Shared Flashcard Set


ATI Fundamentals Chpt 43-47
ATI Fundamentals for Nursing test review
Undergraduate 2

Additional Nursing Flashcards




Specimen Collection
Fecal Occult Blood:
Explain procedure, Ask client to collect specimen in toilet receptacle, bedpan or bedside commode; Apply gloves and use wooden applicator to place stool on test card window; Either label and send out or put developer drops; blue means blood

Explain; Ask client to collect; Put on gloves and use wooden tongue depressor to transfer stool to specimen container; Label; Gloves/hands; Transport to lab
Varying solutions and additives depending on enema
-Tap water/hypotonic solution: stimulates evacuation; never repeated due to water toxicity risks
-Soapsuds: pure castile soap in tap water or saline that acts as irritant to promote peristalsis
-Normal Saline: Safest due to equal osmotic pressure; volume stimulate peristalsis
-Low-volume hypertonic: Good if cannot tolerate high volume enema; Fleet-prepared
-Oil retention: lubricates rectum and color for easier stool passage
-Medicated enema: contains meds to be retained
Enema Procedure
-Prepate solution and pour into enema bag, then close clam
-Explain procedure, have commode ready, and absorbent pads to protect linens
-Position client on left with right leg flexed forward
-Gloves; lubricate tube/nozzle
-Insert 3-4in; 2-3 if child; bag level with hip; squeeze if prepackaged
-Raise 30-45cm; discontinue with cramping or fluid around anus tube
-Ask client to retain amount prescribed, discard, assist for defecation position and remove gloves
Ostomy Care
-Remove pouch from stoma
-Inspect: moist, shiny and pink; peristomal area intact with healthy skin
-Clean: with mild soap/water and dry gently/completely (paste)
-Measure/cut skin barrier; allowing an opening for stoma (barrier pastes)
-Apply: barrier then pouch
-Pouch: fold bottom and place closure clamp

Dispose of used pouches
Bowel Complications (Constipation and Impaction)
-Constipation: difficult/infrequent evacuation of hard, dry feces; improper diet, decreased fluid, lack of exercise, meds; increase fiber/water before laxative; bulk-forming product before others; enemas last resort

-Impaction: stool wedged into rectum with diarrhea fluid leaking; digital removal with lubricated, gloved finger; stool is loosened around edges and then removed in small pieces; be careful of vagus nerve (often preceded by administration of a glycerin or bisacodyl [Dulcolax] suppository)
Bowel Complications (Diarrhea, Fecal Incontinence)
Diarrhea: frequent, liquid stools; cause must be determined and treated; possible moisture barrier and meds to slow peristalsis; frequent hand hygiene and good perineal care

Fecal Incontinence: inability to control defecation, often caused by diarrhea; asses for causes: meds, infection, impaction; perianal care and possible moisture barrier
Bowel Complications (Flatulence, Hemorrhoids)
Flatulence: distension of bowel from gas accumulation; may feel cramps/fullness; asses ability to pass gas; encourage ambulation to promote passage of flatus; notify provider if continued

Hemorrhoids: engorged, dilated blood vessels in rectal wall from difficult defecation, pregnancy, liver disease and heart failure; may be itchy, painful and bloody after; moist wipes may be more comfortable; possible application of prescribed ointments or creams
dehydration characteristics
tachycardia, hypotension, fever, lethargy, poor skin turgor, and abdominal cramping.
Urinary Elimination factors
-Age: prostate enlargement after 40 years
-Pregnancy: fetus compromises/compresses bladder and 30-50% circulatory volume --> renal workload
-Diet: Sodium decreases
-Muscle of bladder, abdomen and pelvis
-Immobility, disease, spinal cord injury, psychosocial
-Surgical procedure: alters glomerular filtration rate causing decrease; lowel abdominal surgery creates obstructing edema and imflammation
-Meds: Pyridium-orange, Amitriptyline-green/blue, Dopar-brown/black; chemotherapy causes kidney toxic environment
Catheter urine specimen for C&S
Requires sterile specimen from a straight or indwelling catheter obtained using surgical asepsis
-Drain catheters tubing of urine
-Clamp tubing below the port for 20m
-Use surgical asepsis while withdrawing the required amount from the port with a syringe
-Unclamp catheter
Timed urine speciments
-discard first voiding
-collect all others in a container placed on ice
-If client discards urine, timing of specimen must begin again with next voiding
Straight or Indwelling Catheter Insertion
size: 8-10 for children, 14-16 for women and 16-18 for men
-Lower side rail and raise bed to a comfortable height with good light
-Position supine; women-knees apart; men-thighs abducted slighty
-With gloves, wash perineal area
-Set up sterile field
-Put antiseptic on cotton balls and check balloon on catheter, then lubricate lower portion
-Apply sterile drape and cleanse the meatus
-Insert using sterile hand until urine returns + 2.5-5cm
0Stabalize with nondominant hand, inflate balloon if indwelling and pull back gently then secure to clients leg
-Drainage bag goes below level of clients bladder
Most caused by E. Coli

Risks: close proximity of women meatus and anus; frequent sexual intercourse; menopause; uncircumcised; use of indwelling catheters
hearing impaired clients
-sit and face the client
-avoid covering your mouth while speaking
-have client use hearing devices
-speak slowly and clearly without shouting in brief simple worded sentences
-minimize background noise
-lower pitch before increasing volume
-write down what is not understood
-ask for a sign language interpreter if necessary
visually impaired clients
-Call by name before approaching to avoid startling
-Identify yourself and stay within clients visual field
-Give specific info about location of items or areas of building
-Explain before touching
-appraise clothing
-Inform of your departure and make a radio, TV, CD/DVD player, or MP3 player available for use
-describe arrangement of food on tray before leaving
aphasia clients
Loss of ability to understand or express speech

-Greet client and call them by name
-Do not shout, speak clearly and slowly in short sentences
-Pause between statements to allow time to understand and check for comprehension
-Ask questions that require simple answers and allow plenty of time to respond
-Reinforce verbal and non verbal
-Use methods by speech therapist. i.e. picture charts
-Acknowledge frustration expressed in communication
disoriented clients
-Call by name and identify yourself
-Maintain eye contact at eye level
-Use brief, simple sentences with one question at a time and plenty of time to respond
-Avoid lengthy convo
-One direction at a time
-Provide adequate sleep and pain management
sensoriperceptual loss clients continued
-Encourage verbalizing feelings about loss
-Orient client to time, person, place and situation (keep a clock in the room and post a calendar; write date visible)
-Provide care they may not be able to perform (reading the menu)
transmission of meds from the location of administration to the bloodstream (enteral: GI tract, parenteral: injection)

Oral: must pass through epithelial cells that line GI tract; absorption pattern varies (solubility, food, pH, emptying time, form of meds, other meds)
SubQ/IntraM: no significant barrier; higher solubility of med and blood perfusion lead to faster absorption
IV: No barriers; Immediate and complete absorption
transportation of meds to sites of action by bodily fluids

Ability to leave the bloodstream effects this (Plasma protein such as albumin binding to bring to target tissue and lipid soluble meds that can cause blood brain barrier/placenta)
Metabolism (biotransformation)
changes meds into less active or inactive forms by enzymes. Occurs primarily in liver (kidneys, lungs, bowels, blood)

-hepatic medication metabolism tends to decline with age
-increase in these enzymes causes need for increased dose
-First pass: some meds are inactivated right through liver (SL or IV route now)
-Malnourishment may lead to deficiency in production of specific enzymes
elimination of meds from the body primarily though the kidneys. Renal dysfunction may lead to an increase in duration and intensity of med response
Half life
Period of time needed for the medication in the body to be reduced by 50% (effected by liver/kidney function)

Usually takes four half lives to achieve a steady state of serum concentration (metabolism=excretion)
Eye administration
Use surgical aseptic technique
-client sit upright or lie supine, head tilted looking at ceiling
-dominant hand on forehead
-dropper 1-2cm to drop into conjunctival sac
-gentle pressure with finger/tissue on nasolacrimal duct for 30-60s
MDI Inhaler administration
-Remove cap and shake 5-6 times
-Hold with thumb near the mouthpiece and index/middle fingers at top; 2-4cm away from mouth
-deep breath, exhale, tilt head back
-press inhaler and behin a slow deep breath for 3-5s
-Hold breath for 10s then exhale through pursed lips
DPI Inhaler administration
-Take cover off, do not shake!
-follow instructions, may turn wheel
-Exhale completely and place it between lips then deep breath in
-Hold breath 5-10s

Rinse inhaler cap once a day with warm running water and dry completely
Suppository administration
Remove foil wrapper and lubricate if necessary
Rectal: Position in left lateral and insert just beyond internal sphincter; retain 20-30 for defecation stim and 60m for systemic absorption

Vaginal: supine with knees bent, feet flat and close to hips, inserted with applicator, remain for prescribed time
parenteral administration
Vastus lateralis: under 2 years
Ventral gluteal: can be used above 2
Both accommodate 2mL; deltoid 1mL
Tuberculin syringe for solution volumes under .5mL
specific parenteral administration
Intradermal: TB/Allergy testing; .01-1mL solution, 26-27 gauge, 10-15 degrees
SubQ: Insulin/heparin/water soluble, 3/8-5/8in, 25-27 gauge needle, insulin syringe gauge 28-31 max 1.5mL; pinch and inject at 90d
IntraM: irritating meds/oils/aqueous, ventro/dorsogluteal, deltoid, vastus lateralis, 1-1.5in needle, 22-25 gauge, 1-3mL at 90d
Intravenous administration
meds, fluid, blood

short term: catheter, long term: infusion port
Trauma: 16 gauge
Surgical: 18 gauge
children, older adults, medical clients, and stable postop: 22-24 gauge

Peripheral veins in arm or hand; neonates can use veins of head, lower legs and feet
IV opioid analgesia
-Catheter is advanced through the needle that is inserted into the epidural space at the fourth or fifth vertebrae
-Infusion pumps to administer meds
types of medication prescriptions
Routine/Standard: meds given on a regular schedule with or without a termination date. May be when provider discontinues or upon discharge

Single/one time: give once at a specified time or as soon as possible

Stat: given once and immediately

PRN: nurse uses clinical judgment to determine client's need for med which the prescription stipulates what dosage, frequency and under what conditions

Standing: specific circumstances and/or units
components of med prescription
Clients name
Date and time
Name of med (generic or brand)
Time and frequency of administration
Signature of precriver
Medication Reconciliation
required by JCo

Nurse should compile a list of current meds ensuring all are included with dosages and frequency. Then it should be compared with new meds and reconciled to resolve discrepancies. This list becomes the current list for meds to be administered.

Should take place on admission, when transferring and at discharge
Six Rights to safe medication administration
Right Client: JCo requires to person specific identifiers; check for allergies
Right Medication: check 3 times-selecting container, removing dose, replacing container; leave in package
Right dose: Calculate correct dose and check drug reference for range
Right time: 30 minutes before or after schedules time is acceptable usually
Right route
Right documentation: immediately record pertinent info including client response
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