exam 1 Flashcards
Patient positions in health assessment
standing
sitting
supine
dorsal recumbent/lithotomy (face down) (stirrups)
sims (left lateral, butt access)
prone (face down)
Trendelenburg/reverse Trendelenburg (head down, feet up)
heart sounds
Aortic pulmonic Erb's point tricuspid mitrial (PMI) APE To Man
examination is used when hands are used to assess skin temp
palpation
stages of a helping relationship
pre orientation
orientation
working
termination
focused interview to complete an admission hisotry
use direct questions
techniques for physical assessment
inspection: smells, situation, reactions
palpation: touch, mass/lumps
percussion: listen for diagnostic info
auscultation: listen with stethoscope
- diaphragm
- bell: vascular (fluids, swishing in carotid fistulas)
lung sounds
wheeze: constriction in lung
sibilant: classic asthma on inspiration and exspiration
stridor: super loud all above neck
Sonorous / Rhonchi: constriction, chronic bronchitis/inflammation, musical/coarse/dull
friction rub: plura of lungs is inflamed; grating on chest walls on inhale/exhale
. . . inserted to drain fluid or air from any of these three compartments of the thorax
chest tubes
Placed in the pleural space to restore the normal negative intrathoracic pressure needed for lung re-expansion after surgery or trauma
Surgery
Tension pneumothorax (most common: lung can’t inflate due to pressure)
Pneumothorax (air in lung)
Hemothorax (blood in lung)
Cardiac tamponade (pericardial sac fills with blood, mediastinal space put pressure on heart)
Penetrating wounds
indications for chest tube
two types of catheters
small bore: 7-12 Fr
large bore: up to 40 Fr
All chest drainage systems have…
- suction source
- collection chamber for pleural drainage
- mechanism to prevent air from reentering the chest with inhalation
amount of suction is determined by the amount of water instilled in the suction chamber
Has a water seal to prevent air from moving back into the chest on inspiration
Drain to gravity
Sucks air out, sends through H2O, can’t get back in
The water level in the water seal chamber reflects the negative pressure present in the intrathoracic cavity
Excessive negative pressure can cause trauma to the tissue
wet water seal
Use a one-way valve and may have a suction control dial in place of the water
at -20
dry suction
Increase in water levels during inspiration and a return to baseline with exhalation
tidaling
A wet suction control chamber
A water seal chamber
Air leak zone
A collection chamber
4 chambers of water seal system
Dry suction regulator
Water seal chamber
Collection chamber
Suction monitor/bellow
4 chambers in dry suction water seal system
collection chamber
one way mechanical valve
dry suction control chamber
3 chambers in dry suction systems with one way valve
The valve allows air and fluid to leave the chest but prevents their movement back into the pleural space
No water seal so it can be set up very quickly in emergencies
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dry suction systems with one way valve
150,000 to 450,000/mm3
Total platelets found in the blood
Platelets
11 to 12.5 sec
Detects deficiencies in the extrinsic coag system. Depends on adequate Vit K
Prothrombin time (PT)
0-1.1
(therapeutic levels are higher)
Same at PT test, but used internationally in all laboratories. Both monitor Coumadin and can detect liver failure
International ratio (INR)
170-340 mg/dL
Protein that converts to fibrin- needed for clots. Screen for DIC
Fibrinogen
0-250 ng/mL
Degradation product of fibrin clots. It’s presence confirms thrombin and plasmin activation. Diagnoses DIC.
D-dimer
O: universal donor
A: can receive A or O
AB: universal recipient: can receive AB, A, B, O
B: can receive B or O
cross matching
Fever Chills Itching Hives respiratory distress low back pain Nausea pain at the IV site anything “unusual”
signs of reaction to blood
1 degree C increase in temp- caused by donor antibodies and leukocytes- most common, especially with increased number of transfusions
signs and symptoms are chills followed by fever, typically sets in 2 hours after transfusion. Not life threatening. Can give Tylenol preop.
febrile nonhemolytic reactions
Most dangerous and life threatening!- incompatibility. Antibodies destroy cells. Can happen with very little blood.
fever, chills, low back pain, nausea, chest tightness, dyspnea, hypotension, hematuria, oliguria, bleeding, anxiety- hypotension, bronchospasm, vascular collapse, DIC
acute hemolytic reactions
Onset 14 days after transfusion- typically not dangerous, difficult to detect
fever, anemia, possibly jaundice
delayed hemolytic reactions
1-3% of transfusions- mild, responds to antihistamines (Benedryl)
uticaria or itching
allergic reactions
Hypervolemia- titrate infusion to their tolerance, diuretics, place them upright
dyspnea, orthopnea, tachycardia, anxiety, JVD, crackles, pulmonary edema (pink, frothy sputum)
circulatory overload
Why for trach
Obstructed airway
Mobilize secretions
Deliver oxygen
Measure from chin to jaw
Respiratory failure (COPD, ARDS) Airway injuries (trauma) SEVERE allergic reactions Head and neck cancer Neuromuscular disease (ALS) (loss of muscle strength) Spinal cord injuries Stroke
conditions for trachs
One way valve
Allows air in, not out
Forces air around tracheostomy tube, through the vocal cords, out the mouth
Patient can speak
helps air move around trach tubes and vocal chordes
passy-muir valve
*Obturator at bedside Suction equipment Ambu bag Spare trach Dressing change PRN *Humidified air
nursing care for trachs
Types of IVs
Peripheral Venous (IV): up to 72096 hours -terminates in peripheral vein Central Venous: implanted and externa (95%)l: stay in longer
Enter of Venous System
peripheral: cephalic or basilica vein
Central (tunneled or non): subclavian, internal jugular, external jugular, femoral vein
gauge: 20-22: common IV fluids
gauge: 14-18: blood or trauma
types of gauge
inflammation of vein
see redness due to irritation of tissue, warm, painful
fix with hot pack
phlebitic
vessel starting to harden
overtime vessel gets harder and stronger like calcified rock
sclerotic
Inserted just above or below the antecubital fossa into the basilica or cephalic veins
Catheter longer than 3 inches
Considered a Peripheral IV
Left in from 2-6 weeks
midline peripheral catheters
With running IV’s done hourly With Saline Locked every shift Monitor site/running fluid/tubing changes (running IV tube/bag 24 hrs, secondary 96 hrs, IV site q 72 hrs, follow agent policy) Redness= phlebitis swelling=infiltration pain=phlebitis coolness = loss of circulation
assessment of IV site
swelling, firmness, coolness
indicates infiltration
blood clots in IV line
so discontinue infusion
Common of dialysis catheters
Usually placed in surgery, may be done under local anesthetic
Two incisions are made on the chest (entrance and exit sites). A tunnel is made under the skin between the two incisions, and the CVC Is threaded through the skin and into a vein under the clavicle.
Sterile dressings are applied and the lumens are flushed with heparin. Caps changed with dressing changes.
tunnel makes difficult for bacteria to track into bloodstream and helps hold catheter in place
sterile due to close <3
tunneled CVCS
“Central line” or “Triple-lumen”
Placed at bedside w/ sterile technique or in OR by MD, with or without guidewire
Tip lies at superior vena cava of heart
Placed at subclavian or jugular veins
Change dressing 24 hours after placed and weekly
Flush per protocol
TRUE CENTRAL LINE: terminates AT superior vena cava
non tunneled CVC
Peripherally inserted in the arm, but the end of the catheter lies the sub-clavian vein.
Used for long term therapy with limited IV access who need antibiotics, blood, vasopressors, or parenteral nutrition
Inserted sterilely under local anesthetic, typically ultrasound guided, by specially trained nurse or doctor.
Sutured or tightly secured. Dressing changes are sterile.
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peripherally inserted central catheter (PICC)
- Pause IV to prevent drawing med that’s lfowing
- Largest lumen
- Aspirate 10 mL and flush*
- Discard 10 mL*
- New syringe- Blood draw*
- Flush*
- Positive pressure technique
how to draw blood
Thrombus (clot) -> embolism(moving clot)
Infection -> sepsis -> shock
Arterial puncture
Catheter malposition
Pneumothorax/hemothorax: try to put in vein and puncture lung or nic something –> blood in lungs
Air embolism Arrthymias
Nerve/tendon damage
Subcutaneous hematoma (under skin bleeding)
Thrombophlebitis (inflammation of clot)
Local: dermatitis, cellulitis, burns
complications
heparin or TPA substances - 5000 U to dissolve clot. Can't give to stroke pt. change position raise arm cough positive pressure technique
occlusions
osmolality equal to serum
stays in intravascular space and expands in intravascular compartment
-Expands blood volume only. Stays where “I” put it
Treats hypernatremia, fluid loss and dehydration
not given in head injuries
isotonic
DSW
osmolality lower than serum. Shifts fluid of intravascular compartment, hydrating cells and interstitial compartments
Goes into cells and sticks there Go “O”ut of the vessel
free water-rids waste in kidneys
decrease BP, cellular edema, cell damage
hypotonic solution
0.45% NACL
osmolality higher than serum. draws fluid into intravascular compartment from cells and interstitial compartments
water follows salt. fluid goes into cells and back out pulling excess fluid
“E”nter the vessel
treat hypernatrema and swollen cells
be careful: circulatory overload Pulmonary Edema
hypertonic solution
3% or 5% NACL
Calculated very specifically, typically daily
5-6X the solutes as blood (lots of pressure to veins)
**CVCs only
Not compatible with anything else
Lots of glucose=lots of bacteria!
Glucose monitoring, fluid overload
Parental nutrition (PN)
needs to be at least 1 wk of therapy
when weight loss/protein calorie malnutrition show up
use in extensive bowel surgeries or pancreatitis
use if can’t, unwilling, or NG/G tube wont work
