Exam 3 Flashcards
Layers of skin + physiology:
Largest Organ: 15% of total body weight
Provides….
Protective barrier against disease- causing temperature
Sensory organ for pain, temperature, touch
Vitamin D synthesis(immune system, mood)
Impaired skin integrity from wound, surgery, pressure injury; injury to skin poses risk to safety and triggers complex healing response
Factors Affecting the skin including developing considerations:
Unbroken and healthy skin and mucous membranes are first line of defense against harmful agents
resistance to injury is affected by age, amount of underlying tissue, and illness
adequately nourished, and hydrated body cells are resistant to injury
adequate circulation is necessary to maintain cell life
Developmental Considerations…
in children younger than 2 years, skin is thinner and weaker than adults
infants skin + mucous membrane are easily injured and subject to infection; child skin becomes increasingly resistant to injury and infection
structure of skin changes as person ages; maturation of epidermal cells is prolonged; leading to thin, easily damaged skin
circulation and collagen formation are impaired, leading to decreased elasticity and increased risk for tissue damage from pressure
Causes of Skin alterations:
Very thin and very obese people are more susceptible to skin injury
—–> fluid loss during illness causes dehydration
—–> skin appears loose and flabby
excessive perspiration during illness predisposes skin to breakdown
Types of Wounds:
Intentional vs unintentional (intentional; surgery, unintentional: cuts)
Closed or open:
( open: abrasions, closed: fall-strain, soft tissue damage)
Acute vs chronic:
(chronic is linked to decreased circulation; venous stasis, arterial ulcers, pressure injury, diabetic foot ulcers, neuropathy; Acute: surgical, trauma)
Partial thickness, full thickness, complex (complex, greater than 3 months)
Principles of Wound Healing:
Intact skin is first line of defense against microorganism
Careful hand hygiene is used in caring for wound
body responds systematically to trauma of any of its parts
adequate blood supply is essential for normal body response to injury
normal healing is promoted when wound is free of foreign material
extent of damage and persons state of health affect wound healing
response to wound is more effective if proper nutrition is maintained
Phases of wound healing:
Hemostasis: vasoconstriction, coagulation, platelet aggregation, beginning of growth factor secretion, exudate is formed- causing swelling and pain, increased perfusion results in heat and redness
inflammatory: vasodilation, WBC (leukocytes and macrophages move to the wound)
Proliferation: Re-epitheliamization, angiogenesis, collagen synthesis, granulation tissue forms a foundation for scar tissue development
Maturation: collagen remodeling, scar tissue becomes a flat, thin, white line
Process of Wound healing:
Primary Intention:
edges are approximated
surgical incisions heal by primary intention
risk of infection low
Secondary Intention:
burn, pressure injury, severe laceration
filled with scar tissue
longer to heal
risk of infection higher
loss of tissue function is permanent
Systematic Factors affecting wound healing:
Age: children and healthy adults heal more rapidly
circulation and oxygenation: adequate blood flow is essential
Nutritional Status: healing requires adequate healing
–> need 1500 kcal/day for skin and wound healing
—> vitamin A, C , calories and protein to heal
—> malnourished patient
Wound etiology: specific conditions of wound affect healing
Infection:
prolongs inflammatory phase, delays collagen synthesis, and prevents epithealization and tissue destruction
Health status: corticosteriod drugs, and postoperative radiation therapy delay healing
Immunosuppresion
Medication use: anti-inflammatory and antineoplastic
adherence to treatment plan
Complications of wound healing:
Hemorrhage (internally or externally)
—>Hematoma (swelling, change in color, sensation, warmth, blueish color)
—>assess post op and greatest risk 24-48 hrs, after surgery/injury
Infection:
- erythema, increased amount of wound drainage, change in appearance of wound drainage (thick, color change, odor) peri wound warmth, pain, edema, fever, tenderness, elevated WBC, wound edges inflamed, drainage is present: odor, purulent: yellow, green, brown color)
Dishiscence:
-partial or total separation of wound layers
Evisceration:
protrusion of visceral organs through wound opening
- emergency: damp sterile guaze over site: call for help
Fistula:
- tunneling: channel that extends in any direction from wound through subcutaneous tissue
- undermining: tissue destruction underlying intact skin along wound margins
Pressure injuries: Risk Factors
Age
Impaired sensory perception
chronic illness
diabetics (decreased perfusion and impaired sensory perception)
immobility
spinal cord and brain injury
neuromuscular disorders
alterations in LOC
friction
shears
moisture (stool or urine)
low blood pressure
Malnutrition
Pressure Injury: Classification
Stage 1: intact skin with no blanchable redness
Stage 2: partial thickness skin loss with exposed dermis
stage 3: full thickness skin loss with visible fat
stage 4: full-thickness skin with exposed bone, tendon, muscles
unstageable: obscured full-thickness skin and tissue loss by slough, and/or eschar, depth unknown
Deep tissue Pressure injury: persistent non- blanchable deep red, maroon, or purple discolorations ( do not massage over non- blanchable reddened areas) difficult to detect in individuals with dark skin tones
Pressure Injury: Risk assessment:
Braden Scale
- risk assessment (the lower score indicated a higher risk of pressure ulcer development)
Sensory perception
moisture (incontinence or diaphoresis)
Activity (mobility, pain control helps promote mobility)
nutrition (malnutrition is a risk factor)
friction/shears
Prevention of Pressure injury:
Risk Assessment: Braden Scale
Adequate nutrition: calories, protein, supplements
skin care:
- assess
- topical skin care and incontinence management
Positioning and mobilization:
- turn and reposition every 1-2 hrs
- positioning devices over bony prominence
- pressure relieving devices
—-> mattresses, overlay
——> seat cushion
—–> heel protecting device
elevating head 30 degrees or less decrease chance of pressure ulcer
elevated heels
transfer device to lift, then drag patient
Pressure injury: Causes
external pressure compressing blood vessels, usually over a bony prominence
Friction or shearing forces tearing or injuring blood vessel
Pressure Injury: assessment
be ready to write + Measure…
assess patient skin
assess level of sensation, movement, continence status
- continually assess skin for signs of breakdown, and/or ulcer development
-visual and tactile inspection of skin
- check over bony prominences, medical devices
Wound Assessment
Wound Location: heal, ankle, sacrum
Wound Age: acute or chronic
Wound Depth:
Partial thickness wounds (epidermis and superficial dermal layers) shallow in depth, moist and painful, and the wound base generally appears red, heals by regeneration
Full- thickness wounds extend into the subcutaneous layer, and the depth and tissue type will vary depending on body location (may expose muscle or bone) heals by forming new tissues, takes longer to heal
Wound Color:
Red = healing
yellow(slough) = caution
black (eschar)= tissue death
Presence of undermining, tunneling, sinus tract
Wound Size:
- length x width x depth (cm)
Wound Culture:
collect specimen from clean areas of granulation tissue of the wound
gram stains
tissue biopsy (gold standard)
Cleaning a pressure injury/wound:
clean with each dressing change
know if the dressing change is clean or sterile: follow providers orders
use new guaze for each wipe and clean from top- bottom and/or center -outside
use .9% normal saline solution to irrigate and clean the injury
once the wound is cleaned, dry the area using gauze sponge in same manner
report any drainage or necrotic tissue
First Aid for wounds:
Hemostasis:
control bleeding
– direct pressure
– do not remove penetrating object (object provides pressure and controls bleeding)
Bandage
Cleaning:
gentle cleaning
normal saline is preferred cleaning agent
protection:
light dressing applied over minor wounds prevents entry of microorganisms
Packing A wound:
Assess size, depth, and shape of wound (measure & doc)
Packing needs to be in contact with entire wound, do not overpack
negative pressure wound therapy:
removes fluid, decreases edema, decrease number of bacteria and improves circulation to area
Comfort Measure with wound care:
Administer analgesic medications 30-60 minutes before dressing changes
carefully remove tape
gently clean wound edges
carefully manipulate dressing and drains to minimize stress on senstitive tissue
turn and position patient carefully
Safety Guidelines: Wound Care
Do NOT use wet to dry dressing (changed w/E-B)
Do NOT pull dressing off a wound; it can cause further damage (moisten dressing with little sterile water)
position patient to prevent the patient from rolling over the side of bed
keep a plastic bag within reach to discard dressing and prevent cross-contamination. keep extra gloves within reach to allow a change of gloves if the gloves become soiled
if irritating a wound, use appropriate PPE
when applying an elastic bandage, check for extremity for temperature, sensation changes
never massage reddened area
Wounds: changing of dressing
know type of dressing, placement of drain, and equipment needed
prepare the patient for dressing change
review previous wound assessment
evaluate pain and if indicated, administer analgesics so peak effects during dressing change
describe procedure steps to lessen patient anxiety
gather all supplies
recognize normal signs of healing
answer questions about procedure or wound
Wounds: purpose of dressing
protects from microorgamisms
aids in hemostasis
promotes healing by absorbing drain and debriding a wound
supports wound size
promotes thermal insulation
provides the right amount of moist environment
Factors influencing heat and cold intolerance:
Method and duration of application
exposed skin: neck, inner aspect of wrist and forearm and perineal region are more sensitive, foot and palm of the hand are less sensitive
Amount of body surface covered by application
Temperature: body responds best to minor temperature adjustments, or larger areas of exposure
Age: very young and old most sensitve
perception of stimuli: reduced sensory perception, risk for injury is high
Effects + devices of Cold:
Effects:
constricts peripheral blood vessels
reduces swelling and pain
reduces muscle spasms
prolonged exposure results in vasodilation
Devices to apply cold:
ice bags
cold packs
hypothermia blankets
cold compresses to apply moist cold
Effects + devices of Heat:
Effects:
dilates peripheral blood vessels and improves blood flow to area
increase tissue metabolism
reduces blood viscosity and increases capillary permeability
reduces muscle tension and stiffness
helps relieve pain
prolonged exposure results in vasoconstriction and can lead to burns
Devices:
hot water bags
electic heating pads
aqua-thermia pads
hot packs
warm, moist compress
sitz bath
warm soaks
Duration of Pain:
Acute:
less than 3 months
rapid onset, varies in intensity and duration
protective in nature
Chronic:
more than 3 months
may be limited, intermittent, or persistent
last beyond the normal healing period
idiopathic pain: no known cause
periods of remission or exacerbation are common
The Pain Process:
Transduction: activation of pain receptors
Transmission: conduction along pathways (A-delta and C-delta fibers)
Perception of Pain: awareness of the characteristics of pain
- pain threshold: point at which a person feels pain
- pain tolerance: amount of pain a person is willing to bear
Modulation: inhibitation or modification of pain
Gate Control Theory of Pain:
describes the transmission of painful stimuli and recognizes a relationship between pain and emotions
small- and large diameters nerve fibers conduct and inhibit pain stimuli toward the brain
Gating mechanism determines the impulses that reach the brain
Origins of Pain:
Cutaneous:
In the skin or subcutaneous
Ex: superficial cut, bee sting
Somatic:
deep and diffuse (sharp, stabbing pain, localized)
ligaments, tendons, blood vessels, and bones
Ex: arthritis, bone fracture, or cancer
Visceral:
deep internal pain receptors
dull, heavy, aching pain occur over wide area, can cause referred pain
Ex: labor, pancreatitis, cancer
Radiating:
arises in one site and extends to another (sciatic pain)
Referred:
arises in one site but is felt in a distant site (MI, appendicitis)
Phantom: percieved as arising from a site that was surgically removed (amputation)
Physical:
cause of pain can be identified
cancer vs. Non- cancer pain
Psychogenic:
cause of pain cannot be identified
outdated term
Common Responses to Pain:
Physiologic:
sympathetic response (moderate and superficial) or parasympathetic responses (severe and deep)
behavioral: grimacing, moaning, crying, restless, guarding
Affective:
stoicism, restlessness, anxiety, weeping, depression, fear, anger, anorexia, fatigue, hopelessness, powerlessness
Factors affecting Pain experience:
Culture
ethnic variable
family, sex, gender, and age variables
religious beliefs
environment and support people
anxiety, fatigue, and other stressors
past pain experience and coping styles
Patient- centered care is required!!!!
be aware of bias!!!
Assessment Parameters for Pain:
Psychological, spritual, sociocutural
characteristic of pain
physiologic responses
behavioral responses
affective responses
General Assessment of Pain:
patient verbalization and description of pain
timing (onset, duration, pattern)
location of pain (superficical, deep, referred, radiating)
Intensity of Pain (severity-severe, moderate, mild)
Periodicity: (continous, intermittent, brief, transient)
Quality of Pain; (dull, stabbing, crushing, throbbing, sharp, burning, diffuse, shifting)
Chronology of pain:
Aggravating and alleviating factors (movement, positions drinking/eating, swallowing, stress, coughing, heat/cold)
Physiologic indicators of pain
behavioral responses
effect of pain on activities and lifestyle
Pain Assessment Tools:
0-10 Numeric Rating Scale
Adult Nonverbal Pain Scale
Wong-Baker FACES
Beyer Oucher pain scale
CRIES pain scale
FLACC scale
COMFORT scale
Safety Guidelines:
the patient is the only person who should press the button to administer the pain medication when PCA is used
monitor the patient for signs and symptoms of oversedation and respiratory depression
keep diary of pain medications to prevent under and overuse
monitor for potential side effects of opioid analgesics
Safety: avoid drinking, operating machinery, alcohol, or other CNS depressants
do not breastfeed without consulting provider
Pain Management regimens for cancer or chronic pain:
give medications orally if possible
administer medications ATC rather than PRN
adjust the dose to achieve maximum benefit with minimum side effects
allow patients as much control as possible over regimen
Numeric Sedation Scale:
S: sleep, easy to arouse: no action necessary
1: awake and alert; no action necessary
2: occasionally drowsy, but easy to arouse; no action necessary
3: frequently drowsy, drifts over to sleep during conversation; reduced dosage
4: somnolent with minimal or no response to stimuli; discontinue opioid, consider use of naloxone
Naloxone (Narcan) can be used to reverse effects of respiratory depression
The WHO 3-step Analgesic Ladder:
Step 1: nonopioid (+/- Adjuvant)
Step 2: opioid for mild to moderate pain (+/- nonopioid, +/- adjuvant)
Step 3: opioid for moderate to severe pain (+/- nonopioid, +/- Adjuvant)
Nonparmacologic: pain relief measures:
Distraction (ambulation, deep breathing, visitors, TV, games, prayer, music, pet therapy)
Humor
Music
Guided Imagery & relaxation (medication, yoga)
Cutaneous stimulation (massage, TENS, heat, cold)
Acupuncture
hypnosis
biofeedback
therapeutic touch
animal-faciliated therapy
Pharmacologic Pain measures:
Nonopioid Analgesics:(acetaminophen and NSAIDS)
tylenol hepatoxic max- 4g/day
NSAIDS long term: GI bleeding
Opioids or narcotic Analgesics: (controlled substances: morphine, codeine, oxycodone, meperidine, hydromorphone, methadone)
- Side Effects: sedation, respiratory depression, N/V, constipation, urinary retention, altered mental processes, orthostatic hypotension, withdrawal/tolerance
Adjuvant Drugs: anticonvulsants, antidepressants, multipurpose drugs
Diagnosing Pain:
type of pain
etiologic factors
behavioral, physiologic, affective responses
other factors affecting pain process
Etiology:
Nociceptive:
type of Nociceptive pain
- cutaneous
-somatic
-visceral
Neuropathic:
damage from abnormal or damaged nerve pain
Ex: phantom limb pain, diabetic neuropathy
pins and needles, burning, shooting, intense
Perioperative Stages:
Preoperative:
beings with decision to have surgery, last until patient is transferred to operating room or procedural bed
Intraoperative:
begins when the patient is transferred to the OR bed until transfer to the post anesthesia care unit (PACU)
Postoperative:
last from admission to PACU or other recovery area to complete recovery from surgery and last follow-up health care providers visit
Classification of Surgical Procedures:
Urgency: elective, urgent, emergency
Risk: Minor or Major
Purpose: diagnosic, curative, preventable, ablative, palliative, reconstructive, transplantation, construtive
Types of Anesthesia:
Anesthesia: loss of sensation in all or part of the body with or without loss
General:
administration of drugs by inhalation or intravenous route
Moderate Sedation/analgesia: (conscious sedation/analgesia) used for short-term minimally invasive procedures
Regional: anesthetic agent injected near a nerve or nerve pathway or around operative site
Topical and local anesthesia: used on mucous membranes, open skin, wounds, burns
Three Phases of Anethesia:
Induction: from administration of anesthesia to ready for incision
Maintenance: from incision to near completion of procedure
Emergence: starts when patient emerges from anesthesia and is ready to leave operating room
states of Anesthesia:
loss of consciousness
Amnesia (loss of memory)
analgesia (absence of pain)
relaxed skeletal muscles
depressed reflexes
Informed Consent Information:
description of procedure and alternative therapies
underlying disease process and its natural course
name and qualification of person performing procedure
explanation of risks and how often they occur
explanation that the patient has the right to refuse treatment or withdraw consent
explanation of expected outcome, recovery, rehabiliation plan, and course of treatment
Advance Directives:
Living Wills:
a legal document that expresses, in advance, a person instructions or preferences about future medical treatments particularly end of life care in the event the person loses capacity to make health care decisions
Durable Power of Attorney for healthcare:
a legal document that appoints a person (typically called a health care agent, but also a proxy, health care representative) to make decisions for the person n the event of incapacity (temporary or permanent) to make healthcare decisions
Do Not Resuscitate (DNR)
Promoting Return to health: surgery
elimination needs
fluid and nutrition needs
comfort and rest needs
helping the patient cope
Interventions to prevent respiratory complications:
monitoring vital signs
implementing deep breathing
coughing
incentive spirometry
turning in bed every 2 hours
ambulating
maintaining hydration
avoiding positioning that decreases ventilation
monitoring responses to narcotic analgesics
Postoperative Assessment and Interventions:
every 10-15 minutes
respiratory status (airway, pulse oximetry)
cardiovascular status (blood pressure)
temperature
central nervous system status (level of alertness, movement and shivering)
fluid status
wound status
Gastrointestinal status (nausea and vomiting)
general condition
TJC protocol:
prevent wrong site, wrong procedure, and wrong person
preoperative patient identification verification process
marking the operative site
final verification just prior to beginning the procedure, referred to as the time-out
Medication Names:
Chemical:
provides exact descriptions of medical composition (N-Acetyl-para-aminophenol)
Generic:
the manufacture who first develops the drug assigns the name, and then it is listed in the U.S pharmacopeia (acetaminophen)
Trade:
also known as brand or proprietary name. this is the name under which a manufacturer markets the medication (look for @ or TM)
(tylenol, pandol, tempra)
Classification:
effect of medication on body system
symptoms the medication relieves
medications desired effects
(analgesia, antipyretic, stimulants)
medication forms:
solid, liquid, other oral forms: topical, parenteral, forms for instillation into body cavities
Pharmacokinetics:
the study of how medications
enter the body
are absorbed and distrubted into cells, tissue, or organs
reach their site of action
alter physiological function
are metabolized
exit the body
Types of Medication Action:
therapeutic effect:
expected or predicted physiological responses
adverse effect: unintended, undesirable, often predictable
Side effect: predictable, unavoidable secondary effect
Toxic effect: accumulation of medication in the bloodstream
Allergic Reaction: unpredictable response to a medication; anaphylatic reaction
Medication Interaction:
when one medication modifies the action of another
Types of Orders in Acute Care Agencies:
standing or routine: administered until the dosage is changed or another medication is prescribed
PRN: given when patient requires it
Single (one-time): given one time only for specific reason
Now: when a medication is needed right away; but not STAT
STAT: given immediately in an emergency
Prescription: medication to be taken outside of hospital
Medication Administration: Nurse Role
determining medication ordered are correct,
assessing patient ability to self-administer,
determining whether patient should recieve mediation at given time
cosely monitoring effect
cannot be delgated
includes patient teaching
nursing students cannot administer medications without supervision by a licensed RN
Timing of Medication Dose Response:
therapeutic range
peak
trough
biological half-life
plateau
time-critical medications
patient teaching
Oral Administration:
tablets, capsules, suspensions, exlixirs, lozenges
Sublingual Administration: under tongue
Buccal Administration: Cheek
Parenteral Medication:
Subcutaneous Injection: subcutanous tissue
Intramuscular injection: muscle tissue
Intradermal Injection: corium (under epidermis)
Intravenous injection: vein
Intra-arterial injection:artery
Intracardial injection: heart tissue
Intraperitoneal injection: peritoneal cavity
Intraspinal injection: spinal canal
Intraosseous injection:
Nursing Assessment: Medications
through the patients eyes (preferences, values, and needs)
History: Allergies, medications, diet history, patients perceptual or coordination problems
patient current condition (some illness place pt. at risk for adverse medication effect)
patients attiude about medication use
factors affecting adherence to medication therapy
patients learning needs, health literacy
Nursing Evaluation: Medication
through the patient eyes…
partner with your patients
response to medication
ability to self care
identify barriers to medication adherence
Patient Outcomes:
use knowledge of the desired effect and common side effects of each medication to compare expected outcomes with actual finding
Rights of medication administration:
6 Rights:
1. right medication
2. right dose
3. right patient
4. right route
5. right time
6. right documentation
11 Rights:
medication
patient
dosage
route
time
reason
assessment
documentation
response
educate
refuse
maintaining patient rights:
A patient has the right to…
To be informed about a medication
To refuse a medication
To have a medication history
To be properly advised about experimental nature of medication
To receive labeled medications safely
To receive appropriate supportive therapy
To not receive unnecessary medications
To be informed if medications are part of a research study
3 checks of medication administration:
Read the label.
First check: when the nurse reaches for the container or unit dose package
Second Check: after retrieval from the drawer and compared with the eMAR/MAR or compared with the EMAR/MAR immediately before poruing from the multidose container
third check:
before giving the unit dose medication to the patinet or when replacing the multi-dose container in the drawer or shelf
Identifying the patient:
checking the identification bracelet
validating the patient name (first identifier)
validating the patient identification number, medical record number and/or birth date (second identifier)
comparing with MAR
asking patient to state his or her name if possible
administering Medication:
check MAR with accuracy of the order
know information about the medication that you plan to administer (action, purpose, normal dose, route, side effects, time of onset, peak, nursing implications
perform assessment (review of lab values, pain, respiratory assessment, cardiac assessment prior to medication administer to ensure the patient is recieving the correct medication for the correct reason. Assess for contraindications
ensure correct dosage calculation. Double check, have another nurse verify calculation
gather medication from the pyxis (no-interuption zone)
make sure medication is not expired and barcode is intact
high alert medication needs a second nurse
hand hyigene
educate the patient about the medication before administering it, Answer questions regarding usage, dose, and special considerations
use at least 2 patient identifers before administration
scan patient bracelet
check for allergies, type of reaction, severity of reactions
scan medication
position patient for proper administration of medication
if oral medication, give with fluid
ensure patient took medication, never leave in the patient room
perform hand hygiene
determine response to medication; complete assessment and/or vital signs
check to make sure no adverse effects
Medication errors-prevention:
report all medication errors
patient safety is top priority, when an error occurs
read all orders, instructions, and labels carefully
ask questions if you do not understand
do not allow anyone or anything to interupt you
double check all calculations
use at least 2 ways to identify patient
identify and report system issues
learn as much as you can about the medication you administer
Oral Administration: how to give medication through a g-tube:
verify that the tube location is compatible with medication absorption
use liquids when possible
if medication is to be given on an empty stomach; at least 30 min before or after feedings
risk of drug-drug interaction is higher
Topical Application:
Skin applications:
use gloves and applicators; clean skin first
use sterile technique if the patient has open wound
follow directions for each type of medication
Transdermal patch:
remove old patch before applying new
document the location of the new patch
ask about patches during medication history
apply a label to the patch if it is difficult to see
document removal of the patch as well
Nasal Instillation:
spray
drops
tampons
Eye Instillation:
avoid the cornea
avoid the eyelids with droppers or tubes to decrease the risk of infections
use only on affected eye
never share medications
Ear Instillation:
instill eardrops at room temperature
have patient sit upright or lie on side
straighten ear canal: adults pull auricle upward and outward Child: down and back
use sterile solutions and aseptic technique
check for eardrum rupture if patient has ear drainage
never occlude the ear canal
Vaginal instillation/rectal instillation:
suppositories, foam, jellies, creams
applicators used (wash with soap and water)
patient often prefer adminstering own vaginal medications and need privacy
suppository insert 7.5-10cm (3-4 inches) stay supine for 5 minutes
Administering Medications by inhalations:
Pressurized Meter-dose inhalers (pMDIs)
need sufficient hand strength for use
may be used with a spacer
Breath Actuated metered-dose inhalers (BALs)
release depends on strength of patient breath
Dry Powered inhalers: (DPIs)
activated by patient breath
hold breath 5-10 seconds, release with pursed lips
rinse mouth with corticosteroid inhale
Administering medications by irrigation:
irrigations cleanse an area, instill a medication, or apply hot or cold to injured tissue
irrigations most commonly use sterile water, saline, or antiseptic solutions on the eye, ear, throat, vagina and urinary tract
use aseptic techniques if there is a break in the skin or muscosa
use clean technique when the cavity to be irrigated is not sterile, as in the case of the ear canal or vagina
How to Mix insulin:
accuracy is critical
roll cloudy insulin, never shake (causes air bubbles- less accurate)
verify with another nurse
wipe top of vials with alcohol swabs
trick to remember: RN or clear to cloudy
administer within 5 minutes
never mix lantus or levemir with other types of insulin
Minimizing Patient Discomfort:
use a sharp-beveled needle in the smallest suitable length and gauge; position patient comfortably
select proper injection site
apply a vapocoolant spray or topical anesthetic
divert the patient attention from the injection
insert needle quickly and smoothly
hold the syringe steady while needle remains in tissue
inject medications slowly and steadily
Subcutaneous Injections:
administer into the adipose tissue layer just below the epidermis and dermis
slower absorption from the IM injection
use 3/8-5/8 inch, 25-27 gauge needle
inject at 45-90 degree angle: for obese patient use a 90 degree angle
small volumes not more than 1.5 mL
do not massage site
rotate sites
Intramuscular Injections:
faster absorption than subcutaneous route
many risks, so verify the injection is justified
angle of administration: 90 degrees
body mass index (BMI) and adipose tissue influence needle size selection
Amounts:
Adults: 2-5 mL (4-5 mL unlikely to be absorbed properly)
children, older adults, thin patients: up to 2 mL
small children and older infants: up to 1 ml)
smaller infants: up to 0.5 mL
Intradermal Injections
used for tuberculin screening or allergy testing
tuberculin or small hypodermic needle
5-15 degrees with bevel of needle pointing up
small bleb appears
Dorsogluteal injection:
not recommended because of proximity to sciatic nerve and major blood vessels
large amount of subsutaneous tissue
Ventrogluteal injection:
safest for adults, children, and infant esp with large volumes
recommended with volumes greater than 2 mL
Volume: average 2-4 mL
flex the knee and hip to relax muscle
Needle size:
Adult: 1.5 inches
Child: 1/2-1 inch
index finger, the middle finger, and the iliac crest form v-shaped triangle
injection site is center of triangle
Vatus Lateralis Injection:
used for adults and children
use middle third of muscle for injection
often used for infants, toddlers, and children receiving biologicals
Deltoid Injection
small volumes and immunizations
Needle length: Adult 1-1.5
child: 1/2- 1 inch
Z-Track:
z track method is recommended to minimize skin irritation by sealing the medication is muscle tissue
zigzag path seals needle track
medication cannot escape from the muscle tissue
change needle before administering medication
use a large muscle such as ventrogluteal muscle
the needle remains inserted for 10 seconds to allow medication to disperse evenly rather than channeling back up the track of the needle
release the skin after withdrawing the needle
Preparing an injection from an ampule:
snap off ampule neck
aspirate medication into syringe using filter needle
replace filter needle with an appropriate size needles or needless device
administer needle
Preparing An injection from Vial:
if dry, use solvent or diluent as needed
inject air into vial
label multidose vials after mixing
refrigerate remaining dose if needed
never put a dirty needle in a multi dose vial
clean multidose vial with alcohol swab
Piggyback IV Administration
a small (25-250 ml) IV bag or bottle connected to a short tubing line that connects to the upper Y port of a primary infusion line or to an intermiitent venous assess
Intravenous Bolus
Introduces a concentrated dose of medication directly into the systemic circulation
Advantageous when the amount of fluid that a patient can take is restricted
The most dangerous method for medication administration because there is no time to correct errors
Confirm placement of the IV line in a healthy site
Determine the rate of administration by the amount of medication that can be given each minute
Make sure the site is healthy
Five Part of the Communication Process
Stimulus or referent
sender or source of message (encoder)
message itself
medium or channel commication
Receiver (decoder)
Disruptive Interpersonal Behaviors
incivility
bullying:
horizontal violence
nurse bullying
negative communication between nurse and physician
aggressive behavior
organizational response to disruptive behavior
Blocks to communication:
failure to perceive the patient as human
failure to listen
nontherapeutic comments and questions
using cliches
using closed questions
using questions containing the words “why” and”how”
using questions that probe for information
using leading questions
using comments that give advice
using judgemental comments
changing the subject
giving false assurance
using gossip and rumors
using disruptive interpersonal behavior
Characteristics of effective and ineffective groups:
group identity
cohesiveness
patterns of interaction
decision making
responsibilty
leadership
power
Interviewing Techniques
open-ended questions or comments
closed question or comments
validating questions or comments
clarifying questions or comments
reflective questions or comments
sequencing questions or comments
directing questions or comments
SOLER:
S: sit facing the client
O: observe an open posture; keep arms and legs uncrossed to receive info
L” lean toward the client
E: establish and maintain intermittent eye contact
R: relax
Forms of communication:
Verbal: (language ~words)
Nonverbal (body language)
facial expressions, touch, eye contact
postur, gait gesture
general physical appearance
mode of dress and grooming
sounds, silence (moaning, crying, gasping, sighing)
electronic communication
Factors influencing Communication:
developmental level
gender
sociocultural differences
roles and responsibilites
space and territorality
physical, mental, and emotional state
values
environment
CUS
I’m Concerned
I’m uncomfortable
This is Unsafe
Developing Listening skills:
sit when communicating with a patient
be alert and relaxed and take your time
keep conversation as natural as possible
maintain eye contact if appropriate
use appropriate facial expressions and body gestures
think before responding to the patient
do not pretend to listen
listen for themes in the patient comments
use silence, therapeutic touch, humor appropriately
developing conversation skills:
control the tone of your voice, know your face
be knowledgeable about the topic of conversation
be flexible
be clear and concise
avoid words that might have different interpretations
be truthful
keep an open mind
take advantage of available opportunities
Rapport Builders:
specific objectives
comfortable environment
privacy
confidentiality
patient vs task focus
utilization of nursing observations
optimal pacing
Dispositional traits:
warmth and friendliness
openness and respect
empathy
honesty, authenticity, trust
non-judgemental
caring
competence
Factors taht promote effective communication:
dispositional traits
rapport builders
Phases of Nurse Patient Relationship:
Orientation phase
working phase
termination phase
Surgical Risks of Medications:
Anticoagulants: precipitate hemorrhage
Diuretics: electrolyte imbalances, respiratory depression from anesthesia
Tranquilizers: increase hypotensive effects of anesthetia agents
Adrenal Steroids: abrupt withdrawal may cause cardiovascular collapse
Antibotics in mycin group: respiratory paralysis when combined with certain muscle relaxants
Surgical Risk Factors:
Smoking: respiratory problems and poor wound healing
Age; very young and older patient
nutrition: increases need for nutrients, thin and obese patients often protein and vitamin deficient
Obesity: Morality increaes due to reduction in ventilary and cardiac function
Obstructive sleep apnea (OSA)
Immunosuppresion: risk for infection after surgery
fluid and electrolyte imbalance: hypovolemia
Postoperative nausea and vomiting (PONV) 30% can have PONV, can lead to pulmonary aspiration, dehydration, arrhythmias, pull apart suture
Patient Risk Factors and strengths:
developmental level
medical and surgical history
medication history
nutritional status
use of alcohol, illict drugs, or nicotine
activiites of daily living and occupation
coping patterns and support system
sociocutural needs
Assessment: surgical
Health history (medical, surgical, developmental, implants, nutrition, alcohol/drugs, ADLs)
physical exam
risk factors and allergies
medication and treatments
pre-operative blood work and testing
teaching and psychosocial needs
determine postsurgical support and referrance
Outpatient/ Same-day surgery
reduces length of hospital stay and cut cost
reduces stress for the patient
may require additional teaching and home care services for certain patient
older patients, chronically ill patient, patint with no support system
Complication: surgery
hemorrhage
shock
thrombophlebitis
deep vein thrombosis
pulmonary embolus
atelectasis
pneumonia
surgical site complications
