Study Guide – SYNC Session – Final Exam

- Respiratory
o Assessment – Rate, effort, chest wall expansion
 Rate
 Tachypnea >20
 Eupnea – normal
 Bradypnea <12
 Depth of breathing – is it normal, shallow, or deep breathing
 Effort – are they using accessory muscles, are they retracting when you look at the neck do you
see any struggling
 Chest wall expansion
 Is the excursion equal put hands on back of chest to be sure lungs expand equally
o Different types of normal breath sounds
o Adventitious breath sounds - crackles, wheezing, rhonchi, stridor
 What they are going to sound like
 Crackles – seen in inspiration, come and go
 Wheezing – high pitched – hear on expiration – usually in people with asthma
 Rhonchi – loud high-pitched sound
 Stridor- more upper airway, comes on suddenly, musical wheeze
o Respiratory distress symptoms: Early RAT is late to BED
 Early – Restlessness, anxiety, tachycardia
 Later – bradycardia, extreme restlessness, Dyspnea
o Acute care strategies (Make sure to look under nursing process) - CLICK
 Maintain and promoted lung expansion
 Cough and deep breathing
 Pursed lip breathing – how it’s done
 Positioning – high fowlers is good
 Incentive spirometer – how to use pt exhales, put mouth on mouthpiece and take deep breath
slowly, hold breath for 5 seconds and then exhale do at least 5-10 times
o Diagnostic tests pulse ox – measures oxygen saturation <90 % ,worrisome
 PFTs – pulmonary function test – how well the lungs take in air and remove gasses
 Sputum culture – best to get in the before drinking, cough deeply and expectorate into the
container
 Oxygen delivery systems - Which is easiest and bothersome, how much oxygen gets delivered in
each
- Cardiac
o Heart assessment
 where do you hear sounds best (APE TO MAN)
 What does it sound like “lub Dub”
o Know APETM locations
o Murmurs
 Listen with the diaphragm and bell
 Low-Pitched: bell
 High pitched - diaphragm
o Bruit, Jugular vein distension
 BRUIT – listen to carotid arteries - shouldn’t hear anything, if you hear a blowing or swishing it’s
concerning
 Distension of jugular vein – if standing will flatten
 If sitting and sticks out - concerning
o Peripheral artery assessment – pulse at radial, know locations, strength, what if you don’t feel
 Know different locations
 Feel both arteries at the same time to compare
  Pulses are on a range from 0 to +4 (2+2 is normal) if 4 it’s a bounding pulse (0-is no pulse)
 If no pulse can use a doclar it can find the pulse
 Listen to apical at the mitral
o Signs of DVT
 What are you going to see if they develop in a thrombus (Swelling, change in skin color – red
could have blue, warmth, pain, tenderness
o Edema
o Modifiable and non-modifiable risk factors for heart disease
 Know the difference
 Things you can’t change
 Age, race, genetics
 Can change
 Diet exercise
o Physical assessment rubric

- GI/GU
o Abdominal assessment
 Go in same order
 Inspect, listen, percussion, & palpate
 Rebound tenderness – press slow and deep then let go quickly
 If pt complains of pain when releasing the hand that’s rebound tenderness
o See with peritoneal (known for appendicitis)
o Abnormal stool finding
 Different colors – what are the different colors and what they mean
 Clay – absence of bile
 Black/tarry – melena or blood in stool
o Stool lab tests
 Guaiac – most often used for colon cancer, measures microscopic amounts of blood
o GU bladder assessment
 When assess, inspect swelling or convex curve, can extend up to umbilicus
 Palpation – might cause pain, or might have to urinate
 If bladder is full (pt can’t urinate)– use scanner
 If bladder is full, you will hear dullness over suprapubic area when percussing
o Factors that affect urination
 Age, how much drank, meds, underlying conditions
o UTI symptoms
 Know these how to obtain urine sample, must have urine
 Urinate in cup
o Obtaining urine samples
 Urine must be sterile, front to back -women
 Urinate first then put cup under
 Urinate in cup
 If male – retract foreskin, clean in circular motion from center outward
- Nutrition
o Different diets
 If on a clear liquid diet, what are they allowed, full, pureed, etc.
o Type of diets different from what counts for intake
 Patient could be on regular diet, and you still need to count I&O
 They could be on a full liquid diet but not everything counts
o Dysphagia screening (when feeding them)
 No straws, seated upright, 90 degrees
 Head flexed slightly to chin down positions
  Unilateral weakness (food to strong side of mouth)
o Oral feeding rubric
o Know what foods cause constipation
- Intake/output guideline
o Measure intake/output in mL (1 oz = 30 mL)
o Monitory I&O for clients who have fluid or electrolyte imbalances
o Weight client the same time everyday after voiding with the same type of clothes
o If using bed scales, use the same amount of linen each day, and reset scale to zero prior to weighing
- Intake/Output guidelines
o Intake includes all liquids:
 Oral foods
 Foods that liquify at room temp - Ice-cream, sherbet, water ice
 Clear liquids - Fruit juices, gelatin, broth
 Full liquids, clear liquids plus liquid dairy products, and all juices
 IV fluids, IV flushes, IV med, blood products
 Enteral feedings via nasogastric, gastrostomy, or jejunostomy tubes, Enteral tube flushes/free
water
 TPN- parenteral nutrients, include lipids, electrolytes, minerals, vitamins, dextrose, and amino
acids
 Ice chips are calculated as half of the reported volume
 1 cup = 240 mL
o Out includes all liquids
 Urine, blood, emesis
 Liquid stool
 Tube drainage – NGT, GT, Nephrostomy, drains – wound drainage, fistula drainage
- Med Admin
o Medication actions
o Orders – routine, stat, prn
 What are the differences in prn, every 4 orders
o Medication error – what should the nurse do?
 Assess the pt
 Notify provider
 Once stable, Note the incidence, fill out report and report near misses they are not apart of
record just apart of quality improvement (report part of quality improvement
o Med reconciliation – maintain accurate list of medications helps to ensure pt is receiving care
 Done when admitted, discharged, or transfer (ICU to floor)
o Controlled substances-pyxis
 Locked in pyxis
 Make sure amount is correct in pyxis BEFORE remove it
 Count at end of shift
 Have another nurse witness waste
o How to administer injections including volumes, needles, sites (hot to find them
 Look at difference sizes, how to give IM angles
 Do not cap needles once injected
o Process of administering topical, eye, and ear medications
 Know whole process
o Medication rubrics (3)
 Identification of pt
 Rights of medication administration
 11 rights
 3 safety checks
 There are 3
 o Take med out and compare to order
o Preparing in syringe
o At bedside confirm right pt
 Needlestick safety – do NO recap
 Once injected do not recap
 Verbal orders – write down by provider and repeat back

Right: PMDR TREATED

- Pt
- Med
- Dose
- Routh
- Time
- Reason
- Education
- Assessment
- To refuse
- Elevation
- Documentation

Sub Q – abs, thighs, posterior arm, butt/lower back, scapular

0.5 -1.5 mL
25-27 gauge
3/8 to 5/8
1” - 45 2” - 90

IM – 1 ½”
18-25
Adults 2-5 ml
Children, older adults, thin pt 2 ml
90 degress
Use Z track

Intradermal - Tuberculin/ small hypodermic syringe

5 -15 degrees with bevel up
Form bleb