Comp 2 Exam Notes

What are Core measures?

 Recommended treatments based on evidence overtime, they look at trends and what evidence based
treatment works for a certain disease process….Managed by the government

What protocols are in place for a stroke?

 NIHSS on arrival or change in mental status. In ICU on arrival and q shift

 Dysphagia screen prior to taking PO (cranial nerve 9)
 Antithrombotic ordered and given 2nd hospital day…..and ordered at discharge
 DVT prophylaxis by end of 2nd day or contraindicated document by a licensed independent practitioner
in the medical record.
 Pte’s w/a-fib on anticoag therapy upon discharge
 Statin on discharge for LDL≥100
 Assessed for rehab
 Labs to measure-LDL, D-Dimer, PT, & INR
 Fibrinolytics within 6 hours (you can use either drug)….clot busters:
o Tissue plasminogen activator (TPA)
 Biggest problem is a hemorrhagic stroke (bleeding in the brain)….if they have an
aneurysm and give TPA it will probably rupture, or the BP is too high and will rupture a
blood vessel and have bleeding in the brain….they now have a hemorrhagic stroke….so
if it’s the case the first sign that it’s happening in a change in LOC

What protocols are in place for surgery?

 SCIP Infection 1:
o Prophylactic antibiotic received within 1 hour prior to surgical incision
 SCIP Infection 2
o Prophylactic antibiotic selection for surgical patients who are at increased for infection from
surgical sites
 SCIP Infection 3
o Prophylactic antibiotics discontinued within 24 hours after surgery end time
 SCIP Infection 4
o Cardiac surgery patients with controlled 6 AM postoperative blood glucose to avoid glucose
levels above 200
 SCIP Infection 6
 o Surgery patients with appropriate hair removal (no shaving that creates abrasions); if shaving is
needed must use electrical clippers to remove hair
 SCIP Infection 9
o Urinary catheter removal on postop Day 1 or Day 2 with day of surgery being Day 0 to prevent
UTI
 SCIP Infection 10
o Surgery with perioperative temperature management to prevent prolonged hypothermia: temp
must be measured within 15 minutes of end of anesthesia
 SCIP CARD 10
o Surgery patients on Beta Blocker therapy prior to arrival who received a Beta Blocker during the
perioperative period. Patients with specific medical conditions must receive the Beta Blocker
prior to and continue the therapy in immediate post op to prevent cardiac events
 SCIP Venous Thromboembolism 1
o Surgery patients with recommended venous thromboembolism prophylaxis ordered to reduce
thrombolytic events
 SCIP Venous Thromboembolism 2
o Surgery patients who received appropriate venous thromboembolism prophylaxis within 24
hours prior to surgery and 24 hours after surgery to reduce complications from post op VTE
What protocols are in place for sepsis?
  2 blood cultures….taken from different sites
 Oxygen 2-4L NC
 ABG’S
 2 IV’s started

What are you going to teach your pte before they go into surgery?

 I.S., cough & deep breathe

What kind of protocols are in place for a STEMI?

 You have 10 min to get a 12 lead EKG

o If you see a STEMI then you have 90 min to get pte to cath lab
 Management of cardiac chest pain
o ABCs first: continually assess ABC
o MONA
 Morphine (2-4 mg IV): it is a priority for STEMI or chest pain b/c it decreases preload
which then decreases O2 demands by the body
 O2: 2 – 4 L NC
 Nitro (1 tab or 1 spray…..can give up to 3 but 5 min apart): systolic must be 100 or
greater; don’t give w/ phosphodiesterase inhibitors (erectile dysfunction meds) b/c drop
BP dangerously low levels …..can also do a nitro dip
 Aspirin (325mg chew….if on daily 81mg)
 Priority: ABC, O2 , Nitro, morphine & aspirin

 Consents
  NPO
 Shave prep (clip)
 ALLERGIES and Medications
o Allergies – worried about iodine & shellfish….when mixed w/contrast dye causes an allergic
rxn…still go to cath lab just give antihistamine and a steroid prior to going….and let cath lab now
o Meds – if pte is diabetic and on metformin, that mixed w/contrast dye will kill the kidney…they
still go but give mucomyst…if scheduled cath lab stop metformin 48-72hrs

Know the difference btwn acute/chronic….acute has a higher priority than chronic? Name some words that
indicate and acute situation?

 Sudden/new onset
 Just developed

Know lab values: ranges and how they’ll present?

What are some priority interventions for newborn care?

 Heat loss….haven’t developed ability to shiver ……and dye if temp drops to low
 Check resp. distress (nasal flaring)
 APGAR
 Bonding
 Suction
 Umbilicus care….keep it dry (dab it dry)

Do you increase the rate of an IV soln. if running late?

 No, bc of fluid overload

Besides checking the IV insertion site, what is the priority assessment for a person receiving an IV?

 Resp. assessment

How are thyroid storm, organ rejection, and infection related?

 ↑temp. (hyperpyrexia), tachycardia,

You have a pte that’s had a thyroidectomy, what do you keep at the bedside?

 Trach kit (to be intubated)

If there is a problem after the pte has had a thyroidectomy what will you see?

 Stridor
 SOB
 Difficulty swallowing
  Excessive swallowing

Sometimes when the thyroid gland is removed, what else is removed and how will the pte present?

 Parathyroid
o Hypoparathyroidism
 Hypocalcemia
 Hyperphosphatemia
 Hypomagnesemia (may cause hypoparathyroidism)
 Manifestations:
o Tetany (Chvostek/Trousseau Signs)
o Muscle twitching and cramping
o Seizures
o Weakness, tingling in extremities
o Headache
o Dysthymias (prolonged QT interval)
o Altered sensorium
o ↑ bone density
o Cataracts and basal ganglia calcifications

What do ACE inhibitors, Addison’s disease, and potassium sparing diuretics have in common?

 Hyperkalemia….Tall Tented T Waves (remember hypokalemia has a u wave)

 ACE inhibitor:
o Used for HF
o 1st line meds
 Enalapril (Vasotec)
 Fosinopril (Monopril)
 K+ sparing diuretics:
o Releases fluid while retaining potassium
o Spironolactone (Aldactone)
 Monitor potassium and renal failure
 Stop if K+ and creatinine levels rise
 Addison’s disease
o Cortisol levels too low, and need to ↑them
o Na+ levels fall and K+ levels rise rapidly
o ↓glucose, Na+, fluid, and ↑K+ (put on tele)….worried about dehydration (where ever fluid goes
sodium goes)
 Hypoglycemia….. sweating, headaches, tachycardia, tremors
 Hypovolemia….tachycardia, dehydrated, poor skin turgor, ↑ risk for falls
 Hyponatremia….N/V, headache, confusion, fatigue, restlessness, irritability, muscle
weakness, spasms, seizure
  Hyperkalemia…..fatigue, numbness, tingling, N/V, chest pain, dyspnea, palpitations
o Treatment:
 Administer insulin w/dextrose in NS to shift K+ into cells
 Administer K+ binding and excreting resin –Kayexalate
 Give loop or thiazide diuretics
 Avoid K+ sparing diurects
 K+ restrictions
 Monitor I&O’s

Your pte has had a thoracentesis what is it?

 Removal of fluid from the thoracic cavity, from the pleural space

What is the normal drainage amount for a chest tube?

 >100ml/hr….call the doc bc suspecting hemorrhage

What do retinal detachment and placenta abruptio have in common?

 Medical emergency….and ↓perfusion (oxygen) bc of the separation of tissues

 Retinal detachment:
o Sudden painless bright flashes/dark spots/floaters
o Sensation of curtain being pulled over visual field
o Vision loss r/t area detaches
 Placenta abruptio:
o Placenta detaches from the womb
o Usually occurs in last 12 wks of pregnancy
o C-section
o S/S:
 Vaginal bleeding
 Abdominal pain

Why do infants and the elderly develop dehydration faster than others?

 Don’t have sense of thirst (↓thirst mechanism), they rely on others, ↓body mass
 Kidney function hasn’t developed enough in infants; and diminishing in function in the elderly (↓kidney
func. due to yrs of nephrons depleting or maturation in the infants case)

How do you assess if an infant is hydrated enough?

 6-8 wet diapers/day

What is the program instituted to reduce SIDS?

 Back to sleep program

 o Child sleeps on their back
o Tight fitted sheet…no blankets or toys in crib
o Supervised tummy time
o Swaddle on back

Understand growth and development for infants and children?

 Infant (Birth – 1 yr)

o V/S: R=20-25, HR=80-140, T=97.9-98.6
o Birth wt double at 6 mths….triples at 12 mths
o Birth length ↑by 50% @ 12 mths
o Explore environment by motor and oral means
o Separation anxiety around 6 mths -30mths
o N/I:
 Implementing usual routine when possible
 Preparation and teaching directed to the family. However, always speak to
the infant and console them, especially while performing painful or stressful
procedures.
o Toys: mobiles, rattles, squeaking toys, picture books, balls, colored blocks, and
activity boxes
o Onlooker play/solitary play
o Activities:
 2 mths – social smile
 6 mths – play “peek-a-boo”
 7-9 mths – develop stranger anxiety
 10 mths – waves bye
 12 mths – say few words…. “mam & dada”
o Milestones:
 3 mths – head turns to locate sounds
 4 mths – steady head control….moro reflex disappears
 5-6 mths – roll over
 7 mths – transfer objects from hand to hand
 8 mths – posterior fontanels close…..sit up unsupported
 10 mths – crawl
  10 -12 mths – fine pincer grasp….walk w/assist
 Toddler (1-3yrs)
o V/S: R=20-30, HR=80-130, T=97.9-98.6
o 50% of adult height by 2yrs
o Growth velocity slows
o All teeth present
o Temper tantrums are common
o Feed self w/spoon and cup at 2 yrs
o N/I:
 Give simple brief/basic explanations immediately before procedures
 During hospitalization, enforced separation from parents is the greatest
threat their psychological and emotional integrity.
 Security objects or favorite toys from home should be provided
 Teach parents to explain their plans to the child (e.g., “I’ll be back after your
nap”).
 Respect child’s routine and implement when possible
 Expect regression (e.g., bedwetting).
 Autonomy should be supported by providing guided choices when
appropriate (e.g., do you want apples or oranges)
o Toys/activities: kickball, board and mallet, push-pull toys, toy telephones, stuffed
animals, and storybooks w/pics….take to playroom bc mobility is important to their
development
o Parallel play….play alongside others not with them
 Preschool Child (3-6yrs)
o V/S: R=20-30, HR=80-120, T=97.9-98.6
o Milestones:
 Each yr gains approx. 5 lbs and grows 2 ½ - 3 inches
 Stands more erect w/slender posture
 Learns to run, jump, skip, and hop
 3yrs – ride tricycle
 4yrs – uses scissors
  5 yrs – ties shoelaces
 Learn colors and shapes
 Visual acuity approaches 20/20
 5-8 word sentences
 Learns sexual identity (curiosity and masturbation common)
 Imaginary playmates and fears are common
 Aggressiveness @ 4yrs is replaced by more independence at 5yrs
o N/I:
 Explain they didn’t cause the illness and painful procedures aren’t
punishment for misdeeds.
 Answer questions at their level….use simple words
 Therapeutic play or medical play that allows the child to act out their
experiences is helpful.
 Fear of mutilation by procedures is common….a Band-Aid is helpful in
restoring body intergrity
 Needs preparation for procedures….they need to understand what is and
isn’t going to be fixed. Simple explanations and basic pics are helpful. Let
the child handle equipment or models of the equipment.
o Toys/activities: coloring books, puzzles, cutting and pasting, dolls, building blocks,
clay, and toys that allows them to work out hospital experiences.
o Associative play….imitative and dramatic play
 School-Age Child (6-12yrs)
o V/S: R=16-22, HR=70-110, T=97.9-98.6
o Can dress self, tell time, understand past present and future, ride bike
o Girls: breast changes, rapid ↑in height and wt, growth of pubic & axillary hair,
menstruation, abrupt deceleration of linear growth.
o Boys: enlargement of testicles, growth pubic/axillary/facial/and body hair, rapid ↑in
height, changes in larynx and voice, nocturnal emissions, abrupt deceleration of
linear growth.
o May need more support from parents than they want to admit.
o Maintaining contact w/peers and school activities
 o Explanations of all procedures….learn from verbal explanations, pics, books, and
handling equipment.
o Privacy and modesty are important (e.g., close curtains during procedures, allow
privacy during baths)
o Participation in care and planning w/staff fosters a sense of involvement and
accomplishment.
o Toys/activities: board games, card games, and hobbies (stamp collecting, puzzles,
and video games).
o Cooperative play…..like games with rules and collecting things
 Adolescent (12-19 yrs)
o V/S: R=12-20, HR=55-85, T=97.9-98.6
o Girls growth spurts begin earlier than boys (may begin around 9 ½ yrs)….and finish
growth around 15
o Boy catch up around 14 and continue to grow…..finish growth around 17yrs
o Secondary sex characteristics develop
o Adult-like thinking begins around 15……they can problem solve and use abstract
thinking
o Family conflicts develop
o Enjoys sports, school activities, and peer group activities
o N/I:
 Hospitalization disrupts school and peer activities; they need to maintain
contact w/both
 Share room w/other adolescents
 Procedures that alter body image can be viewed as devastating
 Teach about procedure w/o parents present….and direct questions to
adolescent when parents are present
 When teaching the focus should be on the here and now (e.g., “How will
this affect me today?”)
In triage when you have limited resources and beds how do you determine who gets a room or early treatment?

 V/S are stable or not

 ABC, Maslow, and Safety
 Look at time frames….who can be discharged who needs to stay
 o Black tag = dead or expected death
 Ex. massive head trauma, extensive full thickness body burns, high cervical spine cord
injury requiring mechanical ventilation
o Red = emergent priority…..bp 70/40 first priority
 Life-threatening ABC, chest pain, stroke, shock, external hemorrhaging
o Yellow= urgent….can wait a few hrs but not days
 Open fractures (compound fractures) w/distal pulses, large wounds needing tx w/in
30min-2hrs
o Green= Non-urgent/walking wounded…. fine have scrapes and usually put to work doing
dressing changes, etc…..injuries can be assessed in more than 24hrs
 Closed fractures (simple fractures), sprains, strains, abrasions, & contusions
What side does a cane go on?

 Position on the strong side and move w/the weak side

What side does a wheelchair go on?

 On the strong side

When a pte is getting up to use a walker what’s the teaching?

 Push up from arms of a chair not the walker…..move the walker 12-16 inches in front…look straight
ahead not at feet

What’s your nursing care for a colostomy site?

 Skin integrity
 Stoma should be moist and bright red (dark or purple is bad….not getting perfusion call Doc!!)

Describe the 3 levels of prevention?

 Primary
o Giving info. before any disease process happens….vaccination
 Secondary
o Screening, uncovering potential problems
o Ex. mammograms yearly after 40yrs; testicular exam once a month, after shower, and for young
men up to 35yr
 Tertiary
o Treatment-education prevent further damage and stop it from further progressing

Which mental health disorders have the highest suicide risk?

  Command hallucinations
 Bipolar in the manic phase
 Those starting antidepressant medications

How do you determine if someone is at risk for suicide?

 Ask them do they have a plan….continue to assess if they say “I don’t want to live anymore”

What’s the most serious hallucinations?

 Command

Your pte has had a stroke and doing a cranial nerve assessment, which one do you want to evaluate?

 9th swallowing , 7th facial, 2nd blink reflex

What do tetralogy of fallot and intussusception have in common?

 Knee to chest position (squatting)

 Intussusception purpose is for the pain
o Telescoping of a segment of the intestine w/in itself
o Jelly-like stools
 Tetralogy purpose is for increased oxygen perfusion

Know your precautions?

What do TB and herpes zoster have in common?

 Airborne

What type of precaution is needed for pertussis?

 Droplet

What type of precaution is used for chicken pox w/open lesions?

 Airborne & contact

What type of precaution is needed for anthrax?

 Standard precautions
 Contact w/spores

A pte is vomiting and gets an NG-tube will have what type of pH?

 Metabolic Alkalosis

What would you expect the potassium to look like for the previous question?

 Hypokalemia….bc the k+ is all the secretions and vomiting so getting rid of it

Your pte has diarrhea what type of pH will they have?

 Metabolic acidosis…..getting rid of bicarb so you are losing it

Your pte has TB how will you transport them?

 Surgical mask for them (particulate respiratory mask)

 N95 mask for you….negative pressure room placed in
What do crush syndrome and tumor lysis have in common?

 Hyperkalemia
 Most concerned about the kidneys bc of the ↓function

Be familiar with cardiac rhythms and what you do for them?

 Atrial flutter….saw tooth no distinct p wave

 Atrial fibrillation….risk for clots, PE
 V-tach
 Fine V-fib….shock
 Supra-ventricular
 Torsade….form of v-tach
 Asystole….check lead and start compressions

What will you see in A Flutter?

 No P wave before the QRS
What happens in A Fib?
 No P wave before the QRS and this is more irregular
What is the concern in A Fib?
 Blood clot in the atrium where the pooling blood occurs as it is not pumped out
 Needs anticoagulation therapy
What will you see in V Tach?
 Tombstones and tombstones (rounded on top) with higher peaks than V Fib
How to get patient out of V Tach?
 Ask them to vagal down as this may put them back in NSR
What will you see in Bradycardia?
 P wave before QRS
 Same as NSR, just slower than 60 BPM
What will you see in V Fib?
 Smaller peaks than in V Tach and peaks are not rounded, more pointed
How do you correct V Tach?
 Defib the patient to correct rhythm
What do you do when you see asystole?
 Check the lead placement, assess patient and start compressions if indicated
What’s the difference btwn assault and battery?
  Assault = verbally threating someone
 Battery = physically touching someone w/out their consent

If a health care professional fails to act in the manner that a prudent person would, what is that called?

 Negligence….carelessness, ignoring your pte, or pte have a condition and you’re not reporting it

If someone makes a false and defamatory oral statement about a person, what can they be charged with?

 Slander

What is a published false statement that is damaging to a person's reputation called?

 Libel

Your pte has osteoporosis and is receiving sodium bisphosphonate, what do you teach the pte about taking this
drug?

 Take with a full glass of water

 Sit upright for at least 30 minutes
 Take on an empty stomach (no food) and in the morning
 Take once a week

You were given an order to give a blood transfusion what are somethings that you need to focus on?

 Blood type
 Signed consent form
 2 RN’s must check
 NS is only fluid to run with blood products
 At least a 20 gauge but preferably an 18 gauge (large bore needle)
 Run over btwn 2- 4 hours: if run too fast can create fluid overload
 Watch for reactions in the first 15 minutes
 VS q 15 minutes for the first hour

Name some labor and delivery emergencies?

 Placenta Abruptio
 Placenta Previa
 Pre-eclampsia
o Swelling more severe edema
o HTN
o Proteins in urine 3+
o ↓fluid volume
o ↑Hct (% of RBC’s to plasma)-caused by dehydration which
 Prolapsed cord….place in Trendelenburg position and don’t touch it, call for help
What’s the difference btwn Diverticulitis and diverticulosis diet?

 Diverticulosis = HIGH fiber to keep the poop moving on along to prevent pockets from rupturing
No seeds, low residue, high fiber
 Diverticulitis = LOW/No fiber: poop is already moving out fast, don’t need to help speed it up

What’s the diet for GERD?

 ↓ Caffeine
 No spicy, no red meats
 Eat smaller, more frequent meals
 Don’t eat before bed
 Elevate HOB after eat

What’s the medical emergency that can occur w/liver cirrhosis?

 Portal HTN, which can result in esophageal varices

You pte has had a stroke and has developed unilateral neglect what are you interventions?

 You approach on the unaffected side

 Teach them to scan the room

What are the dangers of internal/external radiation?

 Internal= radioactive (beta)

o It affects the surrounding organs….so you would empty the bladder and put a foley in, to keep it
flaccid
o Exposure for visitors and you 30 min
o Fresh fruits and vegs, flowers
o Flush the toilet twice
o No children visitors
 External = not radioactive (gamma)
o Teaching:
 don’t wash away the lines (markings)
 stay out of sun for a year, skin care,
 Use gentle soap and lotion on the site
PSTD occurs with what?
 Personal trauma….can be gunshot wounds, car accident, war, child abuse
 Want to convey to pte’s that they’re safe
Be familiar with eating disorders and nursing interventions?
 Bulimia
o Episodes of binge eating in a short period of time, followed by purging
o Watch for at least one hour after to make sure they are not vomiting back up the food
 Anorexia
o Self-induced starvation resulting from fear of fatness
o Monitor to make sure they are eating
How long does it take to develop a pressure ulcer?
 2 hrs…..seen over bony prominences
 Reposition every 2 hours and do a skin assessment to identify
ABG’s:
 Normal pH: 7.35
 Normal CO2: 35 – 45
 Normal HCO3: 22-28
 CO2 = respiratory
 HCO3 = metabolic
What will you see in NSR?

 HR 60 – 100 BPM
 P wave before the QRS
 QRS occurs at regular intervals

What will you see in A Flutter?

 No P wave before the QRS (more saw tooth like)

What happens in A Fib?

 No P wave before the QRS and this is more irregular

What is the concern in A Fib?

 Blood clot in the atrium where the pooling blood occurs as it is not pumped out
 Needs anticoagulation therapy

What will you see in V Tach?

 Tombstones and tombstones (rounded on top) with higher peaks than V Fib

How to get patient out of V Tach?

 Ask them to vagal down as this may put them back in NSR

What will you see in V Fib?

 Smaller peaks than in V Tach and peaks are not rounded, more pointed

What do you do when you see asystole?

 Check the lead placement, assess patient and start compressions if indicated

Where are heart sounds heard?

 Aortic valve – right of sternal border @ the 2 nd intercostal space
 Pulmonic valve – left of sternal border @ the 2 nd intercostal space….hearing stenosis or regurgitation
 Erbs Point - left of sternal border @ the 3rd intercostal space….hearing S2 sounds (closure of aortic &
pulmonic valve)
 Tricuspid valve - left of sternal border @ the 4th intercostal space
 Mitral valve – 5th intercostal space left mid clavicular line