Essentials Exam 3 Flashcards
Disinfection
Removal of pathogenic microorganisms
Sterilization
Process used to destroy all microorganisms,
including their spores
7 Principles of Surgical Asepsis
- Sterile can only touch sterile
- Only sterile objects in sterile field
- Non-Sterile: Object falling below waist, Unattended objects, Turning back on field, Do NOT cross arm over sterile field!
- Prolonged exposure to air contaminates field
- Moisture onto a sterile field causes field to become contaminated.
- Fluid flow in the direction of gravity
- 1” border around field contaminated
causes of urinary retention
Acute: Sudden onset
-Intervention needed ASAP
Post surgical: Anesthesia /medications
Chronic:
- Progressive blockage
- Prostate
- Stricture
Medications
Neural pathway interruption
Stroke
Multiple sclerosis
Trauma/spinal injury
four types of urinary incontenence
overflow stress urge functional
overflow incontinence
overdistended bladder/ urinary retention
stress incontinence
Small leakage due to incompetent
urethral sphincter.
laughing, coughing, etc
urge incontinence
Strong sense of urgency
Frequency, nocturia, unable to
hold urine once the urge begins
STRENGTHEN PELVIC FLOOR
functional incontinence
Causes outside the urinary tract
Mobility, cognitive impairment
(dementia), environmental
barriers
Kegel exercises
- Women
- Urinary Incontinence
- Pain during intercourse
- Fecal incontinence
what’s a concerning urinary output?
Hourly output of less than 30
mL for more than 2 hours is
cause for concern
characteristics of urine
color, odor, clarity
Urinalysis
- Appearance, concentration and content of
urine - Glucose, protein, ketones, nitrites,
leukocytes, pH
Specific gravity
- Concentration (density) as compared to water
- 1.005(less concentrated)-1.030(more
concentrated)
when is a Culture and Sensitivity test used
- Urinary tract infection
another name for the specimen collection cup
hat
delegating urine cup
- Clean void/midstream specimens can be delegated
how soon after collection does a urine sample need to be sent to the lab
within 2 hours
when to refrigerate urine specimen
when completing a culture and sensitivity test for UTI
how to collect a urine specimen
clean voided, midstream
non-invasive bladder exams
KUB, CT, MRI
* Bladder scan
* Intravenous pyelogram (x-ray)
* Urodynamic testing (Uroflowmetry)
invasive bladder exams
Cystoscopy (scope)
Arteriography (xray with dye inserted)
oxybutynin
- Increase bladder contraction, increase
capacity
Intermittent Catheterization
(one time for bladder emptying)
* Relieving discomfort of bladder
distention, providing decompression
* Obtaining sterile urine specimen when
clean-catch specimen is unobtainable
* Assessing residual urine after urination
* Managing patients with spinal cord
injuries, neuromuscular degeneration, or
incompetent bladders long term
Cholinergic drugs
increase bladder
contraction and improve emptying
Short-Term Indwelling Catheterization
(2 weeks or less)
* Obstruction to urine outflow (e.g., prostate
enlargement)
* Surgical repair of bladder, urethra, and
surrounding structures
* Prevention of urethral obstruction from blood clots
after genitourinary surgery
* Measurement of urinary output in critically ill
patients
* Continuous or intermittent bladder irrigations
Long-Term Indwelling Catheterization
(more than a month)
* Severe urinary retention with recurrent
episodes of UTI
* Skin rashes, ulcers, or wounds irritated by
contact with urine
* Terminal illness
* Comfort measures
* When bed linen changes are painful for
patient
indwelling foley catheter
balloon, urine flows down
Indwelling Triple Lumen Catheter
Third lumen
* Delivers irrigations and instillations
* Clearing the bladder of blood, pus or sediment
* Maintains patency of lumen
* Measurement of urine output
* Deduct input to get accurate output
Catheter Irrigations
Common after bladder surgery
* Continuous or intermittent
* Closed catheter irrigation
* Decreased risk of infection
* Keeps catheter free of clots and
sediment
* Cannot be delegated
complications of catheter irrigation
bright red blood
pain
irrigation solution does not return
coude catheter
Single lumen, Stiffer tip
* Enlarged prostate
* Less traumatic
* Easier to guide
Infants Fr
5-6
Children Fr
8-10
Young Girl Fr
12
Women Fr
14-16
Men Fr
16-18
latex catheter
up to 3 weeks
plastic catheter
intermittent
Silicon/Teflon catheter
Long term up to 2-
3 months
What can be Delegated catheter-wise
- Assist with positioning and privacy
- Report patient discomfort/pain
- Leaking of urine around catheter
- Abnormal characteristics of urine: Blood, odor, drainage
- Emptying drainage bag: Report output
- Perineal care: Same sex caregiver if possible
catheter specimen collection characteristics
cannot be delegated
needle free
port sampling
suprapubic catheter
Inserted surgically
* Reinsert immediately if dislodged
* Cover with sterile dressing
* Blockage of outflow: Urethra
* Long term catheterization
abnormal findings from catheter assesment
- More than 500 mL to 1000 mL of urine drains
at the time of insertion - Bladder discomfort
- Unable to advance the catheter
- Lack of urine
- Leakage of urine from around the catheter
- Pain while inflating the balloon: Is the catheter in the urethra?
when to collect specimen from a catheter
Specimen can be collected from drainage
bag ONLY WHEN IMMEDIATELY inserted
delegated care of the suprapubic catheter
Delegated care
* Increase fluid intake (2200 mL/24 hours)
* Empty drainage bag
* Report signs and symptoms of infection
* Drainage at insertion site, foul order, redness
Condom Catheter Indications
- Men who have complete and
spontaneous bladder emptying - Incontinence
- Nocturia
- can be mobile
condom catheter parts
Held in place with adhesive
* Attached to the drainage bag
* Bedside bag
* Large volume
* Leg bag
* Small volume, ambulatory
Orthotopic neobladder
Reconstructed bladders/reservoirs made from intestines
Nephrostomy Tubes
surgically placed catheter into the renal pelvis
due to an obstructed ureter
Ventilation
Process of moving gases in and out of the lungs
Perfusion
Ability of the cardiovascular system to pump oxygenated blood to the tissues and
return deoxygenated blood to the lungs
Diffusion
Responsible for moving the respiratory gases from one area to another by
concentration gradients
Postural drainage oxygenation benefits
Drainage, positioning, and turning that improves secretion clearance and
oxygenation
Positive expiratory pressure (PEP)
Air inhaled easily, forces patient to exhale against resistance
Ambulation oxygenation benefits
Maintains and promotes lung expansion
Immobility leads to atelectasis, ventilator-associated pneumonia, muscle weakness
semi-fowlers position degree and benefits
Maintains and promotes lung expansion
45 degree
Pursed-lip breathing
Deep inspiration and prolonged expiration through pursed lips
Diaphragmatic breathing
Increases tidal volume and decreases respiratory rate
Invasive mechanical ventilation
Aka positive pressure ventilation
Used with artificial airways (ETT or TT)
Physiologic indications
-Reduce work of breathing
-Increase lung volume
-Support cardiopulmonary gas exchange
Clinical indications
- Relieve respiratory distress, reverse hypoxia, prevent/reverse atelectasis and
respiratory muscle fatigue, stabilize chest wall, decrease oxygen consumption, allow
for sedation or neuromuscular block
Ventilator-associated pneumonia (VAP)
Noninvasive positive pressure ventilation
(NPPV)
Treat obstructive sleep apnea (OSA), COPD, neuromuscular disorders,
cardiogenic pulmonary edema
Used at home and in acute care settings
Contraindications
Advantages
Continuous positive airway pressure (CPAP)
Steady stream of pressure throughout a patient’s breathing cycle
Bilevel positive airway pressure (BiPAP)
Provides inspiratory positive airway pressure and expiratory airway pressure (aka
positive end-expiratory pressure (PEEP)
oxygen therapy goal
Goal: Lowest amount of oxygen possible to achieve adequate tissue oxygenation
Low flow devices: Nasal cannula rates
1-6 LPM
FiO2: 24-44%
nasal cannula pros and cons
Advantages
- Safe and simple, easily tolerated, effective for low concentration, doesn’t impede
speaking or eating, disposable
Disadvantages
-Unable to use with nasal obstruction, can be drying, can dislodge, may cause skin
irritation, patient breathing pattern affects Fio2
Low flow devices: Oxygen-conserving
cannula (Oxymizer) rates
8LPM
FiO2: 30-50%
Low flow devices: Oxygen-conserving
cannula (Oxymizer) pros and cons
For long term O2 use in the home
More expensive than standard cannula
Low flow devices: Simple face mask rates
6-12 LPM
FiO2: 35-50%
Low flow devices: Simple face mask pros and cons
Useful for short periods
Contraindicated in patients who retain CO2
Low flow devices: Partial and
nonrebreather masks
10-15 LPM
FiO2: 60-90%
partial and nonrebreather masks
Useful for short periods
Bag should always be partially inflated
Needs tight seal
High flow devices: Venturi mask rates
FiO2: 24-50%
venturi masks purpose
Provides specific amount of oxygen with humidification
Low, constant O2
High flow devices: High-flow nasal
cannula
Provides specific amount of oxygen with humidification
Low, constant O2
high-flow nasal cannula
Adjustable FiO2 with modifiable flow
Provides heated, humidified oxygen
Noninvasive ventilation: CPAP and
BiPAP rates
iO2: 21-100%
Noninvasive ventilation: CPAP and
BiPAP purpose
Avoids use of artificial airway in patients with acute respiratory distress,
postextubation respiratory failure, or neuromuscular disorders
Treats obstructive sleep apnea (OSA)
Stomach functions
- Storage
- Mixing
- Emptying
- Pyloric Sphincter
- Controls gastric emptying
- Small Intestines
Digestion
- Chyme
- Absorption
- Villi and microvilli
Duodenum size function
(approx. 1 foot)
* Process fluid from stomach
* Pancreatic enzymes and bile
Jejunum size function
(approx. 8 feet)
* Absorbs carbohydrates,
proteins, nutrients,
electrolytes
Ileum size function
(approx. 12 feet)
* Absorbs water, fats,
iron, bile salts
Large Intestines parts
(approx. 6 feet)
* Cecum
* Ileocecal valve
* One way valve preventing backup into
small intestines
Rectum parts
- Internal Sphincter
- External Sphincter
ADPIE
assesment
diagnosis
planning
implementation
evaluation
endoscopy
scope top to bottom
colonoscopy
scope bottom to top
Clostridium difficile
- Overgrowth secondary to disruption of normal flora
when to not use anti-diarrheal medications?
Do not use anti-diarrheal
medication with ‘infectious’
diarrhea
purpose of enemas
- Promotes bowel cleansing
- Empties the bowel for diagnostic testing or
surgery - Aids in the visualization of bowel mucosa
- Begin a bowel training program
- Relieves constipation
Hypertonic enema
Cleansing,
Work by osmotic pressure, drawing fluid out of interstitial spaces into the colon, which then fills with fluids and distends
isotonic enema
cleansing,
Oil retention enema
Lubricates the rectum and colon. Feces absorb the oil and
become softer and easier to pass.
Medication enema
Antibiotic enemas are used to treat local infections (worms,
parasites); a type of retention enema
Carminative
Return-flow
Provide relief from distention by stimulating peristalsis to
improve the passage of flatus
Delegation of enema
- Cannot delegate ‘medication’ enemas
- Kayexalate-hyperkalemia
- Neomycin-antibiotic
Positioning during enema
- Sim’s: left side lying, right knee flexed
enema Unexpected outcomes
- Rigid abdomen
- Distention
- Cramping
- Bleeding
Valsalva Maneuver
- Increase in intrathoracic pressure then
release may cause reflex bradycardia
and hypotension - Loss of consciousness
*
when to Suspect Impaction
- Unable to pass stool for several days
- Loss of appetite; N/V; abdominal distention
- Continuous oozing of liquid stool
Digital removal of stool
- Use if enemas fail to remove an impaction
- This is the last resort for constipation
is a health provider order necessary for an impaction
- A healthcare provider’s order is necessary to remove an impaction.
- May stimulate Vagal nerve
- Bradycardia, hypotension, irregular HR
Single Lumen nasogastric tube
- Fine- or small-bore for medication
administration and enteral feedings
(Levin)
double Lumen nasogastric tube
- Large-bore (12-French and above) for
gastric decompression or removal of
gastric secretions - Salem sump
- Blue “pigtail”
Salem slump NG tube
- Double lumen
- Sump: Air vent (blue pigtail)
- Indications: Gastric decompression, Lavage
- Advantages: DOES NOT ADHERE TO GASTRIC MUCOSOA
- Main lumen connected to suction: Air vent: NEVER
-Clamp off
-Connect to suction
-Irrigate
levin tube
*Single lumen
* No pigtail air vent
* Indications
*Gastric decompression
*Enteral tube feeding
*Medication administration
Contraindications to NG insertion by the nurse!
- Head, facial or neck trauma
- Severe craniofacial trauma: Intracranial
insertion - Damage to cribriform plate
- Recent nasal surgery
Suspicion/history of alcoholism with NG tubes
- Esophageal varices: bumps down tract
- Sengstaken-Blakemore Tube: tubes for hemorrhages
-not a nurse job
Measurement of NG placement on face
- Tip of nose to earlobe to xiphoid process
insertion of NG tube
- Water soluble lubricant
- Client position
- High Fowler’s
- Initially tilt head back
- Tilt forward
- Swallow
how to verify NG tube placement
Chest/KUB x-ray confirmation
* Aspirate syringe to obtain gastric content
-Observe color of gastric secretions
-Measure pH of contents
-Should be pH of 5 or less for gastric
contents
how to remove NG tube during resp distress
Remove the tube to the posterior nasopharynx until normal breathing resumes!
NPO
nothing by mouth
Irrigating an NG Tube
- Verify physician’s order
- Medical asepsis/clean technique
- Standard precautions
- Confirm NG tube placement
- reconnect to suction
- Draw up 30 mL of normal saline into
catheter tipped syringe - Attach irrigation syringe
- Instill solution without force
NG tube discontinuation
Verify order
* Assess patient for bowel sounds*
* Disconnect from suction to assess
* Explain procedure
* Medical Asepsis/ Standard precautions
* Apply gown, gloves and goggles
* Turn off suction
* Have client take a deep breath and hold it
* Kink tubing
Smoothly and steadily remove tube
* Dispose of equipment
* Biohazard bag
* Provide mouth care
* Follow up Assessment
* Abdomen for tenderness, rigidity,
distention
* Auscultate bowel sounds
* Assess for presence of
nausea/vomiting after removal
* Status of nares and nostrils
bowel diversions
Temporary or permanent
artificial opening in the
abdominal wall
* Stoma
* Surgical opening in the
ileum or colon
* Ileum (small intestines)
* Ileostomy
colonoscopy =
large intestines
solid waste
ileostomy
small intestines
liquid waste
effluent
fecal material
ostomy care
- Maintain skin integrity
- Assess stoma healing and integrity
- Prevent odors
- Promote comfort
- Maintain or increase self-esteem and dignity
can an ostomy pouch be delegated
pouch care CAN be
new pouch cannot be
ileostomy characteristics
- Odorless/limited odor
- Consistency of effluent
- Liquid
Colostomy characteristics
- Odorous
- Due to bacteria in the colon
- Consistency of stool
- Semi-liquid to solid depending on
site of ostomy
Nutritional considerations for ostomies
- Consume low fiber for the first few weeks.
- Eat slowly and chew food completely.
- Drink 10 to 12 glasses of water daily.
- Avoid gassy foods.
Primary Intention
- Edges are
approximated - Sutures aid in healing
(sutured shut)
4 stages of wound healing
hemostasis/coagulation
inflammation
prolif/migration
remodeling
- Secondary Intention
- Edges contract
- Wound bed fills
- Epithelialization
and scar tissue
(no suture)
- Tertiary Intention
- Closed later
(sutured shut after some healing on own)
Granulating Tissue
- Surface: Pink/red, Moist, ‘Bumpy’
Edges: Clean Intact
internal vs external hemorrhage
external: visibility bleeding
internal: appearing like a bruise (hematoma)
Dehiscence
- Partial or total
separation of wound
layers
Evisceration
- Total separation and protrusion of visceral organs
- Surgical emergency
- Do NOT push organs back in
- Moist gauze
- Continue nasogastric suction
Fistula formation
- Abnormal connection or passageway
nutrition for wound healing and why
vitamins A, C, zinc
increased collagen formation
conditions impacting wound healing
age, iron deficiency, Diabetes, CAD, HTN, Failure to Thrive
characteristics of wound drainage
color odor consistency amount
Serous
- Clear, watery
Purulent
- Thick, yellow, green, tan, brown
- Serosanguineous
- Pale, red, watery
- Sanguineous
- Bright red
Debridement
- Removing non-viable tissue
order to approach wound first aid
airway
breathing
circulation
bleeding
protection/cleaning
Vanderbilt wound flowsheet
sheet to document wounds
Penrose drain
a straight, flexible tube that drains fluid from a surgery site.
prevents infection
looks like flower bud
Jackson Pratt, Hemovac
- Constant, low-pressure vacuum to
remove and collect drainage - Empty when 50% full or once a shift
- Document COCA
- Concern with abrupt decrease/increase in
drainage - Foul smell
- Basic Skin Cleansing
- Clean from the least contaminated to the
surrounding skin - Use gentle friction
Negative-pressure wound therapy
packing wound
* Draws wound edges together
* Decreases edema and fluid removal
* Supports angiogenesis, granulation
- Wet to dry benefits
- Maintains a moist wound
surface - Wicks out drainage
- Debridement
Diabetic neuropathy
- Decreased sensation in hands and feet
Peripheral Vascular Disease signs
- Venous: Wet, weeping, edematous irregular edges. Usually develops above the ankle
- Arterial Insufficiency: Pulses faint, skin cool to touch, +/- edema. Clear demarkation
stage 1 pressure ulcer
- Intact skin with non-blanchable erythema (redness)
stage 2 pressure ulcer
- Partial-thickness skin loss involving epidermis, dermis, or both; can be intact or open blister
stage 3 pressure ulcer
- Full-thickness tissue loss with visible fat
stage 4 pressure ulcer
- Full-thickness tissue loss with exposed bone, muscle, or tendon
2 classifications of pressure ulcers
Unstageable: Cannot see the wound bed; obscured by slough or eschar
Deep Pressure Injury: Intact or non-intact: non-blanchable deep red or maroon/purple discoloration; deep wound bed or blood-filled blister
slough
the yellow/white material in the wound bed
eschar
Dead tissue in wound (usually dark/black appearance)
Deep Tissue Pressure Injury
pressure ulcer
* Persistent non-blanchable deep
red/purple discoloration
* Intact or non intact
* Dark wound bed
* Blood-filled blister
Braden scale
lower the score= greater risk
fall scale/pressure ulcer risk
Baseline (for wound care)
- Admission skin assessment
- Ongoing
can baseline be delegated?
NO
dressings used for pressure ulcer
hydrocolloid dressing
Hydrogel
- Keeps wound moist; absorbs exudate
Effects of cold application
Vasoconstriction
* Swelling and pain
- Effects of heat application
Vasodilation
- Factors influencing heat and cold tolerance
- Exposure time
- Exposed skin
Perception of sensory stimuli
Basal metabolic rate (BMR)
– Energy needed at rest to maintain life-sustaining
activities for a specific amount of time
- Resting energy expenditure (REE)
– Amount of energy needed to consume over 24-
hour period for the body to maintain internal
working activities while at rest
Anabolism
– Building of more complex biochemical
substances by synthesis of nutrients
Catabolism
– Breakdown of biochemical substances
into simpler substances; occurs during
physiological states of negative nitrogen
balance
– Ovolactovegetarian
(avoids meat, fish, and poultry, but eats eggs and milk)
– Lactovegetarian
(drinks milk but avoids eggs)
– Zen macrobiotic
Buddhist religious diet
– Fruitarian
(consumes fruit, nuts, honey, and
olive oil)
An ideal body weight (IBW)
provides an
estimate of what a person should weigh
- Body mass index (BMI)
measures weight
corrected for height and serves as an
alternative to traditional height–weight
relationships
Abdominal fat (waist circumference) vs BMI risks
Abdominal fat (waist circumference) has higher risk correlation than BMI
Hyperalimentation
artificial nutrition (example IV)
dysphagia
Difficulty in swallowing
assisting eating with dysphagia
small bites
sit upright
avoid distractions
chin tuck to chest
Enteral Access Tubes why one route over another?
gastric reflux
Nasogastric (NG) and NasoJejunal (NJ)
tubes time of use and delegation
–Provide a short-term feeding method
for nutritional intake and hydration.
–Insertion of an NG or NJ tube may
not be delegated to UAP.
Enteral Tube Feeding- Intermittent/Bolus
– Initiation
* Full strength; Bolus over 20-30 minutes
* 2.5-5mL/kg 5-8 times per day
* 60-120 mL per feeding 8-12 hours
– Tube placement
* X-ray confirmation
* pH 4 gastric secretions; pH 6 intestinal secretions
– Residual: flush with air then aspirate
* 250mL or less return contents and feed
* 500mL hold feed
– Flush with 30mL water Before and after feeding
– Position
* Elevated HOB: 30 degrees, preferably 45 degrees
* Right side lying
irrigation for enteral feeding tubes
- Intermittent
– Irrigate with 15-30 mL water before and after feeding - Continuous
– Irrigate with 30 mL water every 4 h
Feeding Intolerance
- Signs of intolerance may warrant holding
feeding
– Abdominal distention
– Vomiting
– Pain
– GRV 250mL-500mL
patient position during feedings
semi-fowlers
at least 30-45 degrees
how to administer meds during tube feeding
always liquid or powder mixed into sterile water
flush with 20-30 ml water before and after
extended or sustained release
medications
NEVER CRUSH
