Nursing Assessments
Name two common IV complications and their s/s
- Infiltration: swelling, discomfort, burning, tightness, cool to touch, blanching of the skin
- Extravasation: blanching, burning, discomfort, cool to touch, swelling, blistering/skin sloughing
- Phlebitis: redness/red streak, tenderness, swelling, warm to touch
What is the rationale for compressing a JP or hemovac drain prior to capping it?
To create negative pressure to drain fluids.
Name at least 2 types of common PRN medications
- antiemetics
- analgesics
- electrolyte replacement meds
- bowel protocol meds
Interpret this: "AVSS"
Afebrile. Vital signs stable.
You are reading a new order for a medication: "Lasix 20mg x 1 dose now". What is your first thought?
The route is missing.
Describe a focused pain assessment
- review of pain medications on MAR and last dose
- relevant pt. history
List the 7 medication rights.
right patient, medication, dose, route, time & frequency, reason, documentation
What is Zofran?
Also known as ondansetron. An antiemetic used to reduce post operative nausea and vomiting.
Interpret this: "IV TKVO"
Intravenous fluids running to keep vein open.
You notice your patient is diaphoretic, pale, has difficulty concentrating, complaining of dizziness and blurred vision. You take a set of vitals and their HR is faster than usual. What do you do?
Notify the nurse and check the patient's blood sugar.
Name at least 7 components of a focused Cardiac assessment
- BP
- apical HR
- CWMS
- peripheral pulses
- cap. refill
- relevant pt. history
- relevant pt. meds
- chest pain
- peripheral edema
Name 5 principles of sterile technique when performing a dressing change.
- hand hygiene
- use of clean gloves + non-touch technique or sterile gloves
- 1 inch border when opening dressing tray
- no reaching into your sterile field unless using forceps or wearing sterile gloves
- cleaning and drying site from clean to dirty
- avoid spills when introducing liquids to the tray
Name at least 4 types of antihypertensives
- calcium channel blockers
- ARBs
- ACEIs
- diuretics
- beta blockers
- vasodilators
Interpret this: "RL @100cc/hr - SL WDW"
Ringer's lactate @ 100ml/hr. Saline lock when drinking well.
You're removing staples on a patient's surgical incision. After the first couple of staples you removed, you notice a small area of dehiscence. What do you do?
- stop removing staples
- apply steri strips to reinforce wound edges
- report to primary nurse and surgeon
- document
How does one assess for compartment syndrome
5 Ps: pain, pallor, paresthesia, pulselessness, paralysis
Describe the steps of hanging a secondary bag.
- Backflush: swab port, prepare line, clamp, connect, unclamp, prime, clamp, spike bag, program, unclamp
- Prime: swab port, prepare line, clamp, spike bag, unclamp, prime, clamp, connect, program
A medication needs to be administered via secondary bag and should run over 15-30 minutes. The bag is 50ml. What should the rates be?
30 minutes = 100ml/hr
15 minutes = 200ml/hr
Interpret this: "TOV. I/O x 2 if PVR > 500"
Trial of void. In and out catheterization x 2 if post void residual is greater than 500ml.
- IV fluid bolus to increase renal perfusion
- monitor urine output
- potential foley catheter insertion
- repeat and/or daily blood work to reassess/monitor
Describe an NG tube assessment.
- focused GI assessment: n/v, bowel sounds, abdomen (distended/non-distended, hard/soft), pain, flatus, LBM
- indication of NG tube: meds? dysphagia? gastric decompression? bowel obstruction? bowel rest?
- measurement
- Xray confirmation
- clamped or to correct suction (typically low intermittent suction)
- diet: NPO or clear fluids etc.
Describe the steps for urinary catheter insertion.
- assess need for catheterization (retention, monitoring, etc.)
- double check orders or agency policy/protocol
- prepare supplies
- don PPE + HH
- prepare patient
- open tray + prepare sterile field
- don sterile gloves
- lubricate catheter
- transfer tray + catheter to the bed
- nondominant hand at the site while dominant hand cleans
- locate urethra
- insert until urine drains
- remove catheter
- wipe patient
- dispose urine + supplies
- HH
- document
A medication needs to be administered via secondary bag and should run over 15-30 minutes. The bag is 100ml. What should the rates be?
30 minutes = 200ml/hr
15 minutes = 400ml/hr
Interpet this: "Clamp x 2 hrs. If no PONV, start CF --> DAT"
Clamp NG tube for 2 hours. If no postoperative nausea and vomiting, start clear fluids. Progress diet as tolerated (clear fluids -> full fluids -> general diet)
A patient had an unwitnessed fall on the unit. What should be a nurse do?
- do not move the patient
- call for help + declutter/ensure safe surroundings
- assess ABC and neuro status
- do a set of vitals, focused neuro assessment (GCS, PERRLA), CWMS, blood glucose
- check for bleeding, injuries
- assess need for further orders (ex: Head CT)
- initiate post falls assessment & management protocol
- notify MRP, PCCs, family
- administer anagelsic PRN
- figure out cause + consider extra safety precautions for patient (hip precautions, non-skid socks, mobility aids within reach, bed alarm)
- document incident in your charting
- document PSLS