final Flashcards
1
Q
primary intention
A
all tissues, including the skin, are closed with suture material after completion of the operation
2
Q
secondary intention
A
wound will be left open (rather than being stitched together) and left to heal by itself, filling in and closing up naturally. It will mean you need regular dressings to the area for up to six weeks, but the time to full healing depends on the size, depth and site of the wound
3
Q
risk factors for wounds
A
- decreased LOC
- impaired mobility
- moisture/incontinence
- age
- medications
- friction/shear
4
Q
pressure injury stage 1
A
- intact skin, local non-blanchable erythemia (redness) with change in temperature/firmness
5
Q
stage 2 pressure injury
A
- partial thickness tissue loss showing viable, pink/red, moist with distinct wound margin
- intact or ruptured serum-filled blister
- slough/eschar NOT PRESENT
6
Q
pressure injury stage 3
A
- full thickness tissue loss with just subcutaneous adipose layer exposed
- slough/eschar initially present
- healing wounds show granulation tisue
- rolled edges (epibole) may be visible in chronic wounds
7
Q
pressure injury stage 4
A
- full thickness tissue loss, damage going through subcutaneous adipose layer; fascia, muscle, tendon, ligament
- slough/eschar initially present
- healing wounds = granulation tissue
- rolled edges
8
Q
unstageable wounds
A
dry, stable eschar firm cap
OR
moist, boggy eschar cap
9
Q
deep tissue injury
A
dusky, boggy, or discoloured area of purple, maroon, ecchymosis, or blood-filled blister
10
Q
medical devicde injury
A
injury can have appearance of any one of the stages or be instageable or DTI
usually conforms to the pattern or shape of device
11
Q
mucosal injury
A
injury can have appearance of any one of the stages or unstageable but itself is not staged
usually conforms to pattern or shape of device
12
Q
when wound bed is covered with slough/eschar….
A
unstageable, once visible, can be restaged either as stage 3 or 4
13
Q
can you back stage/reverse stages of pressure injuries?
A
NO
14
Q
venous ulcers
A
leg ulcers caused by problems with blood flow (circulation) in your leg veins. Normally, when you get a cut or scrape, your body’s healing process starts working to close the wound. In time, the wound heals. But ulcers may not heal without proper treatment
15
Q
arterial ulcers
A
painful, deep sore or wound in the skin of the lower leg or foot. The ulcer doesn’t heal as you’d expect an ordinary sore to heal. That’s because there isn’t enough blood flowing to the area. Blood supplies oxygen and nutrients to the tissues.
16
Q
venous vs arterial ulcers
A
They often form on the lower extremities, such as the legs and feet. Arterial ulcers develop as the result of damage to the arteries due to lack of blood flow to tissue. Venous ulcers develop from damage to the veins caused by an insufficient return of blood back to the heart.
17
Q
phases of wound healing
A
- inflammatory phase
- proliferative phase
- remodeling
18
Q
inflammatory phase
A
hemostasis, clots form a fibrin, damaged tissue and mast cells secrete histamine = vasodilation, WBC
19
Q
proliferative phase
A
new blood vessels appear, filling wound with granulation tissue, fibroblasts synthesize collagen
20
Q
remodeling
A
maturation, can take up to 2 years
21
Q
wound assessment
A
pain, size, bed, exudate, edge, odor, periwound skin
22
Q
measuring wounds
A
length “head to toe” at longest point
width side to side at widest point
measure depth by sticking qtip in
23
Q
tunneling/sinus tract
A
narrow channel or passage extending in nay direction from the base of the wound = dead space with potential risk for abscess formation
24
Q
undermining
A
open area extending under intact skin along the edge of wound
CLOCK!! 12 = head, 6 = legs
25
wound irrigation syringe size
30 or 35 cc syringe w/ saline or water
26
how do you irrigate wound
start at wound edge, apply full force of syringe, slowly sweep along wound bed
flush all sinus tracts using catheter tip and solution runs clear
27
how much solution should you flush with total
100 cc to adequately flush wound bed
28
purpose of packing wound
loosely fill dead space
facilitate removal of exudate and debris
encourage growth of granulation tissue from base of wound to prevent premature closure and abscess formation
29
overfilling wound
cause pressure on wound tissue which can cause pain, impair blood flow and potentially cause further tisssue damage
30
underpacking wound
not provide enough packing material to be in contact with base and sides of cavity, undermining or sinus/tunnel and can lead to rolled wound edges and/or abscess formation
31
what should you do with the tails of packing
leave clearly visible or on the peri-wound skin (secured with steri-strips_
ensure 2 or more pieces are knotted together and palced in wound cavity
32
moisture wound healing
similar to whites of eyes
healable wounds with sufficient perfusion to tissues
33
autolytic debridement wound dressing selection
gels, hypertonic dressings, honey based/antimicrobial dressings, dressing that retain moisture
34
non-healable wounds dressing selection
due to inadequate blood supply, inability to treat cause or wound exacerbating factors that cannot be corrected
35
typical size of catheters for males and female
M = 14-16 fr
F = 12 - 14 fr
36
3 way lumen catheter parts
- drainage
- balloon
- irrigation
37
aim to insert catheter ...
5-7.5 cm for female
17-22cm for male
38
ADVANCE EXTRA 2.5-5CM ONCE URINE FLOWS BEFORE INFLATING
YES
39
documentation of catheter insertion
size, ballon size inflated, amount of urine drained & characteristics, specimens, pt tolerance
40
how would catheter-associated UTI prevented
sterile technique
cleansing perineum well
promoting one-way flow of urine
41
closed irrigation catheter
flushes the bladder with sterile liquid.
prevent or remove blood clots after surgery in the urinary system.
Sterile solution enters the bladder through a thin tube, then the fluid is removed and collected in a bag.
CONTINUOUS
42
open irrigation catheter
flushed with saline via saline connected to irrigation port
stop-go
43
instructions to pt after foley removal
- increase fluid intake
- tell nurse first time need to void (needs to assess first void within 6-8 hrs post removal)
measure first void
some irritation
try to empty bladder fully
44
what is nasogastric tube
tube inserted through one of nostrils, down nasopharynx, down esophagus into stomach
45
large tubes (NG) used for
salem sump tubing for gastric decompression and medications
46
small tubes (EN) used for
feeding and medications
47
how do you determine length of tube for insertion
nose to ear to xyphoid process
48
how can we determine correct tube placement
pH of gastric fluid should be 1.5-5
chest xray
49
if there is a pH greater than 6.. then
it is likely in the tracheal-bronchial tree
50
ongoing care and management of ng tubes
- pH checks
- external measurement check
- inspection of nostrils (discharge, irritation, adhesive tape)
- resp assessment
- abdo assessment
- mouth care
- connection to suction
51
what position should pt be in for EN tubes
high fowlers
52
EN tube placement..
duodenum to reduce aspiration risk
53
how do you verify placement for EN
xray!
54
complications of EN
tube displacement
tube occlusion
abdo cramping, N & V
diarrhea
pulmonary aspiration
55
pulmonary aspiration can present like & how to prevent
SOB, crackles, gurgly, cyanosis, anxiety
high fowlers, check placement, tell dr
56
flushing meds through tubes
30 cc before meds
mix med with 15-30 cc
flush inbetween with 15-30 cc
flush with 30 cc after ALL meds
57
tips for flushing meds through tube
use warm water to mix
use liquid if possible
crush finely
flush well inbetween and after
58
open feeding solutions
pour solution into bag and prime tubing
59
closed feeding solutions
comes prepared so oyu spike bag with tubing
60
gastrojejunum (GJ) tubes
long term use
surgically inserted
no risk for aspiration d/t placement
61
goal of ostomy management
promote client's independence and quality of life through client teaching
62
ileostomy
surgically created opening in abdo that ileum is brought through
RIGHT SIDE
63
indications for ileostomy
crohns, ulcerative colitits, cancer
64
loop ileostomy
- temp rod
- proximal and distal opening
65
normal ileostomy output
- 500 to 750 mls
- toothpaste to oatmeal consistency
66
ileostomy considerations
- require "drainable" system that will allow for frequent emptying
- empty 1/3 full
- empty 4-6 times daily
67
if pouch is leaking, change it!
TRUE
essential to have peri-stomal skin protected with a properly fitted appliance
68
for ileostomy, diet and fluid modifications
- 6 to 8 weeks AVOID high fiber
- chew food well and smaller
69
ileostomy daily fluid loss
500 to 750 mls
70
hydration considerations for ilestomy
drink extra 2-3 cups
71
partial / complete obstruction of ileostomy
client education!!
- symptoms: no output or high liquid output, cramping, bloating/nausea
72
colostomy
surgically created opening in the abdo which part of large bowel is brought out
73
indications for colostomy
trauma, IBD, obstruction
74
types of colostomies
loop & end colostomies
- LEFT SIDE!!!!
75
colostomy dietary considerations
- no changes required
- healthy diet
- adequate fluids, fruit, milk, meats
76
bowel care for colostomies
- may experience constipation, a bowel protocol
- stomal enemas are more effective if used with an irrigation cone for fluid retention
77
normal output for colostomies
1-3 movements daily
varying shades of brown
semi formed to formed
78
types of urinary diversions
ileoconduit = urostomy
79
what side urostomy located
right side
80
normal output for urostomy
1000 - 2000ml
yellow with mucous shreds
81
people with urostomy should
maintain adequate fluid intake
monitor for signs/symptoms of UTI
82
ideal stoma should..
- 2.5cm, visible for pt
- location of lumen: apex of stoma
- colour: red = indicates adequate circulation
- shape: round
- location on body: smooth surface
83
frequency of appliance change
- depends on output, shape, abdo contours
- colostomy: q5-7 days
- ileostomy: q3-6 days
- urostomy: q3-7days
84
chemical damage of peri stomal skin
output in contact with skin
shallow moist, burning, pain
tx: new appliance
85
mechanical damage of peri stomal
stripping of dermis d/t inappropriate removal
denuded, wet, bleeding, painful
tx: client teaching
86
indications for suctioning
- visible secretions
- course crackles or gurgling on auscultation
- suspected aspiration of gastric or upper airway secretions
- increased resp distress
- decrease O2 sats
87
symptoms associated with hypoxia and hypercapnia
- decreased spO2
- increased HR BP
increased RR
- anxiety
- decreased ability to concentrate
- lethargy
- decreased LOC
- dizziness
88
types of suctioning
- oropharangeal
- orotracheal
- nasopharangeal
- nasotracheal
89
characteristics of oropharangeal suctioning
- remove pharangeal secretions through mouth
- clean gloves
- insert with suction into mouth, move catheter around mouth, pharnyx, gumline
- encourage coughing
- rinse with water
90
indications for tracheal suctioning
- maintain patent airway & remove saliva, pulmonary secretions, blood, vomit, foregin material
- stimulate cough
- obtain a sputum sample to identify & treat pulmonary infection
91
equipment needed for nasopharangeal
- sterile saline
- appropriate sized sterile sunctioning catheter
- water based lube
- sterile bowl
- wall suctioning
- sterile gloves
92
position for nasopharangeal/nasotracheal
semifowlers / upright
93
do you need to preoxygenate for nasophar/trach
YES
94
do you put the sterile glove on ur dominant hand during sterile suctioning
YES, and clean glove on nondom
95
describe nasopharangeal
- attach to wall suction
- insert along naris, during inhalation NO SUCTION
- phar = 16cm, trache = 20cm
- intermittent suction & rotate catheter on removal
- 10 - 15 sec
- flush with NS
- apply O2 & wait 1 min if another pass required
96
how many passes total for suctioning allowed
2
97
complications associated with tracheal suctioning
- hypoxemia (O2 level low in blood)
- cardiac arrhythmias
- atelectasis
- mucosal trauma
- infection
- increased intracranial pressure
- laryngospasm
- aspiration
98
documentation for suctioning
- amount, consistency, colour of secretions
- # of suction attempts
- resp status pre/post
- skin colour
- O2 sats pre/during/post
- RR, HR
- pt tolerance
99
A blood group
RBC = A
antibodies in plasma = ANTI-B
antigens in RBC = A ANTIGEN
100
B blood group
RBC = B
antibodies in plasma = ANTI-A
antigens in RBC = B ANTIGEN
101
AB blood group
RBC = AB
antibodies in plasma = NONE
antigens in RBC = A & B ANTIGENS
102
O blood gorup
RBC = O
antibodies in plasma = ANTI A & ANTI B
antigens in RBC = NONE
103
O- is
universal donor
104
O donor can give blood too
AB, B, A, O
105
A donor can give blood too
AB, A
106
B donor can give blood too
AB, B
107
AB donor can give blood too
AB
108
AB recipient can receive blood from
O, A, B, AB
UNIVERSAL RECIPIENT
109
B recevier of blood can get
O, B
110
A receiver of blood can get
O, A
111
O receiver of blood can get
O
112
Transfusion options:
1. A+
2. A-
3. B+
4. B-
5. AB+
6. AB-
7. O+
8. O-
1. A+, A-, O+, O-
2. A-, O-
3. B+, B-, O+, O-
4. B-, O-
5. A+, A-, B+, B-, O+, O-
6. A-, B-, O-
7. O=, O-
8. O-
113
blood component
- therapeutic component of blood
RBC, platelets, plasma, cryporecipitate
114
blood product
product derived from human blood or plasma and produced by a manufacturing process (albumin, immunoglobulin)
115
blood is living tissue so...
various anticoagulants and preservatives are used to maintain shelf life (35-42days)
116
pre-transfusion..
informed consent REQUIRED
order for blood documented in pt medical chart & on relevant request forms
117
blood product order should specify
- # of units in mls required
- rate or duration of infusion
- special requirements
118
gauge for blood products
18-20
large enough to allow flow rate and avoid cell damage
119
per pt assessment for blood transfusion
- 30 mins prior & before spiking bag
- baseline VS & chest auscultation & review fluid balance for high risk pts
120
what is compatible with blood
NS
121
administration set for blood
- micron filter
- prime administration set wtih compatible fluid to end hte line
122
how quick to initiate transfusion
within 20 mins of removal from temperature controlled storage
123
at first, blood transfusions should infuse..
1ml/kg/hr up to max 50ml/hr for 1st 15 mins
124
if there are no signs of transufsion reaction during first 15 mins then adjust flow rate?
YES
125
blood products must infused within
4 hrs of spiking
126
pt monitoring blood transfusion
- observe 1st 15 mins start each unit
- record VS 15 mins after start, 60 mins after start, & hourly during transfusion
127
how often change blood tubing
2 units or every 4 hrs
128
symptoms of transfusion reactions
- temp > 38.0 / change of 1 degree
- hypotension/shock
- rigors
- anxiety
- back/chest pain
- N & V
- SOB
- tachycardia
- generalized flushing
- rash > 25% of body
- urticaria
- hypothermia
- headache
129
types of transfusion reactions
- acute hemolytic
- febrile, nonhemolytic
- mild allergic
- anaphylactic
- circulatory overlaod
- sepsis
130
suspected transfusion reaction..
1. STOP transfusion
2. Administer 0.9% NS
3. Reassess patient VS
4. Seek assistance
5. Reconfirm unique identifiers on both patient and Blood product
6. Call Transfusion lab immediately if an error has occurred
7. Administer resuscitative care
8. Report suspected reaction
131
completion of transfusion
- stop infusion when bag empty
- flush set withNS
- disconnect line
- VS within 1hr of completion
- perform post transfusion BW PRN
- continue to monitor for SX transfusion reaction
132
what is tracheostomy tube
surgically incision in trachea below larynx
4-10cm tube inserted through stoma into trachea
133
indications for tracheostomy
- maintain patent airway by bypassing upper airway obstructions
134
components of tracheostomy tube
outer cannula
plug
cuff, inflation line, balloon
inner cannula
obturator
135
why are trache pts more prone to lung infections?
bypassing upper airway so the air is not filtered from nares, not moist, not warmed
136
indications for tracheal suctioning
- maintain patent airway by removing secretions
- improve resp status (easier resps, increase O2 sats)
- prevent infection cuased by retained secretions
137
do you suction prior to performing trach care
yess because you need to remove secretions so not occlude outer cannula when inner cannula removed
&&
decrease risk of airway being blocked by secretions
138
trach suctioning pressure
80-120
139
what is risk of using too much suction during trach
tracheal tissue damage
140
describe trach suctioning
- insert catheter into trach until meet with resistance at bifurcation, withdraw 1cm before intermittent suctioning
- NO suction while inserting
- max 10 sec from insertion to withdrawal
- max 2 times
- hyperoxygenate 1 min inbetween suction
141
complications of suctioning
hypoxemia
hypoxia
atelectasis
mucosal damage
infection
142
how often change trach stuff
q12 hr / PRN
143
why do we perform trach care
maintain patent airway, prevent infection, promote comfort
144
unexpected outcomes of trach care
- accidental decannulation while handling
- infection
- tracheal wall necrosis
- skin breakdown around peri-stoma
145
verifying safe peds dosages: body weight method
1. convert weight from lbs to kg
2. calculate safe dose in mg/kg (multiply mg/kg by weight)
3. compare ordered dose to rec dose & decide if safe
4. calculate amount to give
146
weight conversion
1kg = 2.2lbs
147
different restraints
- physical: pineal
- chemical = medications
- environmental = locked unit
148
target behaviours are
- pacing/wandering
- unsafe mobility
- impaired safety awareness
- unable to follow instructions
- imminent danger to self/others
- pulling tubes
149
alternatives to restrains
- reorienting
- 1:1
- reposition/mobilization
- change environment
- use calm, simple statements
- decrease stimulation
- toileting, food, fluids, needs
- pain assessment
150
chemical restraint before physical?
YES
151
