. McCaffery

Nociceptive pain – damage to somatic or visceral tissue

somatic pain – Localized – superficial or deep, stabbing, aching, throbbing

Visceral pain – damage to nerves PNS or CNS – in terms of internal organs

  • not always fully controlled with opiates

increase in vital signs does not always mean that the patient is in pain

the nurse cannot always tell whether or not the patient is in pain

pain can be associated with depression

there are many different scales but most measure from 0-10, 0 being no pain

  • there needs to be a system about assessment of pain

non medical interventions

  • relaxation
  • meditations
  • hypnosis
  • Acupuncture
  • Therapeutic massage

types of pain medications

opiate, non opiate, and Co-analgesic or adjuvant

fentanyl – is one of the quickest opiates, half life is .5 – 1 hr

respiratory depression is a fear when withholding pain medication

tolerance – need to increase the dose for same effect

physical dependence – suffering when the drug is stopped

IM injection is a bad way to administer pain medication

PCA – patient controlled analgesia

  • can track the number of attempts
  • usually morphine or dilaudid
  • loading dose is already given
    • the medication is locked in the pump
  • the basal rate is the minimum that will be given w/out the button being pushed
  • PCA dose by proxy is controlled by a family member or someone close to the patient
  • the delay/lockout is set so that the dose can only occur a specific amount of times per hour.
  • verify the programming of the pca pump

NARCAN is the antidote for opiates

Epidural analgesia – given into the space around the spine

  • block is a single dose
  • PCEA is a PCA but into the epidural space
  • risk for hypotension
    • fall risk
  • should not be on anticoagulants

maintenance of the epidural catheter

  • reinforce dressing as needed
  • monitor sight for issues

testing sensation for epidural

  • test sensation with ice at levels bilaterally
    • test to area away from numb site
    • OK: T7-L1 L=R
    • OR different: L T7-L1, R: T8- L2

Fundamentals Session 8:

Hey all, here are the notes for fundamentals session 8! This is the last session for test 4, then after that it is the final! Good luck guys and happy studying!

-Peter

Session 8:

Nutrition and Altered Bowel Function, Interventional Hygiene, Fall Risk, and Safety

Nutrition and Altered Bowel Function

Important for all patients

Swallowing ability is crucial

meds that affect:

  • steroids increase appetite
  • insulin
  • Chemotherapy

subjective data:

  • 24 hour recall
  • Dx processes

objective data:

  • observations
  • height, weight
  • arm circumference
  • skin folds
  • Calorie count

serum albumin vs prealbumin

  • SA is > ½ of the body’s total protein, assess the long term protein stores.
  • Prealbumin has a shorter life and can test the short term protein stores.

types of diets

  • NPO – none through mouth
  • clear diet
  • full liquid
    • liquid at room temperature (ICE CREAM!! 🙂
  • Soft
  • diet as tolerated
  • Restrictive (Na, renal, ADA, reduced calorie diet)

why do we with hold food?

  • before surgery
    • prevent aspiration

We can have a pt NPO for up to 24-48 hours

Renal diet

  • low protein, K, Na, and fluid restriction

Liver Dx

  • early, only low Na
  • Late in Dx, low protein(lactulose can get the ammonia out of the blood), Na, and fluid

CHF – restrict Calories and fluid

CAD – lower Na, calories, Sat fat, and cholesterol

Burns- fluid replacement early, high protein, calories, Vit C and B

Respiratory – soft, high calorie and protein

HTN – restrict sodium

Normal bowel function

body pulls fluid from GI tract first if needed

narcotics and pain management can cause impaction and constipation

If you have a pt that chronically uses laxatives they need teaching to show them that taking them that frequently is not optimal.

Diarrhea can cause fluid and electrolyte imbalances

Ostomies

  • temporary or permanent
  • continent or incontinent
  • stoma or artificial opening
  • colostomy in the colon
  • ileostomy  
  • challenge body image

Enemas – cleanse bowel of stool

  • use warm water
  • cramping will occur if too fast infusion

Nutrition and tube feeding

different tube sizes

  • the large bore gastric tube is not used for too long due to the

Naso gastric – nose to stomach

  • large bore
    • salem sump tube
  • can suction and feed
  • placed by nurse
  • less than 4 weeks (short term)
  • hard to place, tuck the chin to avoid the trachea
    • can spray back of throat with medication to lessen the gag reflex
  • If connected to suction measure I/O’s

Dobb-hoff

  • nose to illium
  • white opaque, small
  • no suction only feedings
  • placed by radiology
  • weighted end that can be visualized in radiology

Jejunostomy tube

  • surgically
  • long term
  • small intestine out at stomach

Confirm placement before putting anything in the tube with x-ray

The rate of the feeding should not feed faster than the pt can digest

Checking gastric residuals volume Only for gastro, not small intestine, if the residual amount is over ½ of the previous bolus, then the rate of nutrition may be too fast.

There are pumps that can select the feeding rate

  • you ramp up to the rate you want and ween off when done.

Medications can go through these tubes

  • crush meds (some meds cannot be crushed, enteric coating and extended release drugs)

If the Patient is laying down flat there is a risk for aspiration

Parenteral Nutrition

not through the GI

TPN ALWAYS goes through a central line

    • large volumes
    • contains nutrients, insulin, and/or PPIs
  • BAG and LINE are changed every 24 hours
  • have to use a pump, and it is always continuous infusion
  • filter in the line

PPN Peripheral Parenteral Nutrition – same as TPN, but lower amounts, and in the peripheral vein

  • supplementally for short periods of time
  • may not have lipids

both of these are specific to patient

Complications:

  • Risk of infection
  • High Glucose levels

Interventional hygiene

Very important for the rapport with the patient and the patient’s family, shows that you care.

Patient safety:

positioning:

  • they all have risks and values

Left sided sims is a good position for an enema

reposition an immobile patient every 2 hours

Assess every single patient for fall risk

  • Age, hypotension, meds that depress CNS, or diuretics because of the need to get up a lot, post op, highly tethered patients, weakness, confusion

educate the patient and the family about their risk and how to deal with it.

Make sure the patients have their call light.

Restraints

    • they are dangerous and there needs to be an order
  • you must document the sefer ways that have been tried first before restraints are used
  • use measured interventions to lead up to restraints.
  • document the skin integrity, circulation, and status every 2 hours
  • Mitts to stop the patient from pulling things out.
  • Quick release knots are imperative and required to know how to tie.

Fundamentals session 7:

Hey guys, here is session 7 of the fundamentals lecture. It is the beginning of the test four material and covers, skin therapy with wound assessment, and urinary elimination techniques. Nice and quick with out to much to trip up on.

Thanks for reading!

-Peter

Skin integrity and wound healing

beginning of test 4 material

Session 7

Skin is the largest organ in the body

  • epidermis
  • Dermis
    • where the hair anchors to
    • the sweat gland starts in the mid bottom of the dermis
    • vascularity though the dermis
    • beefy red and wet wound is superficial dermal
    • pink red and less wet to dry wound is deep dermal
  • Subcutaneous

Assessment

  • color, vascularity, turgor, lesions

History

  • Age, diagnosis, DM, moisture(fecal or urinary incontinence), smoker(slow angiogenesis and vessel atrophy), nutrition(decent protein and water intake, zinc and vit C), perfusion assessment (ABI), mobility (bedridden), nasal cannula,

inspection of skin

  • jaundice will be seen in eyes first
  • erythema: palpate and inspect, temp, and blanch, erythema will blanch
  • assess on admission, when bathing, and moving

excoriation

  • abrasion or scration mark, uneven and red

Skin lesion

  • elevation- flat, raised, pedunculated
  • size in cm
  • exudate – drainage, from the white cells that were cleaning the wound
    • clean with NS or water, if infected the smell will not go away
  • chronology of appearance, and change in morphology
  • infected wounds hurt in a specific location
  • healing wounds hurt overall when exposed to air

Perfusion and O2 assessment

  • baseline VS
  • cap refill
  • color, temp

chronic wounds

  • not healed in 4 weeks
  • disorganized healing and chronic inflammation
    • inflammation over 96 hours, can be caused by DM or steroids
  • ex. DM ulcer, vessel ulcer

Acute wound

  • predictable healing less than 3 weeks
  • laceration, abrasion, incision
  • inflammation 96 hr

wound closure

  • First intention (primary union) – incision, sterile, early suture, small scar
  • second intention Granulation- gaping irregular wound, biggest scar
  • third intention (secondary suture)- wound, closure with wide scar
  • we want the least scarring for the pt’s well being and self image

phases

  • inflammation – reactive – macrophages
  • proliferation – reparative – Angiogenesis
  • maturation – collagen remodeling, in 6 months the wound skin is 90% as strong as uninjured skin.
  • extend the joint to avoid contracture
    • this can be painful

wound assessment

  • red yellow black
  • types of tissue
  • granulation tissue
    • red, moist, beefy, good sign of healing
  • slough
    • yellow, stringy substance on wound bed, use % for colors
  • eschar
    • described as “%covered in eschar
    • uncategorizable until eschar removed

tunneling – narrow channeling in wound

undermining – the skin is over the unhealed wound

Periwound – tissue around the wound

increase in drainage when the wound is getting infected.

Braden score assessing the skin 3-21, 18 is at risk for pressure ulcers higher is better

Deep tissue injury – acutely immobile, maroon/purple blood blister, if it breaks i can be a stage IV

  • off load the pressure!
  • stage if breaks

Stage 1-IV

  • I – skin unbroken
  • II – breaks epidermis into dermis
  • III – deep dermis
  • IV – into subcutaneous tissue  
  • unstageable – the wound is covered in eschar and level cannot be seen

MAAD – moisture associated dermatitis

IAD – incontinence associated dermatitis

psoriasis – skin growing too quickly and creates a silvery scaly patch

wound cleaning

  • Keep a moist wound covering over the wound
  • don’t scrub wounds anymore, just rub gently and tap water is ok for cleaning ie shower

Keloid scar – raised scar

Urinary Elimination: Altered Function Assessment

factors affecting the process – renal conditions

  • Prerenal
  • intrarenal
  • Postrenal

Healthy adequately hydrated patient will produce 30 ml of fluid an hour  

  • > 30ml for more than 2 hr is important and action needs to be taken

UTI – bacteria entered the urinary tract

  • cloudy(turbid) urine

Altered urinary elimination define:

  • Dysuria, polyuria, oliguria, urgency, frequency, nocturia(urination at night), hematuria(blood in urine) pyuria(pus in urine)
  • find the pt’s normal range

5 types of incontinence – Urge, stress, functional,

Urinary samples that are less self explanatory

  • Clean catch – sterile.
  • 24 hour specimen – collect urine over 24 hours.

catheter types

  • intermittent
    • spinal injury pt’s use this as opposed to a sterile foley.
  • Indwelling:
  • Foley
    • insert to the Y tubing before inflating the balloon to avoid inflating in the urethra.
    • keep bag lower than the bladder. (no back flow)
    • 50% infection rate after 7 days
    • Can be delegated
      • still responsible!
    • secured to leg
    • document time of removal

CAUTI – catheter Associated UTI

  • risk factor is duration of foley insertion

when is it ok for indwelling cath

  • accurately measure output (kidney injury)
  • bladder outlet obstruction
  • immobile
  • end of life care

Meatal care – skin around the foley needs to be clean

Non invasive therapies

  • Bladder Ultrasound measures volume
  • Bed pan

Stoma is an internal organ to the abdominal wall, in this case to transport urine from the ureters to the outside of the body. this would happen if a bladder was removed.

Neobladder – new bladder from intestinal tissue

Ureterostomy – brings ureters to the abdominal wall to drain,
supra pubic catheter is surgically placed and is long dwelling, the tube is directly inserted into the bladder.

Fundamentals study guide for test 3:

Hey guys, here is the fundamentals study guide! Its a little late, but I think this material is reasonable and somewhat easier to understand than the previous tests. I will post the not filled out study guide below and the finished one will be in a link at the end. Thanks for reading!

-Peter

test three study guide

  1. Crystalloid vs colloid fluids
  2. Bolus and push are pretty synonymous in this class, how long are they infused over?
  3. Intermittent infusion is what?
  4. what are primary and secondary bags used for?
  5. When do you change the IV line?
  6. how much does one liter of water weigh
  7. Normal values for Na, K, Ca, Glu, BUN, creatinine
  8. when giving a bolus of K what should always be used to set the rate?
  9. A high/low specific gravity indicates what?
  10. s/s with fluid volume excess
  11. s/s with fluid volume deficit
  12. 8oz of ice is 240ml but ___ml when melted?
  13. Donor vs autologous blood?
  14. types of blood products, 4 types?
  15. which has the biggest volume
  16. ABO blood typing system and rh factor
  17. three reactions to blood products?
  18. Pulmonary embolism s/s
  19. Sa02 Sp02 and Pa02 definitions
  20. flow rates range for nasal cannula, and nonrebreather
  21. what is a yankauer? what level of suction does it use?
  22. What does VAP stand for?
  23. Patient satisfaction organizations of management (3)?

Here is the filled out version!

Fundamentals session 6: fluid and electrolytes, blood therapy, and the end of IV

Hey all, this session was filled with a ton of material. overall I do not think that it was overly difficult material, but there was quite a bit of it. The main foci were the administration of blood products, the end of IV, and fluid and electrolytes. A lot of this material is common sense, and in some cases review, so take a quick look at it and hopefully you can make it though my errors!

-Peter

 

Fundamentals

 

Beginning of test three material:

 

    • containers: we are moving towards plastic containers
      • glass is non collapsible
      • this may have a vent if non collapsible
    • crystalloids: fluids that are clear
      • isotonic
      • hypotonic
      • hypertonic
    • colloid: contain proteins or start molecules
      • albumin, blood products, hetastarch
    • examples of IV solutions
      • D5 W, 0.9%NaCl, 0.45% NaCl
    • needleless systems
      • heprin lock, buff cap
      • Positive pressure cap (possi-flow)
    • Admin sets
      • spike bag w/out breaking sterility
      • prime line to take out air
    • Infusions
      • intravenous bolus (less than 5min)
        • also called a push!
      • IV infusion
        • continuous
        • intermittent – can be a secondary bag or piggy back.
      • Primary – maintenance fluids
      • secondary bag – infuses through the primary solution (piggy back)
        • higher bag will infuse first.
      • flow rate: IV pump or manual roller clamp
        • factors that affect flow – kink in the line, IV patency, clogged air vent (in a bottle), height of IV bag, hight of IV in patient
        • VTBI: volume to be infused
      • the nurse is responsible for the IV line!
      • when do we change the IV solution and line?

 

  • lipid emulsion w/out TPN (change with each bag) w/ TPN every 24 hours. Max is 24 hours

 

      • change bag with line
      • Max line change time for any solution 96 hours (4 days)

 

Fluid balance and electrolytes nursing assessment and intervention

  • ECF: extracellular fluid
  • ICF: intracellular fluid

 

    • RASS system controls the blood pressure and changes the fluid amounts in the different areas.
    • daily weight – have it a same time each day

 

  • one liter = 1 kg

 

      • loss 6.6 lbs means about 3 liters of fluid was removed from the body
    • I/Os – ins and outs
    • Basic metabolic panel: BMP
      • important lab values to know: Na, K, Ca, Glu, BUN, creatinine
    • Na- 135-145 mEq/L
      • need to know for NCLEX, but in the hospital there are usually a normal limits guide next to the lab value.
    • K – 3.5 – 5

 

  • Always when giving a bolus of K, use an IV pump.

 

    • don’t exceed 10-20 mEq/hr infusion
  • Ca – 8.5 – 10.1 mg/dL
  • Mg – 1.5 – 1.9 mEq/L
  • Phos – 1.7 – 2.6 mEq/L

 

fluid volume deficit – nausea, vomiting,

  • s/s weight loss, thirst, orthostatic hypotension
  • interventions – start with the least invasive (PO) and move to more invasive, (IV)

 

fluid volume excess – dt cardiac, liver, or kidney dx

  • I/O is very important
  • s/s edema, JVD, tissue tugor
  • lab studies – CBC, serum electrolytes, urine pH and specific gravity, ABG
  • connection to respiratory distress is the fluid will back up from the heart into the lungs.

 

management of Fluids and electrolytes

  • I/O
  • weight
  • calorie count
  • LOC
    • Changes in LOC are always important.
  • skin tugur

serum albumin – >½ body’s total protein,

prealbumin – short term and is better at assessing current values

 

Ascites – over all body edema

  • paracentesis: pulling fluid out of a patient w/ needle and vacuum bottle

Fluid volume deficit:

(hypovolemia)

increased HR

decreased BP

increased RR

decreased UO

decreased skin turgor

decreased weight

Restlessness, lethargy

Assess electrolytes

Give fluids

 

Fluid volume excess

(hypervolemia)

increased HR

increased BP

increased weight

increased edema

Neck vein distention

Crackles

Headache, confusion

Assess electrolytes

Remove fluids

 

electrolyte replacement

  • PO or IV
  • use caution
  • normal saline is not considered replacement of electrolytes

 

fluid restriction

  • ex. 2000ml FR apply evenly over 24 hours
  • ice melts to half its volume
    • 8 oz = 240ml = 120ml when melted (record this number)

 

I/Os – totalled over 24 hrs, monitored every hr (ICU) or 8 depending on unit

 

NG tube – nasogastric tube – suction out of the stomach for GI rest.

  • falls into the OUTput category usually but can be input

 

Labs

  • usually pulled by phlebotomus
  • there may be a specific order to the drawing of labs
  • administering the wrong blood type can be fatal
    • cross match and type of blood needs to be redone every three days.
    • optimally ¾ filled with blood in the draw tube
    • labeling labs is extremely important.
    • performing veno puncture
  • critical results
    • promptly communicate to caregiver, caregiver writes it down and reads it back.
    • communicate to LIP within 30 min.

 

IV therapy: blood product administration

 

why give blood products?

 

sources of blood products

  • donor
  • Autologous: donor is self
  • Autotransfusion: returns own blood to self

 

whole blood is the highest volume

  • one unit = 500ml

PRBC- packed red blood cells

  • 80% of plasma removed
  • one unit = 250 ml

WBC

Platelets (thrombocytes)

  • for thrombocytopenia

 

ABO is carried on RBC

    • O- is universal donor
    • AB+ is universal recipient
    • -Rh
    • +Rh
    • Know comprable blood types

 

  • double check blood type with two licensed RNs
  • student cannot give blood products, only spike bag

 

 

giving products:

  • Prime IV line with normal saline
  • double check all ID information
  • PRB can take 4 hr to infuse 1 unit
  • Reaction to reaction to blood type will be a change in vitals
    • take baseline before and 15mins after
    • s/s: facial flushing, fever, HTN, increased HR,
    • Febrile reaction
      • hypersensitivity to donor WBC
      • s/s fever, chills, headache, malaise
    • allergic reaction
      • s/s flushing, hives (urticaria), wheezing, rash
    • Septic reaction
      • fever chills, vomiting, diarrhea, and hypotension

 

Respiratory compromise Interventions

 

use the ABC’s to prioritise patients

 

Shortness of breath (SOB) can be caused by many things

 

Breathing quality and pattern

 

circulation

  • change in LOC may be one of the first critical signs
  • pulse oximetry
  • color
  • VS

 

Pulmonary edema

  • ronchi, crackles, hypoxic

Pulmonary embolism

  • hypoxic, pain on inspiration, history of DTV,

pneumonia

  • fever, hypoxic

 

ABG’s are the most current O2 status

  • very invasive, sticking the artery

 

Sa02 – arterial O2 (hypoxia)

Sp02 – Hemoglobin saturation %

Pa02 – tissue oxygenation (hypoxia)

 

Deep breathing and coughing can prevent atelectasis

 

incentive spirometer – inspire slow and steady and record the number that it maxes out on.

 

 positioning and ambulation

  • tripod: leaning on hands or elbows while pt is sitting or standing
  • fowler’s position 45 – 60 degrees
    • semi fowler’s 30 degrees
    • high fowler’s 90 degrees

MDI – metered dose inhaler

  • spacer can hold the med and inhale when ever

 

aerosol given via nebulizer

  • most common is bronchodilators

 

O2 therapy

  • prescribed in terms of liter flow or concentration
  • can be used without an order if the patient is in immediate need
  • use the least amount necessary to prevent the drying of the nasal membranes
  • low flow – 1-6L/min of 02
  • high flow – 10-15L/ min