1
Q
Why are observations and documentation important elements of nursing care?
A
Vital signs can determine the patients health status, documentation improves communication and promotes nursing care, documentation is an important legal standard and changes in condition can be noted and compared
2
Q
Why do we do OBS on acute patients?
A
- Alteration can provide objective evidence of body’s response to physical and psychological stress or changes in physiological function
3
Q
Legal documentation issues:
A
- Poor documentation can lead to negligence
- Gaps can lead to someone filling in blanks or tell stories
- Libel suits may be filed if judgemental terminology is used
4
Q
Nursing diagnosis is different to medical diagnosis how?
A
Nursing diagnosis is concerned with caring for the patient while medical is about curing the patient
5
Q
Negligence is:
A
Failure to provide care or perform a duty that prudent nurses would
6
Q
ANMC negligence with practice:
A
Failure to act professionally, acting in a negligent manner (breach of conduct, threatens registration)
7
Q
When do we need consent?
A
ALL care and interventions should be consented and if not it can be considered ASSAULT. Consent improves patient compliance
8
Q
Duty of care is:
A
Legal obligation on an individual requiring adherence to standards of care. (Nurses to patients, hospital to staff)
9
Q
Quantitative research:
A
Systematic collection of numerical information (trials)
10
Q
Quantitative analysis:
A
Analysis of information using statistical procedure to determine relations in data
11
Q
Qualitative research:
A
Collecting and analysing data
12
Q
Why we put in intermittent catheters:
A
- Pre and post abdominal, pelvic, rectal investigations
- Determine residual urine (retention)
- Allow bladder irrigation
- Bypass obstruction (tumour)
- When introducing cytotoxic drugs
- Reduce moisture and promote healing
13
Q
Why we put in NGT:
A
- Access route for fluid and medication administration
- Allow for drainage of stomach contents
- Removal of air
14
Q
Patients with NGT:
A
- Long term: nutritional
- Surgical: remove gastric contents/gas
- Pancreatitis: remove gastric acid and stomach contents
- Pre-term infants: nutritional
15
Q
Complications of enteral feeding:
A
Insertion: aspiration, trauma, vomiting, coughing, gagging, pain (3 attempts only)
GI/Metabolic: not meeting caloric requirement, over hydration, diarrhoea, constipation
Mechanical: tube migration, tube blockage (measure length every shift, flush with 50ml before and after feeds)
Infection: aspiration pneumonia, tube contamination, contamination of feed (no touch technique, expiry date)
16
Q
Nursing responsibility with patient teaching of medications in GERD/GORD, gastritis and peptic ulcer disease?
A
- Take OTC periodically
- Lifestyle changes to manage heartburn and reflux
- Heartburn and reflux prescribed if symptoms occur more than twice a week
- Avoid food and drinks that trigger reflexes
- Avoid large and late meals
- Lose weight, stop smoking, reduce alcohol intake
17
Q
Pre and post operative information for patient with Hiatus Hernia? (information and anatomical models)
A
- Model of lungs to bowel
- Brochures and flyers
- Function of diaphragm and lower oesophageal sphincter
- Protrusion leading to pain
- Lifestyle changes (reduce alcohol, weight loss, avoid large meals, quit smoking)
18
Q
Why is acute pancreatitis painful?
A
- Increased pressure in ductal system
- Inflamed pancreatic nerves
- Elevated levels of neuropeptides and neurotransmitters
- Obstructed common bile duct
- Duodenal stenosis
19
Q
Interventions to diminish pain from acute pancreatitis:
A
- Prophylactic antibiotics
- Analgesia and anti emetics
- NGT
- Regular LFT to monitor biliary obstruction
- Fluid replacement
20
Q
Medications for acute pancreatitis:
A
Analgesic: opiates (fentanyl, morphine) Antiemetic's: metoclopramide/ondansetron Antibiotic: ceftriaxone Insulin Nitrates: sublingual GTN
21
Q
Advice when a patient with acute pancreatitis is being discharged:
A
- Avoid alcohol
- Discuss with DR possible cholecystectomy
- Avoid paracetamol
- High carb low fat diet
- Small regular meals
- Monitor BSL
22
Q
Nursing care with BOWEL obstruction:
A
- Prep for surgery
- Radiography/ultrasound
- Pain management
- Maintain fluids (IV hydration)
- IV antibiotics
- Obs
- Urine output
- Education
23
Q
What is an ileus?
A
Temporary cessation of peristalsis. Symptoms of nausea, vomiting, abdominal discomfort, absent bowel sounds. Diagnosed with X-ray/ultrasound
24
Q
Nursing responsibilities with fluid sequestration?
A
NGT (nil by mouth)
Monitor peristalsis (abdo sounds)
Maintain fluid balance
Check girth and distension
25
Treatment for diarrhoea
Opioids: codeine, loperamine
Bulk-forming laxative: psyllium
Oral rehydration salt: gastrolyte
26
Treatment for constipation
Bulk forming laxative: best for simple constipation
Osmotic laxative: gylcerol, lactulose, sorbitol
Stimulant laxative: directly stimulate nerve endings in colonic mucosa to increase intestinal motility
27
Information to clients with constipation/diarrhoea:
- Adequate fibre intake
- Increasing activity/exercise
- Increase activity and exercise
- Immediately respond to urge to defecate
28
What is golitely and how is it administered?
Polyethylene glycol- osmotic laxative, draws water into the bowel
29
Advice given to patient on golitely:
- Diarrhoea within an hour
- Drink clear fluids
- Broth and clear fruit juices
- Continue until stool appears with no debris
30
Why is food easier to swallow than water?
Chewing forms a bolus which can be moved via peristalsis
31
Essential steps in swallow assessment: (8)
1. Patient can swallow and cough on demand
2. Sit patient up more than 30 degrees
3. Mouth care
4. Assess gag reflex and control of mouth/tongue
5. Assess LOC, speech disturbance, facial droop
6. Swallow spoonfuls of water
7. Observe patient drink small cup of water
8. Screening tools
32
Difference between one and two step questioning:
One step: pick up pen, now write name
Two step: pick up pen and write your name
One step: yes or no
Two step: options
33
Muscles used in micturition:
- Urine made in kidneys
- Urine stored in bladder
- Spinchter relaxes
- Bladder contracts
- Bladder emptied through urethra and urine removed from body
34
Trajectory of deterioration in rising ICP if signs missed:
- Higher mortality risk/permanent neurological impairment
- Delaying treatment worsens tissue hypoxia
- Alteration of blood volume (dilation/constriction)
- Compression of optic nerve results in impaired pupillary response
- Herniation
- Changes in BP, pulse and respiratory are LATE signs
35
Monro-Kellie hypothesis:
The cranial cavity is a closed rigid box and that therefore a change in the volume of blood, tissue or CSF will result in displacement of one or two components
36
If someone complains about their TEDS you say:
Leave them on, they reduce your risk of DVT
37
Can improve comfort when complaining about TEDS by:
- Reduce linen on end of bed
- Ensure correct fit not rolling or gathering
- Encourage ambulation
- Empathy and reassurance
38
Why is traction force applied over large area:
Evenly distribute pulling force
39
Why is traction applied distal to fracture:
Maintain pulling force on the end of the bone
40
RICE and likely candidates
Rest, Ice, Compression, Elevation
Commonly used in sprains and strains
41
Interventions for falls risk (elderly):
- Assessment and plan
- Mini Mental state exam
- Non slip socks
- Aids and equipment close (hearing aid, frames, glasses)
- Call bell within reach
- Bed lowered
- Supervised mobilisation
- Nurse near station
- Med review
42
Bladder and bowel function different with spinal cord injury:
Not feel the sensation of fullness in bladder or rectum, may trigger hyper-reflexia
43
Routine bladder and bowel care of spinal cord injury placements:
Bladder management by way of Urodome, long term IDC, suprapubic catheter
44
3 stages of wound healing:
1. Inflammation: (0-3 days) normal response to injury, activate vasodilation leading to increased blood flow (HEAT, REDNESS, PAIN, SWELLING, LOSS OF FUNCTION)
2. Proliferative: (3-24 days) time when the wound is healing, body makes new blood vessels covering wound surface. (RECONSTRUCTION)
3. Maturation: (24-365 days) final healing phase, scar tissue is formed
45
Healing by primary intention:
A wound closed by approximation of wound margins, best choice for clean fresh wounds, clean wounds where tissue is tension free, treat with irrigation, within 24 hours following injury
46
Healing by secondary intention:
Describes a wound left open and allowed to close by epithelialisation, manage contaminated and infected wounds, wound left open, presence of granulation
47
WHY specific infection control when MRSA +ve patients admitted:
Prevent transmission of MRSA to unaffected patients
48
WHY are limited antibiotics available for MRSA +ve patients:
Bacterial resistance, identify usual dose of Vancomycin, route of administration, precaution and side effects
49
Maximum dose of paracetamol:
```
ADULT= 4g/24hrs
CHILD= 10-15mg/kg QID
```
50
Treatment with paracetamol overdose:
Hepatoxic dose of paracetamol reversed by n-Acetylcytesine infusion over 20 hours
51
Pain in pain 1 hour post paracetamol administration:
Assess nature of pain, WILDA/PQRST, provide adjuvant analgesia, non-pharmacological interventions
52
Paracetamol and ibuprofen:
Not a problem if within recommended dosing
53
Colonoscopy:
Examine large bowel and distal part of small bowel= bowel prep maybe pre med
54
Total hip replacement:
Femur replaced= educate patient, analgesia plan, physiotherapy plan, DVT
55
Appendectomy:
Remove appendix= Open/lap, ultrasound/CT, DVT, hair clipping, antibiotic
56
Gastrectomy:
Remove part/all stomach= education, analgesia, physiotherapy, DVT, nutrition, bowel care plan
57
Arthroscopy:
Examine inside of joint= Educate, analgesia plan, physiotherapy plan
58
Mastectomy:
Remove breast= educate, analgesia, DVT, physio, breast nurse referral, wound management
59
Rhinoplasty:
Repair/reshape nose= Ointment to clear MRSA, expectations
60
Salpingectomy:
Remove fallopian tubes= Social work, expectations
61
Laparotomy:
Surgical incision into abdominal cavity= education, DVT, analgesia
62
Reasons we give O2 to patients:
Demand (sepsis, intraoperative support, post cardiac or respiratory arrest), reduced oxygen carrying capacity (hypovolemia, anaemia), reduced oxygen exchange (lung disease)
63
Patient safety when administering O2:
Monitor SATS, titrate to lowest dose, nurse patient upright, humidify, limit nasal prong flow
64
O2 delivery types:
Nasal cannulae
Hudson mask (5-10L/min, 40-60%)
Venturi mask (Variable, 24-50%)
Non-rebreathing mask (10-15L/min, 60-90%)
65
O2 of room air:
21%
66
Adrenaline from epipen lasts:
5-15minutes
67
Difference between anaphylaxis and anaphylactoid:
Anaphylactic occurs only after previous exposure, anaphylactoid is a first exposure
68
Main immune disorders:
Overactive (allergy/asthma)
Autoimmune (RA, lupus, Type 1 diabetes)
Underactive (HIV, chemotherapies)
69
Frank blood:
Bleeding at site, would notify the DR ASAP, advise of how long it took and how much fluid, advise of previous levels and characteristics
70
Respiratory interventions:
Educate on importance of oxygen, deep breathing and coughing, positing of bed 30 degrees and upwards, encourage movement and mobilisation, contact senior staff if potential complications
71
If BP is 85/50:
retake Bp and other vital signs, ensure medication has been taken MET CALL
72
BP 147/92:
High, noted and perform frequent observations, perform a pain assessment
73
Postoperative observations with hip replacement:
Vitals, pain assessment, neurovascular assessment of the leg and GCS, assess the wound site, drainage and IV site, note fluid, read surgical documentation and post operative instructions, ensure patient is comfortable, provide reassurance and question comfortability
74
3 major areas of DOC:
View and assess pain from patient POV, objective assessments, do not judge the patient on pain and assess the pain as they say it is
75
What s compartment syndrome:
Occurs when tissue pressure within a closed muscle compartment exceeds the perfusion pressure and results in muscle and nerve ischaemia. It begins when tissue pressure exceeds the venous pressure. Lack of oxygenated blood and accumulation of waste results in pain and decreased peripheral sensation. Pressure rises in compartment, decrease in perfusion and oxygenation, interstitial pressure overcomes intravascular pressure in capillaries, vessel walls collapse impeding blood flow
76
Signs and symptoms of CS:
Pain (persistent, progressive, unremitting)
Pallor (limb pale and dusky)
Pulselessness (absent/diminished pulse)
Paraesthesia (as nerves become ischaemic)
Paresis (feelings of weakness)
77
Decerebrate posture:
Arms abducted and extended with the wrists pronated and the fingers flexed, legs stiffly extended with plantar flexion of feet
78
Decorticate:
Arms are adducted and flexed with wrist and fingers flexed on chest, legs stiffly extended and internally rotated with plantar flexion of feet
79
Difference between ischaemic and haemorrhagic stroke:
Ischaemic stroke occurs as a result of obstruction within blood vessel supplying blood to the brain, haemorrhagic occurs when a weakened blood vessel ruptures (aneurysm)
80
Risk factor and prevention of pressure ulcers:
Caused by hypoxia of tissues related to altered blood supply from prolonged pressure, blood supply blocked, reduced blood and oxygen supply, reduced immune response. Pressure relief, 2 hourly turns, elevate feet of bed, nutrition, hydration, NGT, avoid soaps
81
Management with CVA:
Requires immediate diagnosis and treatment, time dependent tissue damage can occur (death rate of 25%). Immediate diagnosis of stroke to alter treatment is required. Ischemic stroke: treatment is aimed at minimising the size of infarct and preserve neurological function, medication (anti platelet, thrombolytic, anticoagulant). Haemorrhagic: treatment aimed at reducing blood pressure without inducing ischaemia, HHH therapy (hypovolemia, hypertension, haemodilution), surgical evaluation of the clot, evaluate bleeding in ventricles, evacuation of CSF to reduce ICP
82
Signs someone is not tolerating enteral feeding:
Abdominal distension, cramping, tenderness, patient complaint, nausea and vomiting, constipation
83
What is aspiration pneumonia, why is it bad for stroke:
Swelling in infection or lungs, occurs when food or saliva is breathed into lungs. Following a stroke the gag reflex is lessened and increases the risk of aspiration pneumonia. Promote oral hygiene, dietary modification
84
Why is it not ideal for surgical drains to remain in situ for long periods of time:
Delay wound healing, can act as a portal of entry for pathogens and may cause trauma to tissues, fluid accumulation increases the risk of infection and wound dehiscence
85
Zollinger ellison and why does it increase peptic ulcers:
One or more tumours form in pancreas or upper part of small intestine, secrete a large amount of gastrin causing stomach acid leading to ulcers
86
Fine bore feeding:
Insitu for up to 6 months, long term
87
Coffee grind vomitus:
Sign of coagulated blood it is a serious condition that requires immediate medical attention it may be an indication of liver disease, cancer, peptic ulcers, GERD, ebola. Additional XRAYS are performed and endoscopy
88
Nutritional support with ileostomy:
Malabsorption due to inability to absorb nutrients from food prior to expulsion. Promote skin and health
