PCCN: CHAPTER 1 - ASSESSMENT OF PROGRESSIVE CARE PATIENTS AND THEIR FAMILIES EXAM | QUESTIONS & ANSWERS (VERIFIED) | LATEST UPDATE | GRADED A+

1 PCCN: CHAPTER 1 - ASSESSMENT OF PROGRESSIVE CARE PATIENTS AND THEIR FAMILIES EXAM | QUESTIONS & ANSWERS (VERIFIED) | LATEST UPDATE | GRADED A+ Why is assessment of acutely ill patients and their families essential? Correct Answer: information obtained identifies immediate and future needs so a plan of care can be initiated Traditional approaches to Patient Assessment include: Correct Answer: - include a complete evaluation of patient history - comprehensive physical exam of all body systems Progressive care clinicians must balance: Correct Answer: -need to gather data -prioritizing and providing care Collection of assessment data is obtained in: Correct Answer: -phased or staged manner -consistent with pt care priorities 2 What is the crucial element to developing competence in assessing progressive care patients? Correct Answer: -consistent and systematic approach Discuss the importance of a consistent and systematic approach to assessment of progressive care pt and families? Correct Answer: - helps avoid missing subtle signs or details that identify actual or potential problem -indicate a pt's changing status Assessments should first focus on (2): Correct Answer: -patient (focal point of practitioner's attention) -technology (augments info obtained from direct assessment) What are the TWO standard approaches to assessing patients? Correct Answer: -head-to-toe approach -body systems approach Most progressive care nurses use a (2): Correct Answer: -combination systems approach -applied in a top-to-bottom manner 3 Assessment of the progressive care patient begins (2) Correct Answer: -moment nurse aware of pending admission/transfer -continues until transitioning to next phase of care The pre-arrival assessment helps the nurse (3): Correct Answer: -paint an initial picture - to anticipate physiologic and psychological needs -determine appropriate resources needed The information received in the prearrival phase is crucial because (2): Correct Answer: -allows nurse to adequately prepare environment -meet specialized needs of pt/family When should the arrival quick check assessment be obtained? Correct Answer: -immediately upon arrival to the unit What assessment acronym is used in the arrival quick check assessment? Correct Answer: _"ABCDE" Define what the letters in the assessment acronym, "ABCDE" represent. Correct Answer: A = Airway B = Breathing 4 C = Circulation, Cerebral Perfusion and Chief Complaint D = Drugs and Diagnostic tests E = Equipment The FOCUS of the quick check assessment is a quick overview of the: Correct Answer: -adequacy of ventilation and perfusion -to ensure early intervention for life threatening situations -(obtaining a quick overview of the key life-sustaining systems) Why is the arrival quick check is ESSENTIAL because: Correct Answer: -validates that basic cardiac and respiratory function is sufficient When is a comprehensive assessment done? Correct Answer: As soon as possible The timing of the comprehensive assessment is dictated by: Correct Answer: -degree of physiologic stability -emergent treatment needs 5 When the patient is admitted directly to PCU from OUTSIDE the hospital, the comprehensive assessment includes: Correct Answer: -an in depth assessment of PMH and social hx -complete physical exam of each body system If the patient is TRANSFERRED to PCU from another area in the hospital the comprehensive assessment includes: Correct Answer: -review of admission assessment data -comparison to the current assessment The comprehensive assessment is VITAL because: Correct Answer: - it influences successful outcomes -provides invaluable insight into proactive interventions What follows the conclusion of the comprehensive assessment? Correct Answer: - Ongoing assessments begin Define: ongoing assessment Correct Answer: -an abbreviated version of the comprehensive assessment that are more focused and driven by the stability of the pt What do the ongoing assessments determine? Correct Answer: -TRENDS 6 -response to therapy -identify new problems -changes from baseline Name the FOUR types of assessments performed: Correct Answer: -pre-arrival assessment -arrival quick check assessment -comprehensive initial assessment -ongoing assessment Identify the assessment priorities for each of the four types of assessment: Correct Answer: Pre-arrival = prepare environment Quick Check = validates basic cardiac/respiratory function is adequate -Comprehensive = vital to successful outcomes by providing insight into proactive interventions -Ongoing = re-evaluates pt's specific condition, treatments & response to therapy Admission of an acutely ill pt can be chaotic and staff must be cognizant of: Correct Answer: -accurate assessments & data gathering to ensure the pt is cared for safely with appropriate interventions. 7 Obtaining inaccurate information on admission can lead to: Correct Answer: -ongoing errors that may not be easily rectified or discovered -lead to poor pt outcomes Obtaining information from an acutely ill pt may be difficult. Name other sources that must be utilized: Correct Answer: -family -electronic health records (EHR) -past medical records -transport records -pt belongings What is of particular importance when a pt is admitted? Correct Answer: -obtaining accurate pt ID -PMH -allergies -current Rx Identifying current meds the pt takes can: Correct Answer: -provide clues to medical condition -contributing facts to the current condition 8 Name THREE types of imperative medical information: Correct Answer: -advance directives -allergies -next of kin What is of particular importance during the assessment? Correct Answer: -risk for pressure ulcers formation -alteration in mental status -falls accurate patient ID Name FOUR things that can contribute to skin breakdown in elderly patients. Correct Answer: -loss of muscle mass -osteoporosis -osteoarthritis -kyphosis Name some safety issues nurses need to be cognizant of as treatment begins. Correct Answer: -accurate programming of pumps infusing high-risk Rx -use all safety equipment available -pre-programmed drug libraries -bar coding technology 9 -ensure safety of invasive procedures Identify the key information that should be included in the pre-arrival report: Correct Answer: -chief complain -diagnosis -reason for admission -pertinent history details -physiologic stability -gender & age -presence of invasive tubes & lines -medications being administered -ongoing treatments -pending or completed labs/diagnostic tests -isolation requirements Why is being prepared for isolation needs important? Correct Answer: -prevents potentially serious exposures to patient, roommates and HC workers What should be VERIFIED prior to the pt's arrival? Correct Answer: -proper functioning of all bedside equipment From the moment the pt arrives in the PCU, what is 10 IMMEDIATELY observed? Correct Answer: - general appearance -assessment of "ABCDE" What type of 'needs' are addressed FIRST? Correct Answer: -Urgent needs Identify actions that take place when pt first arrives in PCU? Correct Answer: -seriousness of problems determined and addressed -connected to monitors & support equip -Rx being admin are verified -essential lab/diagnostic tests ordered List THREE ways the nurse can validate the pt is properly identified: Correct Answer: -hospital wristband -personal ID -family ID When identifying pt allergies, what else must the nurse verify? Correct Answer: -type of reaction that occurs -what, if any, treatment is used to alleviate the allergic response 11 When a pt is transferred to the PCU, who is the LEADER of the receiving team? Correct Answer: -the PCU nurse What are the responsibilities of the PCU nurse? Correct Answer: -assumes responsibility for assessing the "ABCDE's" -directs team in completing delegated tasks Why is having a designated LEADER of the receiving team so critical? Correct Answer: -prevents fragmentation of care -reduces possibility that vital assessment clues overlooked If preliminary assessment deviates from normal then: Correct Answer: -interventions are immediately initiated BEFORE continuing with the arrival quick check assessment How does the nurse verify the patency of the pt airway? Correct Answer: -have pt speak -watching chest rise or fall -both What INITIAL action is initiated if the airway appears compromised? Correct Answer: -verify the head positioned properly to prevent the tongue 12 from occluding the airway What should the upper airway be inspected for before inserting an artificial airway? Correct Answer: -blood -vomitus -foreign objectys What should the nurse ENSURE if a pt has an artificial airway such as a cricothyrotomy or tracheostomy? Correct Answer: -airway is secured properly -note position and size markings Describe Correct Answer: Identify THREE characteristics of secretions, that should be assessed when suctioned from the airway? Correct Answer: -amount -color -consistency Identify elements observed when assessing a pt's breathing status? Correct Answer: -rate, depth, pattern 13 -symmetry of breathing -effort -use of accessory muscles When a pt is on mechanical ventilation assess for: Correct Answer: -whether breathing is in synchrony with the ventilator Identify THREE nonverbal signs of respiratory distress> Correct Answer: -restlessness -anxiety -change in mental status Auscultate the chest for: Correct Answer: -presence of bilateral breath sounds -quality of breath sounds -bilateral chest expansion During the arrival quick check assessment, where does auscultation of the chest usually take place? Correct Answer: -anterior chest When chest tubes are present, assess for: Correct Answer: -type (pleural or mediatsinal) 14 -connected to suction (wall or water) -not clamped or kinked -functioning properly (FOCA & DOPE) Define mnemonic: FOCA Correct Answer: -F = Fluid fluctuation with respirations -O = Output -C = Color of drainage (amount and character) -A = Air leak Define mnemonic: DOPE Correct Answer: -D = Dislodgement -O = Obstruction -P = Pneumothorax -E = Equipment functioning properly When assessing circulation: Correct Answer: -palpate a pulse -observe EKG for rate, rhythm and presence of ectopy -BP and Temp When assessing PERIPHERAL perfusion: Correct Answer: -evaluate color, temp, moisture of skin 15 -capillary refill -inspect for active bleeding What is the FOCUS when assessing CEREBRAL perfusion: Correct Answer: -determining the functional integrity of the brain as a whole How do you assess the functional integrity of the brain? Correct Answer: -by rapidly evaluating the gross LOC Define the elements assessed in evaluating the gross LOC. Correct Answer: -Alert -Aware of surroundings -Type of stimulus required to obtain a response ( verbal or painful) -Unresponsive What kinds of things can be assessed during transfer from a stretcher to the PCU bed? Correct Answer: -are the eyes open & watching events -follow simple commands -if unable to speak due to artificial airway, do they nod head appropriately to questions 16 List some reasons why it is NOT advised to use family or friends to translate for a nonEnglish speaking patient. Correct Answer: -protection of pt privacy -not understand appropriate medical terminology -avoid well-intentioned but potential bias In the absence of a history source, practitioners must depend exclusively on what sources of information to identify the potential causes of admission? Correct Answer: -physical findings (presence Rx patches, permanent pacemaker, old surgery scars) -knowledge of pathophysiology -access to prior paper or electronic medical records What does assessment of the chief complaint FOCUS on? Correct Answer: -determining the body systems involved -extent of associated symptoms -time of onset -precipitating factors -severity What additional information is integrated into the priority of the arrival quick check? Correct Answer: -infusing medications -diagnostic tests 17 Identify common DIAGNOSTIC tests obtained during the arrival quick check assessment. Correct Answer: -serum electrolytes -glucose -complete blood count with platelets -coagulation studies -CXR -EKG At what time does the comprehensive assessment begin? Correct Answer: -after completion of the "ABCDE's" If any component of the ABCDE's has not been stabilized & controlled, what happens next? Correct Answer: -energy is focused FIRST, on resolving the abnormality -THEN, proceeding to the comprehensive admission assessment What are some possible pitfalls that can occur during handoff report? Correct Answer: -safety gaps may occur -omission of pertinent information -miscommunication can result in pt care errors 18 What is an example of a standardized handoff format? What is the advantage of using this format? Correct Answer: -SBAR - it can minimize potential for miscommunication Define mnemonic: SBAR Correct Answer: -S = Situation -B = Background -A = Assessment -R = Recommendations What does the comprehensive assessment determine? Correct Answer: -physiologic and psycho-social baseline -defines pt pre-event health status What does the comprehensive assessment include? Correct Answer: -pt's medical history -brief social history -physical exam each body system Why should additional emphasis be placed on the PMH of patients who are elderly? Correct Answer: -frequently has multiple, co-existing illnesses 19 -taking multiple prescriptive Rx & OTC - What elements of the social history must be addressed in patients who are elderly? Correct Answer: -home environment -support systems -self-care abilities What MUST be taken into consideration when interpreting clinical findings in the elderly patient? Correct Answer: -the coexistence of several disease processes + diminished reserves of body systems results in more RAPID PHYSIOLOGIC DETERIORATION When inquiring about the use and abuse of caffeine, alcohol, tobacco and other substances, questions are aimed at determining what? Correct Answer: -the frequency, amount and duration of use Information revealed during the social history can be verified during the physical assessment by: Correct Answer: -presence of needle track marks -nicotine stains on teeth and fingers -smell ETOH on breath 20 Why should patients be asked about physical and emotional safety in their home environment? Correct Answer: -to uncover potential domestic or elder abuse What are the primary body systems that aging effects? Correct Answer: -Nervous -Cardiovascular/Circulatory -Respiratory -Renal -GI -Endocrine, Hematologic & Immunologic -Skin -Musculoskeletal -Psycho-social Identify specific effects aging has on the NERVOUS system. Correct Answer: -diminished hearing and vision -ST memory loss -altered motor coordination -decreased muscle tone and strength -slower response to verbal and motor stimuli -decreased ability to synthesize new information 21 -increased sensitivity to altered temperature states -increased sensitivity to sedation (confusion/agitation) -decreased alertness states -nerve cells transmit more slowly -increased incidence intracerebral hematomas (due to anticoagulant use) How does nerve cells that transmit more slowly effect the body of an older patient? Correct Answer: -reduces reflexes -reduces sensation -problems with movement & safety -reduced pain perception and control Brain tissue atrophy results in the following: Correct Answer: -stretching parasagittal bridging veins (making them more susceptible to rupture -additional space in cranial vault (that allows bleeding to accumulate before S/Sx of increased ICP present) -higher incidence of chronic subdural hematomas Identify THREE factors that increase bleeding tendancies in older adults: Correct Answer: -anticoagulant therapy (Coumadin, Heparin, Lovenox) -antiplatelet therapy (ASA) 22 -alcohol abuse How does alcohol abuse directly effect bleeding tendancies? Correct Answer: -causes brain atrophy -causes liver damage that precipitates clotting problems Identify age related compromises to the CARDIOVASCULAR system. Correct Answer: -increased effects of atherosclerosis of vessels/heart valves -decreased stroke volume with resulting decreased cardiac output -limited cardiac reserve -decreased myocardial conpliance -increased workload of heart -diminished peripheral pulses -orthostatic hypotension (due to loss of sensitivity of baroreceptors) -left ventricular thickening (decreases filling capacity and delays filling time) -muscle mass reduction (results in decreased contractility) -reduction in total body water (increases risk for dehydration) -anemia 23 Identify THREE reasons why anemia is common in older adults. Correct Answer: -nutritional deficiencies -chronic inflammatory disease -chronic renal disease What may be an indicator of significant physiologic stress? Correct Answer: -heart rate greater than 90 bpm Identify age related compromises to the RESPIRATORY system. Correct Answer: -decreased compliance and elasticity (recoil) -decreased vital capacity -increased residual volume -decreased gag and cough reflexes (increased incidence of aspiration, infection & bronchospasm) -decreased response to hypercapnia -oral/nasal mucosa thinner -atrophy of oral mucosa (lead to poorly fitting dentures) -relaxed musculature of oropharynx (increased incidence of aspiration) -Temporomandibular & C-arthritis (make intubation more difficult) -loss of strength in muscles of respiration & diminshed endurance 24 -rib calcification -respiratory fatigue occurs more easily (resulting in hypoxia) What complications can occur when small airways lose recoil (elasticity) ? Correct Answer: -potential airway collapse -air trapping -uneven distribution of ventilation List THREE factors that reduce arterial oxygen saturation and cardiac output. Correct Answer: -pain -injury -extended supine positioning Identify FOUR effects that rib calcification can have on maintaining adequate ventilation. Correct Answer: -decreases inspiratory/expiratory force -reduces chest expansion -increases RR -reduces tidal volume Following minor thoracic injuries, older patients experience higher complication rates with: Correct Answer: -pulmonary edema 25 -atelectasis -pneumonia When inserting an oral or nasal airway & when suctioning, use caution because: Correct Answer: -mucosa is thinner in older adults -may be on anticoagulant therapy Elderly patients on anticoagulant therapy, requiring insertion of a nasopharyngeal or oropharyngeal airway are at greater risk for what complications? Correct Answer: -swelling -bleeding -hemorrhage Define: hypercapnia Correct Answer: -excessive carbon dioxide in the bloodstream, typically caused by inadequate respiration Identify TWO examples of rheumatic conditions that can make intubating older patients more difficult. Correct Answer: -arthritis -osteoporosis 26 What specific effects can arthritis and osteoporosis have during intubation of older patients? Correct Answer: -limited visualization of vocal chords (due to decreased mobility with the jaw thrust) -increased possibility of C-spine injury during instrumentation Identify age related compromises to the RENAL system. Correct Answer: -decreased glomerular filtration rate -increased risk of fluid and electrolyte imbalances -decreased number of nephrons (limits the ability to concentrate the urine) -diminished sense of thirst (leads to dehydration) Identify age related compromises to the GI system. Correct Answer: -increased presence of dentition problems (dentures) -decreased intestinal mobility -decreased hepatic metabolism -increased risk of altered nutritional states Identify age related compromises to the ENDOCRINE, HEMATOLOGIC & IMMUNOLOGIC system. Correct Answer: -increased incidence of DM; thyroid D/O; anemia; 27 -decreased antibody response & cellular immunity -thyroid function drops (slowing metabolism) -parathyroid levels rise (increasing risk osteoporosis) -increased incidence of metabolic syndrome (Type 2 DM) ( blunting effects of insulin) -aldosterone production drops (predisposing orthostatic hypotension and dehydration) Identify age related compromises to the SKIN. Correct Answer: -decreased skin turgor (due to breakdown of elastin) -increased capillary fragility & bruising -decreased elasticity -decrease thermoregulation -loss of SQ fat = thinning of the skin -decreased ability to sweat Define: thermoregulation Correct Answer: impaired heat conservation, production and dissipation Identify situations that contribute to the risk of compromised thermo-regulation: Correct Answer: -loss of SQ fat & thinning of skin -decreased ability to sweat -neurologic changes 28 -chronic cardiac or thyroid conditions -poor nutrition -psychotropic medications -temperature extremes Identify environmental factors that cause skin to age. Correct Answer: -lifestyle -diet -heredity -sun exposure -smoking -obesity -immobility Identify age related compromises to the MUSCULO-SKELETAL system. Correct Answer: -older adults predisposed to C-injury -osteoporosis -changes in bone density -osteopenia -development of spinal stenosis -increasing rigidity C4-C6 levels -rigidity from neurologic D/O (Parkinson dx) 29 -Kyphosis (limits C-range of motion) -fat and fibrous tissue replaces lean body mass -diminished force of contractile muscle -increased weakness and fatigue -poor exercise tolerance -slower, limited movement -slower & shorter gait, unsteadiness Define: osteoporosis Correct Answer: -reduction in the quantity of bone or atrophy of skeletal tissue Define: osteopenia Correct Answer: -decreased calcification or density of bone; -reduced bone mass Define: kyphosis Correct Answer: -excessive outward curvature of the spine, causing hunching of the back Identify age related compromises to the PSYCHO-SOCIAL system. Correct Answer: -difficulty falling asleep and fragmented sleep patterns -increased incidence of depression & anxiety 30 -cognitive impairment D/O -difficulty with change What THREE techniques are used during the physical assessment of body systems? Correct Answer: -inspection -auscultation -palpation The PAIN assessment includes: Correct Answer: -differentiating acute from chronic pain -related physical symptoms -investigating pt perceptions -emotional reactions to pain -quality and characteristics of pain Identify the TWO divisions of the nervous system. Correct Answer: -central -peripheral The CRANIAL NERVES are in which division of the nervous system? Correct Answer: -peripheral 31 In the acutely ill patient, the majority FOCUS of evaluating the nervous system is on which division? Correct Answer: -central nervous system Name THREE factors that can alter CNS functioning. Correct Answer: -physiologic status -psychological impact of acute illness -pharmacologic interventions What is the single most important indicator of cerebral functioning? Correct Answer: -LOC INSPECT the pupils for: Correct Answer: -size, shape, symmetry -reactivity to direct light When interpreting the implication of ALTERED pupil size, remember: Correct Answer: -medications may affect pupil size (atropine, MS, illicit Rx) -some people have unequal/unreactive pupils normally When assessing motor function of extremities, observe: Correct Answer: -symmetry -quality & strength 32 Name TWO examples of common motor strength exercises. Correct Answer: -squeeze hands -plantar flexing/dorsiflexing Name TWO ways the nurse can 'estimate' strength and quality of movements? Correct Answer: -observing activities such as pulling against restraints -thrashing What should the nurse check if the patient has no voluntary movement or is unresponsive? Correct Answer: -the gag reflex If a head trauma is involved or suspected, check for: Correct Answer: -signs of fluid leakage around nose or ears Why are cranial nerves III, IV and VI routinely assessed in facial trauma? Correct Answer: -they evaluate Extra-occular movements (EOM) of the eyes What assessment is the baseline standard for SCI, extremity trauma and epidural analgesia? Correct Answer: -sensory testing 33 When evaluating mental status, observe: Correct Answer: -orientation to person, place and time -state understanding of what is happening - eye contact - pressured/muted speech -rate of speech What is a patient's rate of speech consistent with? Correct Answer: -psychomotor status Cognitive impairments are exacerbated during an acute illness due to: Correct Answer: -physiologic changes -Rx -environmental changes Identify common DIAGNOSTIC tests pertinent to the nervous system include: Correct Answer: -serum electrolytes -urine electrolytes -urine osmolarity -urinary specific gravity -drug toxicology -ETOH level 34 Identify the FOCUS of assessments of these body systems: Correct Answer: -Nervous = evaluating the CNS -CV = evaluating central/peripheral perfusion -Resp = oxygenation & ventilation -Renal = function of kidneys & impact on fluid volume -GI = nutritional & fluid status -Endocrine = hormonal regulation -Hematologic = oxygen-carrying capacity of blood and clotting mechanisms -Immunologic = fighting infection -Integumentary = intactness of the skin If a patient is on telemetry monitoring, assess the ECG for: Correct Answer: -T-wave abnormalities -ST segment changes -determine the PR, QRS, and QT intervals -abnormalities/indications of myocardial damage -electrical conduction problems -electrolyte imbalances If treatment decisions will be based on the cuff pressure, which are is used? Correct Answer: -the pressure is taken in BOTH arms 35 A difference of how many mmHg between a cuff BP and an arterial line pressure, require a decision to be made as to which pressure is the most accurate and will be followed for future treatment decisions? Correct Answer: -10 - 15 mmHg When assessing the skin, INSPECT: Correct Answer: -color -temperature -nail color -capillary refill -edema When evaluating the color and temperature of the skin, emphasis is placed on observing the: Correct Answer: -lips -mucous membranes -distal extremities Name THREE areas where dependent edema frequently occurs: Correct Answer: -feet -ankles -sacrum 36 AUSCULTATE heart sounds for: Correct Answer: -S1 and S2 -quality, intensity and pitch -presence of extra heart sounds (murmers, clicks, rubs) -any changes with RR or pt position PALPATE the peripheral pulses for: Correct Answer: -amplitute -quality Identify common DIAGNOSTIC tests pertinent to the cardiovascular system include: Correct Answer: -electrolyte levels -CBC -coagulation studies -lipid profiles -drug levels of commonly used CV medications What are the THREE most common cardiac enzyme levels drawn for complaints of chest pain or suspected chest trauma? Correct Answer: -troponin -creatine kinase MB -B-natruretic peptide 37 Identify FOUR reasons why a 12 lead ECG might be ordered? Correct Answer: -complaints of chest pain -irregular rhythms -suspected myocardial bruising -baseline What TWO questions should a nurse ask if continuous infusions of medications, such as antiarrhythmics, are being administered? Correct Answer: -ensure infused through appropriately sized vessel -compatible with any piggybacked IV solutions INSPECTION of the respiratory system assessment includes: Correct Answer: -rate, rhythm -symmetry chest wall movement -productive cough/secretions suctioned > color, amount and consistency -trachea midline or shifted -thoracic cavity shape -AP diameter -structural deformities (kyphosis or scoliosis) PALPATION of the respiratory system assessment, includes: Correct Answer: -equal chest excursion 38 -presence of crepitus -areas of tenderness or fractures During AUSCULTATION of the anterior/posterior chest, listen for: Correct Answer: -bilateral breath sounds -presence of air movement -adventitious sounds (crackles, wheezes) -quality & depth -length & pitch of inspiratory/expiratory phases Arterial Blood Gases (ABG's) are used to assess: Correct Answer: -oxygenation -ventilatory status -acid-base balance Hemoglobin and Hematocrit values are used to assess: Correct Answer: -impact on oxygenation -fluid balance In the patient on a mechanical ventilator, VERIFY: Correct Answer: -ventilatory mode -tidal volume -RR 39 -positive end expiratory pressure (PEEP) -% of oxygen against prescribed settings In the patient on a mechanical ventilator, OBSERVE: Correct Answer: -presence/absence spontaneous breaths -rate and average tidal volume of each breath, if present -amount of pressure required to ventilate pt In the patient with a tracheostomy, OBSERVE: Correct Answer: -size and type -location In the patient receiving BiPAP, OBSERVE: Correct Answer: -pressure settings against ordered parameters -tolerance to full face mask/nasal mask In the patient with chest tubes, OBSERVE: Correct Answer: -area around insertion site for crepitus -amount and color of drainage -air leak present -type of drainage system (underwater seal or suction) What TWO parameters are used to assess the function of the RENAL system? 40 Correct Answer: -urinary characteristics -electrolyte status In the patient with a FOLEY catheter, observe: Correct Answer: -amount and color of urine -abnormal presence of glucose, protein, blood INSPECT the external genitalia for: Correct Answer: -inflammation -swelling -ulcers -drainage In the patient with a suprapubic catheter or a ureterostomy, INSPECT: Correct Answer: -position of drainage tube -amount and characteristics of drainage -any leakage around drainage tube Identify common DIAGNOSTIC tests pertinent to the renal system: Correct Answer: -urinalysis -serum electrolyte levels -blood urea nitrogen (BUN) -creatinine 41 -urinary and serum osmolarity INSPECTION of the abdomen includes: Correct Answer: -overall symmetry -contour (flat, round, protuberant, distended) -discoloration or straie What FOUR factors are used to evaluate the nutritional status of a patient? Correct Answer: -weight -muscle tone -condition of oral mucosa -lab values (serum albumin; transferrin) AUSCULTATION of the abdomen includes: Correct Answer: -bowel sounds in all four quadrants -characteristics and frequency -adventitious sounds (friction rubs, bruits, hums) How are BOWEL SOUNDS auscultated? Correct Answer: -clockwise fashion in all four quadrants -note frequency -presence/absence of sounds 42 What are the FOUR ratings for bowel sounds? Correct Answer: -absent -hypoactive -normal -hyperactive Before noting ABSENT bowel sounds, a quadrant should be auscultated for how long? Correct Answer: -60 - 90 seconds PALPATION of the abdomen helps determine: Correct Answer: -areas of fluid -rigidity -tenderness -pain -guarding (rebound tenderness) Why do you auscultate BEFORE palpation? Correct Answer: -palpation may change frequency and character of the peristaltic sounds In a patient with GI drainage tubes, OBSERVE: Correct Answer: -location -function 43 -characteristics of drainage -validate proper placement -ensure patency -drainage/leakage around tubes INSPECT emesis and stool for: Correct Answer: -occult blood INSPECT ostomies for: Correct Answer: -location -color of stoma -peristomal skin condition -type of drainage Identify common DIAGNOSTIC tests pertinent to the hematologic system: Correct Answer: -evaluation of RBC's -coagulation studies Diminished RBC's may affect: Correct Answer: -oxygen-carrying capacity of the blood Identify common S/Sx of anemia (diminished RBC's): Correct Answer: -pallor 44 -cyanosis -light-headedness -tachypnea -tachycardia Insufficient clotting factors are evidenced by: Correct Answer: -bruising -oozing from puncture sites/mucous membranes -overt bleeding Identify common DIAGNOSTIC tests pertinent to the immunologic system: Correct Answer: -white blood cells (WBC's) -differential counts List additional things that can be indicative of underlying infection? Correct Answer: -puncture sites/mucous membranes for oozing drainage -inflamed/reddened areas -spiking or persistent low grade temp INSPECTING the skin involves: Correct Answer: -head-to-toe, A - P, & between skin folds skin integrity -color, temp, turgor -rashes, striae, discoloration, scars, lesions 45 -abrasions, pressure ulcers, wounds -note size, depth, presence/absence of drainage Name factors that can affect communication: Correct Answer: -culture -developmental stage -physical condition -stress -perception -neurocognitive deficits -emotional state -language skills What non-verbal clues can provide important information about the patient? Correct Answer: -body gestures -facial expressions -eye movements -involuntary movements -changes in HR,BP and RR Name the TWO ways anxiety is exhausting. Correct Answer: -physhologically -physiologically 46 How does being in a prolonged state or arousal (anxious) negativelly affect a pt's recovery? Correct Answer: -uses up the adaptive reserves needed for recovery List some of the environmental stressors in the PCU that can contribute to increased anxiety in patients. Correct Answer: -constant auditory/tactile stimuli -forced isolation from social supports -dependency -loss of control -trust in unknown care providers -helplessness -inability to solve problems List the S/Sx that are warning signs of escalating anxiety. Correct Answer: -restlessness -distractibility -hyperventilation -unrealistic demands for attention List some of the medications that can induce anxiety? Correct Answer: -interferon 47 -corticosteroids -ACE inhibitors -vasopressors -abrupt withdrawal from benzodiazepines, caffeine, nicotine and narcotics List additional etiologic variables associated with anxiety. Correct Answer: -pain -sleep loss -delirium -hypoxia -ventilator synchchronization/weaning -fear of death -loss of control -high tech equipment -dehumanizing setting -admission to PCU Identify manipulative behaviors patients use to cope and feel safe when their anxiety and stress escalates. Correct Answer: -impuslsivity -deception -low tolerance for frustration 48 -unreliability -superficial charm -splitting among the provider team -avoidance of rules or limits What behavior is commonly used by patients to blunt the stimuli and stress of their environment? Correct Answer: -withdrawal -request sedatives, sleeping medications -frequent requests for pain Rx Name some common objects of fear that influence a patient's ability to cope. Correct Answer: -treatments -procedures -pain -separation List some of the specific fears associated with the dying process. Correct Answer: -unknown -loneliness -loss of body -loss of self-control -suffering 49 -pain -loss of identity -loss of everyone loved by patient Name the phases of the grieving process. Correct Answer: -denial -shock -anger -bargaining -depression -acceptance Define: advance directive Correct Answer: -a physician order for life sustaining treatment (POLST) When does transition or discharge planning start? Correct Answer: -arrival of the patient to PCU Identify FIVE situations in which an ongoing assessment should occur: Correct Answer: -caregivers change -before/after major procedure -before/after transport off the floor -deterioration in physiologic or mental status 50 initiation of any new therapy