Milestone Exam Blueprint #1

Milestone Exam Blueprint #1 KEY: NSG 121:RED NSG 122:BLUE NSG 124:GREEN Display Name Node NOTES Eye drop admin-teach NSG.122.06.03.03 applications to the eye seldom are placed directly onto the eyeball. Because direct application cannot be made onto the sensitive cornea, applications intended to act on the eye or the lids are placed onto, or instilled or irrigated into, the lower conjunctival sac. Avoid cornea, never touch eye/eyelid w administration device, apply pressure to lacrimal duct after giving medications, inner to outer canthus. Pressure ulcer-assessment Pre-test item not graded 122.05.01.04 Stages: 1. Non-blanch able erythema of intact skin 2. Partial-thickness skin loss with exposed dermis 3. Full-thickness skin loss 4. Full-thickness skin and tissue loss Unstageable: Obscure full-thickness skin and tissue loss Shearing force Pretest item not graded 122.05.02.02 Minimize skin injury from friction and shearing forces by using proper positioning, turning, and transferring techniques. Use lubricants, protective films, dressings, and padding to diminish the effects of friction on the skin. Allergic reaction NSG124.01.02.04 Is an immune response; need to be sensitized to a prior exposure before having an allergic reaction. Reactions can range from mild to anaphylaxis (reaction based on immune response, not dose of drug) Tylenol-lab check NSG124.03.03.03 Associated with liver toxicity - don’t take more than 4000 mg/day. Hepatic toxicity occurs 48-72 hours after ingestion (leads to hepatic necrosis) - need to check liver labs before giving Insulin-regular peak NSG124.07.01.03 Regular insulin (Humulin R and Novolin R) peaks in 1-5 hours Isoniazid-Tyramine NSG124.06.01.03 Do not give with high tyramine foods, alcohol: Tyramine foods: strong or aged cheeses (blue cheese, parmesan), cured meats (salami, pepperoni), smoked/processed meats (hot dogs, smoked fish), pickled or fermented foods (sauerkraut), sauces (soy sauce), yeast extracts (sourdough bread, brewer yeast), alcoholic beverages (beer, wine), improperly stored/soiled foods, soybeans, snow peas, dried over overripe fruits (raisins, overripe bananas). Antacids- Renal Failure NSG124.04.03.03 Antacids contain lots of sodium, so excess sodium in the body can have an impact on the kidney with renal failure. Antacids in large amounts can alkalinize the urine, accelerating the excretion of acidic drugs and delaying excretion of basic drugs. Furosemide (Lasix) NSG124.08.02.02 Loop Diuretic. Indicated for patients with pulmonary edema associated with heart failure, edema of hepatic, cardiac or renal origin, uncontrollable hypertension and patients who need diuretic therapy but have low renal blood flow. Use with caution in patients with cardiovascular disease, renal impairment, diabetes mellitus, gout, pregnancy and pt. Taking digoxin, lithium, and NSAIDS. Can be given PO, IV or IM. can take with food. Key adverse side effects: hyponatremia, hypotension, hypokalemia, ototoxicity, hyperglycemia, and hypotension. Tetracycline - Teach NSG124.05.04.02 Teach about the effects on teeth (discoloration), possibility for superinfection, hepatotoxicity, renal toxicity, and photosensitivity. Clindamycin should be taken with a full glass of water. Thyroid-overdose signs NSG124.07.02.04 Overdose is called thyrotoxicosis; S&S: tachycardia, angina, tremor, nervousness, insomnia, hyperthermia, heat intolerance, sweating Metronidazole - Teach NSG124.06.02.02 Used for protozoal infections and infections caused by obligate anaerobic bacteria. Metronidazole is used for infections of the CNS, abdominal organs, bones and joints, skin and soft tissues, and the GI tract. Take with meals before or after to avoid GI symptoms Do not break, crush, or chew ext rel product Notify provider of rash immediately Steroids- DC protocol NSG124.03.04.03 Oseltamivir - Use NSG124.06.04.03 (Tamiflu) Antiviral: prevention and treatment of influenza type A or B, Avian fu Antihistamine-action NSG124.03.02.02 H1 Antagonists are classic antihistamines. Bind selectively to H1-Histaminic receptors, blocking actions of histamine at these sites. Byetta-hypoglycemia NSG124.07.01.06 Exenatide: (Byetta) antidiabetic - Hypoglycemia occurs whenever insulin levels exceed insulin needs. Inform the patient about potential causes of hypoglycemia (e.g., insulin overdose, reduced food intake, vomiting, diarrhea, excessive alcohol intake, unaccustomed exercise, termination of pregnancy), and teach the patient and family members to recognize the early signs and symptoms of hypoglycemia (tachycardia, palpitations, sweating, nervousness, headache, confusion, drowsiness, fatigue). Rapid treatment is mandatory. If the patient is conscious, oral carbohydrates are indicated (e.g., glucose tablets, orange juice, sugar cubes). However, if the swallowing or gag reflex is suppressed, nothing should be administered PO. For unconscious patients, IV glucose is the treatment of choice. Parenteral glucagon is an alternative. Antitussive-evaluate NSG124.04.02.02 Evaluate: decreased cough There are opioid antitussives and nonopioid antitussives. Opioid antitussives act on the CNS and can suppress respiration, and also potential for abuse. Enema- Prep NSG122.09.02.04 Explain the purpose and correct any misconceptions pt. might have. Provide privacy. A good time for teaching due to people normally being uncomfortable talking about GI. Place the patient in the left side lying position, upper thigh pulled toward abdomen or chest. Elevate the head of the bed slightly. Reinforce need to retain solution Residual urine NSG122.09.01.02 Urine left in the bladder after voiding. Droplet precautions NSG122.04.01.03 Use for infections spread by large particle droplets, such as rubella, mumps, diphtheria and adenovirus. Use a private room, doors can remain open, wear PPE upon entry, transport patient out of the room when necessary and place a surgical mask on them. Keep visitors 3 feet from patient Ambulation- Tolerance NSG122.10.02.01 Note whether the patient uses any assistive devices such as a wheelchair, brace, cane, walker, or crutches to aid in ambulation. Wheelchair transfer- post CVA NSG122.10.02.03 Transfer patients on their strong side. Use a gait belt, lock wheels, use a countdown. Wheelchair safety NSG122.10.02.03 Lock wheels, ensure foot pedals are out of the way of transfer, position the chair properly for patient needs. Assess patients ability to transfer themselves around in a wheelchair. Cannula pressure Pre-test item not graded Respirations- Action Pre-test item not graded Restraints NSG122.03.01.04 Used to limit movement for patients. Use alternatives first (bed alarms) and restraints as a last resort. Restraints need to be ordered by a physician: type of restraint, justification and criteria for removal. Never written as a PRN order. Bed rails are considered a restraint- need an order for more than two side rails up. Saline flush NSG122.13.02.04 Flushing before an infusion is important to ensure the patency of the line. Flushing is also important after an infusion to ensure the line is clear and the patient gets what they need to receive. Basically to ensure nothing is left in the line. Braden interpretation NSG122.05.02.01 Braden scale is used to assess the risk of a patient's skin integrity. The scale includes: mental status, continence, mobility, activity, and nutrition. Score or 19-23 indicated no risk, 15-18 mild risk, 10-12 high risk, and 9 or lower very high risk. Nutrition assessment-labs NSG122.08.02.01 Blood glucose, blood cholesterol, and blood triglycerides. Albumin levels (long term nutritional status) are important to measure protein status. Prealbumin (short term nutritional status) daily changes in a patients protein status. Indicate malnutrition within patients. Cranial nerves- GERI NSG121.11.03.02 1. Olfactory (sensory) 2. Optic (sensory) 3. Oculomotor (motor) 4. Trochlear (motor) 5. Abducens (motor) 6. Trigeminal (sensory and motor) 7. Facial (sensory and motor) 8. Acoustic (sensory) 9. Glossopharyngeal (sensory and motor) 10. Vagus (sensory and motor) includes gag reflex 11. Spinal accessory (motor) 12. Hypoglossal (motor) CT-diarrhea-action NSG124.04.05.03 Antidiarrheal agents: Opioids are the most effective. They decrease intestinal motility and slow intestinal transit, which allows more time for absorption of fluid and electrolytes. Activating opioid receptors decrease secretion of fluids into the small intestine and increase absorption of fluid and salt. Other antidiarrheals include Bismuth subsalicylate (pepto-bismol), bulk-forming agents, and anticholinergic antispasmodics. Cath-check for kink NSG122.09.01.04 Check for kinks and ensure a continuous downward flow. Urine staying within the tube can cause backflow, potential infection and result in the HAI and the hospital not being reimbursed. Pressure ulcer-infection NSG122.05.01.01 Important to have proper sterile supplies and skin preparation when conducting a new wound dressing- the risk of infection decreases and wound healing is facilitated. Chronic wounds such as a pressure injury with impaired healing are more at risk for infection. ACE inhibitor-hyperkalemia NSG124.09.01.02 ACE Inhibitors are used to treat hypertension, HF, diabetic nephropathy and MI. Adverse effects of ACE Inhibitors include first-dose hypotension, dry cough (very common), hyperkalemia, renal failure, fetal injury, neutropenia and angioedema (potentially life-threatening rxn). Sucralfate - NGT administration NSG124.04.03.04 Sucralfate promotes ulcer healing by creating protective barrier against acid and pepsin Leukotrienes - Teaching NSG124.04.01.04 Leukotriene is an inflammatory mediator. It causes tightening of airway muscles and the production of excess mucus and fluid. Bronchodilators and glucocorticoids work well to decrease inflammation. Methadone NSG124.02.03.03 Pure opioid agonist. Prolongs QT interval. Use with great caution in patients with existing QT prolongation or family history of long QT syndrome. Should receive ECG before treatment, 30 days later and annually after. If the interval exceeds 500msec stop treatment or lower dosage. BP - Lie, sit, stand NSG121.04.03.04 Orthostatic blood pressure Anaphylaxis- PCN NSG124.05.02.02 An immediate hypersensitivity reaction mediated by igE. Occurs most frequently with penicillins than any other drug. When these reactions do occur, the chance of mortality is high. Primary treatment is epinephrine. When there is a history of anaphylaxis avoid all cephalosporins. Morphine overdose NSG124.02.03.05 Naloxone (Narcan) Carbamazepine- Admin Pre-test item not graded ROM Adduction NSG121.10.01.01 Movement of a part toward the center of the body Droplet precautions- mask Pre-test item not graded Tympanic Temperature NSG121.06.04.03 Ear temp. For adults and adolescents pull up and back. For children and infants, pull ear down and back. Antihypertensives - orthostatic hypotension NSG124.09.03.01 Vasodilator Agents work directly on arteriolar and/or venous smooth muscle to cause relaxation. Vasodilators treat hypertension, angina pectoris and HF. Adverse effects: Increased risk of falls (symptoms of hypotension) and reflex tachycardia. Be aware of orthostatic hypotension in older adults who are taking vasodilators. Diclofenac- Liver NSG124.03.03.02 ADL Assessment NSG121.13.03.03 Rely on general observations and focus on the patient’s functional abilities. Documentations of unexpected findings in older populations because of frequent transitions in healthcare settings. General Survey: Observe expected changes that occur with aging. Assess for any decreasing abilities to function and care for self. Note any changes in mental status. Height and Weight: Height and weight are important components of the calculation for BMI. Assess Pulse -GERI NSG121.04.03.02 Newborn: 70-190 bpm Infant: 80-160 bpm Toddler: 80-130 bpm Child: 70-115 bpm Preteen: 65-110 bpm Teen 55-105 bpm Adult: 60-100 bpm Conditioned athlete: 50-100 bpm Pedal pulse NSG121.04.03.03 Circulation to the legs and feet may be assessed at the femoral, popliteal, posterior tibial, or dorsalis pedis sites. Assess carotid artery NSG121.08.03.01 Inspect the carotid artery for a double stroke seen with S1 and S2. Palpate the carotid artery medial to the sternomastoid muscle in the neck between the jaw and the clavicle. Palpate the strength of the pulse and grade it, as with peripheral pulses. ONE at a time. Auscultate with the bell: Bruits are swooshing sounds related to atherosclerosis. Have the client hold their breath to avoid hearing breath sounds. Perianal assessment NSG121.09.02.02 Wound irrigation fluid NSG122.05.02.03 A direct flow of solution over tissues, sterile equipment and solutions are required. Sterile 0.9% sodium chloride or sterile water, commercially prepared wound cleanser, antiseptic or antibiotic solution. Muscle atrophy- Assess NSG121.10.03.02 Inspect and palpate. When inspecting, look for drooping or asymmetrical features. When palpating feel for muscle or lack thereof and tenderness. Interview - allergic reaction NSG121.02.01.02 Pre Interaction: before meeting the patient, gather data from the medical record. Beginning: introduce yourself, ask how they prefer to be addressed. Working: collect data by using open and close ended questions. Closing: ending, summarize and state the two most important problems. Review for completeness. Health history - menopause NSG121.09.01.02 12 consecutive months without meses. Estrogen levels decrease, uterus becomes smaller, ovaries shrink, normal vaginal rugae flatten, and the epithelium atrophies. These normal changes may lead to vaginal infections, UTIs, dyspareunia, and diminished libido. Older women need education regarding unexpected signs and symptoms. Menorrhagia NSG121.09.02.02 Menorrhagia is menstrual bleeding that lasts more than 7 days. It can also be bleeding that is very heavy. Infection control - biohazard NSG122.04.01.03 A red bag marked biohazard is used to dispose of the materials containing liquid, semi liquid blood or other potentially infectious material. If these materials are compressed it can release these substances during handling. Nasopharyngeal suction - assess NSG122.07.02.04 Before suctioning assess the need: patient may have an order, pain or the potential to cause pain by obstruction in airway (mucus, food particles), and adventitious breath sounds. Bronchial breath sounds NSG121.07.03.02 Loud, high-pitched, and found over the trachea and larynx. Coarse or tubular. Inspiration less than expiration. Ca channel blocker - OD SE NSG124.09.02.02 Assess leg NSG121.08.03.03 Identify symmetry, ROM, color, hair, nails. Identify tenderness, warmth, erythema, palpate pulses to assess for effectiveness of peripheral circulation. Assess for edema Abdominal inspection and palpation NSG121.08.02.02 Inspect from the right side bending down to the patient, the foot of the bed, and the left side, look for distention. Inspect for contour (flat, rounded), symmetry, umbilicus, skin (color, striae), pulsations or movement, hair distribution, demeanour (do they seem tense or relaxed). Palpation RLQ, RUQ, LUQ, LLQ order. Light and deep palpation in a rotation motion. Watch for guaring, tenderness, facial expressions. Palpate liver, spleen, Percussion - cardiac NSG121.08.03.02 Detecting percussion sounds over an obese or muscular chest or female breast tissue can be difficult. Percussion may be useful in identifying the left border if the heart is enlarged (as in cases of suspected heart failure). Identification of the right border is rarely useful. Beginning at the anterior ancillary line in the 4th ICS, percuss medially toward the sternum. Repeat in 5th and 6th ICS. Carpal tunnel NSG121.10.03.02 Compression of median nerve Smoking and effect on sleep NSG122.11.01.01 Nicotine is a stimulant that makes it more difficult for people to fall asleep. Stop smoking after evening meals. Dressing change - findings NSG122.05.02.01 Color, odor, consistency, location, size, drainage, tunneling, amount. Reduced LOC - Pain NSG121.04.01.04 Pain: OPQRST or OLDCARTS Sleep assessment NSG122.11.01.012 Ask questions pertaining their sleep tendencies: best nights sleep, worst nights sleep, factors that affect sleep, what is the effect of lack of sleep, sleep-walking, sleep aids. Comprehensive to determine their sleep patterns- can be linked to other factors of their daily living. Pupillary responses NSG121.06.04.02 Assessment of the pupils is essential in patients with visual blurring, field defects, third nerve palsy, neck pain, and stroke. Using light: Normal findings - Pupil is black, round, and equal with a diameter of 2–6 mm. Both pupils constrict directly and consensually. (size & shape) To test reactivity to light, darken the room and hold a light on the side of the eye and observe for nystagmus (jerking) in one or both eyes. Bring light closer to eye and observe the first eye and the reaction of the other. Normal: This is recorded as PERRLA (pupils equal, round, reactive to light, and accommodation) (Fig. 13.21). Pupils constrict (accommodation) and eyes cross (converge). Barrel chest NSG121.07.03.01 Can accompany COPD, The AP to transverse ratio approximates 1:1, gives the chest a round appearance. Thorax-palpate-adult Pre-test item not graded Palpation of PMI Pre-test item not graded Opioid - Respirations Pre-test item not graded Placebo- admin NSG122.02.03.05 A placebo ex is giving a sugar pill in place of medication. The patient SHOULD NOT know they are receiving a placebo. Power of attorney NSG122.02.03.05 Nurses have the right to an attorney. In order to protect themselves, nurses should document all clinical observations and clinical diagnostics, document conversations, which health care provider was notified at specific times, document chain of command and that the medical record reflects that you pursued your concerns to resolution. Nursing process - outcome statement NSG122.01.05.01 ADPIE. Establish priorities, identify and write expected outcomes, select evidence based interventions, communicate the nursing care plan. Health history-seizures-documentati on NSG121.02.03.02 Peripheral Parasthesia-document NSG121.11.02.02 Changes in senses of taste, touch, or smell: Have you noticed changes in touch, taste, or smell? Any numbness, tingling, or hypersensitivity? Where do you feel it? Paresthesia: Most common in the hands, arms, legs, and feet but can occur over other body parts. Causes include neurological disease or traumatic nerve damage, such as carpal tunnel syndrome or cervical stenosis. Benzodiazepines- Pregnancy NSG 122.06.02.01 Sensory history NSG121.11.03.01 Temperature sensation, vibration sensation, motion and position sense, stereognosis, graphesthesia, two-point discrimination, and extinction. Orientation NSG121.04.01.02 Level of Consciousness: continually assess the patient’s mental status throughout all encounters. Is the patient awake, alert, and oriented to person, place, and time. A&Ox3 End of Life - DNR NSG122.12.02.03 DNR – A Do Not Resuscitate order means that no attempts are to be made to resuscitate a patient whose breathing or heart stops. Must have an order Grief - Mastectomy NSG122.12.02.03 Stages of grief: (1) shock and disbelief, (2) developing awareness, (3) restitution, (4) resolving the loss, (5) idealization, and (6) outcome. Support with coping: Assess first 1. Assess family’s support system 2. Assess Family’s coping ability 3. Assess family’s understanding of loss and grief 4. Family may want you present or not Amitriptyline- Teach Pre-test item not graded NSAIDS-POC NSG124.03.03.04