RNSG 1216 Professional Nursing Competencies J1 [Skills Exam Correct 100%

Objective Assessment - Answer - What do you see? - What do you smell? - Observable - Measureable - Vital signs, physical assessment Subjective Assessment - Answer - Direct information from the patient - "I feel sick" "I have chest pain" - Write direct statements in quotes Methods of Oxygen Delivery - Answer - Nasal Cannula - Simple face mask - Venti mask (Venturi) - 100% Non rebreather and - Partial rebreather masks - Oxygen tent - Oxygen Concentrators Artificial Airways - Answer - Oropharyngeal airway - Nasopharyngeal airway - Endotracheal tube - O.R. or ICU - Tracheostomy - cancer, obstruction, congenital abnormality, unable to wean from ET tube - Suction only as needed - Keep safety equipment at bedside - Keep secretions moist if able Tracheostomy - Answer - Cuffed or low pressure cuffles - Keep oxygen, obturator, spare trach and smaller spare trach, and suction equipment available at bedside - Intermittent suction only if needed - Trach care with trach pads when new or increased drainage - Personal protective equipment - Keep manual resuscitation bag at the bedside Chest Tubes - Answer - Don't clamp the tube when taking patient for testing. - No milking or stripping of the chest tube - Keep chest drainage tube straight on bed- no looping or twisting. - Monitor site and drainage from chest and document directly on drainage unit. - Have occlusive dressing and Kelly clamps at bedside. - Assess vital signs, respiratory status, SpO2, and breath sounds frequently. - Palpate around insertion for crepitus (subcutaneous emphysema) - Observe the water seal chamber for water level fluctuation with inspiration and expiration Diaphragmatic breathing - Answer breathing with the use of the diaphragm to achieve maximum inhalation and slow respiratory rate. Pursed Lip Breathing - Answer This exercise reduces the number of breaths you take and keeps your airways open longer. More air is able to flow in and out of your lungs so you can be more physically active. To practice it, simply breathe in through your nose and breathe out at least twice as long through your mouth, with pursed lips. Deep Breathing, Coughing, and Moving After Surgery - Answer It's important to practice deep breathing and coughing so that you'll be able to do the exercises below easily after surgery. These exercises will help your breathing, clear your lungs, and lower your risk of pneumonia. Coughing Exercises - Answer It's best to do coughing exercises when you're feeling comfortable. Your healthcare provider will tell you if you shouldn't do the coughing exercises in this handout. If you're lying on your back, bend your knees (if your surgeon says you can), and rest your feet on the bed. Depending on the surgery you had, support your incision firmly with your hands or a small pillow before you try to cough. Breathe in deeply and cough firmly. If you cough up some mucous, clear it into a tissue. Repeat the coughing until there isn't any more mucous. If you have a lot of mucous, you may need to take a break so you don't get too tired. Deep Breathing Exercises - Answer Do these exercises every hour when you're awake. Breathe in deeply and slowly through your nose, expanding your lower rib cage, and letting your abdomen move forward. Hold for a count of 3 to 5. Breathe out slowly and completely through pursed lips. Don't force your breath out. Rest and repeat 10 times every hour. Rest longer if you become dizzy or lightheaded. Incentive spirometer - Answer a resistive breathing device that helps patients exercise their breathing muscles The pain experience - Answer - Pain is a multidimensional experience - Pain is highly subjective - No two people experience pain and respond to pain in the same manner - Many factors influence how the pain stimulus is transmitted, how it is perceived, and the response made to it. The pain process - Answer - Transduction - Transmission - Perception - Modulation Source of pain - Answer - Cutaneous: superficial - Somatic: originates in tendons, bones, blood vessels, and nerves - Visceral: originates in body organs, thorax, cranium, and abdomen The Joint Commission supports the patient's rights to pain management: - Answer - Teach all patients to rate their pain using a pain rating scale - Determine a pain rating goal with each patient - Provide appropriate care to treat the pain Pain Assessment - Answer - Patient's verbalization - Behavioral responses - Physiologic - Affective Characteristics of the pain - Answer - Location of pain - Quantity and intensity of pain: pain scale - Quality of pain: sharp, dull, stabbing, throbbing - Chronology - Aggravating factors - Alleviating factors 0-10 NUMERIC RATING SCALE - Answer - Most common - Uses numbers to rate intensity of pain WONG BAKER FACES PAIN RATING SCALE - Answer - Used for older adults and children under 3 years - compare pain to a series of faces - broad smile to tearful grimace FLACC SCALE - Answer - Used for infants and children from 2 months to 7 years Why Do Medication Errors Occur? - Answer 1.Lack of knowledge about drug 2. Faulty communication (written/verbal) 3. Equipment Errors 4. Calculation & measurement errors 5. Patient identity not checked 6. Nurse fatigue 7. Inadequate lighting What are the Rights of Medication administration? - Answer 1. right medication 2. right patient 3. right dosage 4. right route 5. right time 5. right reason 6. right documentation How many times do you check medications before administering them? - Answer 3 For which patients are oral medications contraindicated? - Answer unconscious, uncooperative, or unable to swallow due to a medical problem USE A FILTERED NEEDLE to - Answer trap glass fragments when drawing up a medication from an AMPULE Bevel - Answer Bevel up How will you draw your insulins in the same syringe? - Answer - clear before cloudy - put intermediate air in first, even though regular goes in first What sites will you use for insulin injection? - Answer Subcutaneous fat (abdomen, back of arm) What type of injection will you give for insulin injection? - Answer subcutaneous ?What type of syringe and needle size will you use and what angle will you administer your injection at? - Answer INSULIN syringe because they have units - 100 units or 30 units given - 5/16 to half inch needle - 45 or 90 degree angle ?What type of injection will you give for heparin? What site, syringe, needle, and angle will you choose? - Answer Subq. - 25 gage needle - 5/8th to 1 half inch - 45-90 degree angle - .1 to 1 mL injection ?What sites will you use for IM injection for a dose of 2ml of Antibiotics for your 84kg male patient? What size syringe, needle, angle, site will you choose? - Answer - IM injection- ventrogluteal or thigh site - 3mL syringe or 5 mL syringe (depending on size of client) - 1 or 1.5 inch needle - 23-23 gauge needle - 90 degrees ?-What if your patient is 96kg? What would change in this scenario? -What if you were giving 5ml of medication? What would change in this scenario? - Answer - inch and gauge - use the 5mL syringe Pulse oximetry (SaO2 or SpO2) - Answer - noninvasive technique that measures the arterial oxyhemoglobin saturation of arterial blood - Patients receiving oxygen therapy, titrating oxygen therapy, monitoring those at risk for hypoxia and monitoring postoperative patients Thoracentesis - Answer puncturing the chest wall and aspiration pleural fluid, because cavity doesn't usual have fluid or air Electrocardiogram (ECG) - Answer - electrodes attached to the skin can detect these electric currents and transmit them to an instrument that produces a record of cardiac activity. - Can detect myocardial ischemia and infarction, heart damage, rhythm, and conduction disturbances, chamber enlargement, electrolyte imbalances, and drug toxicity Echocardiogram - Answer ultrasound of the heart Incentive spirometry - Answer - Provides visual reinforcement for deep breathing - Assist the patient to breath slowly and deeply and to sustain maximal inspiration - Gauge allows them to measure their own progress Pursed lip breathing - Answer - Exhaling through pursed lips creates a smaller opening for air movement, effectively slowing and prolonging expiration - Prolonged expiration is thought to result in decreased airway narrowing during expiration and prevent the collapse of small airways - Decreased dyspnea and feelings of panic (good for COPD patients) Diaphragmatic breathing - Answer - Reduces respiratory rate, increases alveolar ventilation, and sometimes helps expel as much air as possible during expiration - One hand on stomach and other on middle of the chest. Patient breaths in slowly through the nose, letting the abdomen protrude, then breaths out through pursed lips while contracting the abdominal muscles, with one hand pressing inward and upward on the abdomen Nasal Cannula - Answer disposable plastic device with two protruding prongs that are inserted into the nostrils Simple face mask - Answer has vents on the side that allow room air to leak in at many places, thereby diluting the oxygen. Also allows carbon dioxide to escape Oxygen tent - Answer an enclosure within which the air supply can be enriched with oxygen to aid a patient's breathing Endotracheal tube - O.R. or ICU - Answer polyvinyl airway inserted through nose or mouth into the trachea. Used to administer oxygen by mechanical ventilator, to suction secretions easily, or to bypass upper obstructions. Often method of choice, especially in emergency, because insertion is easier