Final Exam Flashcards
(283 cards)
1
Q
CN I
A
Olfactory - smell
2
Q
CN III
A
Oculomotor - upper eyelid movement (upper movement, down and out angle, and inward)
Test: EOM
3
Q
CN IV
A
Trochlear - eye movement downward angle to nose
Test: EOM
4
Q
CN V
A
Trigeminal - sensation of face and motor
Test: have pt clench their jaw and assess for strength, tenderness, and superficial pain sensation
5
Q
CN VI
A
Abducens - move eyes laterally towards ear
Test: EOM
6
Q
CN VII
A
Facial - facial expression, lacrimation, taste of anterior 2.3 of tongue
Test: smile, wrinkle forehead, puff out cheeks
7
Q
CN VIII
A
Vestibulocochlear aka acoustic - transmits sounds to brain and responsible for balance/equilibrium
Test: whisper in one ear and have pt repeat (auditory) and rhombergs test (balance)
8
Q
CN IX
A
Glossopharyngeal - posterior 1/3 taste
Test: gag reflex
9
Q
CN X
A
Vagal - muscles of larynx and pharynx, taste from tongue to epiglottis
Test: gag reflex
10
Q
CN XI
A
Accessory - torticollis (twisting neck)
Test: shrug shoulders and turn head side-to-side
11
Q
CN XII
A
Hypoglossal - tongue movement side-to-side
Test: stick tongue out and move side-to-side
12
Q
Pupil accommodation (what nerves are involved and how do you test it?)
A
CN II & III - start with light by nose and pull it away
Distance = dilate
Close = constrict
13
Q
Corneal reflex (what nerves are involved and how do you test it?)
A
CN V & VII - test blink reflex by stimulating the eye
14
Q
How should the ears be aligned?
A
Top of ear should be at or above the outer canthus of the eye (if lower, consider fxn of kidneys b/c of time of development)
15
Q
What should the tympanic membrane look like?
A
Shiny, grey, translucent
16
Q
How should light reflect on the tympanic membrane?
A
@ 5 o’clock on the right
@ 7 o’clock on the left
17
Q
What are the CNs of the ear?
A
VIII - acoustic
18
Q
What does the Rhombergs test assess for?
A
Test equilibrium and assess for any ataxia (or loss of motor coordination)
19
Q
Ptosis
A
Drooping of the upper eyelid
20
Q
Exopthalomus
A
Bulging of the eyes r/t hyperthyroidism
21
Q
Xanthelasma
A
Yellow pre-orbital lesions r/t lipid disorder (hypercholesteremia)
Most common in F >50
22
Q
EOM (nerves responsible, cardinal movements, concerns, and balance)
A
CN III, IV, VI
6 cardinal movements - up and out, up and in, abduction, adduction, down and out, down and in
Strabismus
Test balance with corneal light reflex (light should reflect symmetrically)
23
Q
CN of the Eye
A
CN II, III, IV, VI
24
Q
CN II
A
Optic - near and distant vision
Test: Snellen chart @ 20’ and Rosenbaum chart @ 14”
E chart used for language barriers
Confrontation test for peripheral vision
25
Presbyopia
loss of near vision r/t age >40
26
What CN is involved in a confrontation test and what population is it most important for?
CN II - glaucoma and MS (people who tend to lose their peripheral vision first)
27
PERRLA
Pupils equal, round, reactive to light, and accommodating
| Look for consensual reaction
28
Anisorcia
Unequal pupil sizes
29
Mitosis
Pupils <2 mm (think: opioids)
30
Mydriasis
Pupils >6 mm (think: cocaine or THC)
31
Glaucoma
Loss of peripheral vision that progresses to loss of central vision due to nerve damage from fluid buildup that has increased pressure behind the eye (incurable)
32
Cataracts (what is it and what are the types?)
Progressive clouding of the lens
1. Senile - most common, age >50
2. Trauma - injury or radiation
3. Medication - steroids
4. Disease - diabetes
Surgery to replace lens
33
Retinal Detachment
Painless vision loss when retina separates from back of eye due to fluid buildup underneath it
Surgery to insert gas bubble
34
Strabismus
Cross-eyes (can lead to a lazy eye)
Weakness of CN III, IV, or VI
Test: corneal light test
35
Macular Degeneration
loss of central vision
36
Lymph Nodes (purpose and types)
Part of immune system; detect and eliminate foreign substances (drain into cervical chain)
1. Pre-auricular
2. Occipital
3. Post-auricular
4. Parotid and tonsillar
5. Submandibular
6. Submental
7. Anterior cervical
8. Posterior cervical
9. Supraclavicular
37
What do normal lymph nodes feel like?
moveable, discrete, non-tender
38
What do acutely infected lymph nodes feel like?
bilaterally warm, tender, non-firm, moveable
39
What do malignant lymph nodes feel like?
hard, >3 cm unilaterally, non-tender, matted, fixed
40
CNs of the Face
CN V & VII
41
CNs of the Neck
CN IX, X, XI, XII
42
How to Assess Movement of the Neck
Chin to chest, side to side, extension, ear to should (note any limitations)
43
What are the AV valves?
Tricuspid and mitral
44
What are the SL valves?
Aortic and pulmonic
45
Are valves of the heart uni or bidirectional? Do they work through passive or active movement?
Valves are unidirectional and work through passive movement with pressure increases
46
Where can you assess the aortic valve and what should you hear?
2 ICS, RSB, S2>S1
47
Where can you assess the pulmonic valve and what should you hear?
2 ICS, LSB, S2>S1
48
Where can you assess erb's point and what should you hear?
3 ICS, LSB, S1=S2
49
Where can you assess the tricuspid valve and what should you hear?
4 ICS, LSB, S1>S2
50
Where can you assess the mitral valve and what should you hear?
5 ICS, MCL, S1>S2
51
What is the S1 sound and where is it loudest?
Closure of AV valve, beginning of systole
| Loudest at apex
52
What is the S2 sound and where is it loudest?
Closure of the SL valve, end of systole and beginning of diastole
Shorter and high pitch than S1
Loudest at base
53
What is the S3 sound, where is it heard, and who is this most common in?
Extra sound; caused by turbulent blood flow
Can result in fluid backing up b/c of rapid ventricular filling >>> cardiac failure
Hear "slushing" at apex @ end of 1st 3rd of diastole
Most common in pregnant women and children b/c of increased CO
54
What is the S4 sound, where is it heard, and who is this most common in?
Extra sound; sound of non-compliant ventricles due to "stiff wall"
Heard over tricuspid and mitral valves
Most common in HTN, elderly, and those with history of MI
55
What is the carotid artery, how do you inspect/palpate/auscultate it, and what are normal/abnormal findings?
Purpose: supplies neck and brain with blood
Assess: never palpate bilaterally (can occlude blood flow); auscultate while pt holds breath (only perform on older adults or those with s/s CVD)
Normal findings: local, brisk pulse that is not interrupted by sitting or talking; soft blowing, loud grunting, beat of HR, or no sound at all
Abnormal findings: bruits
56
What is the jugular vein, how do you assess it, and what are normal findings?
Purpose: returns blood to heart via SVC- determines hemodynamic function of right side
Assess: sit pt at 45 degrees and have them turn head away from you
Normal findings: no distention
57
Heaves (what are they and what do they indicate?)
abnormal visible pulsations of the the heart due to hypertrophy and increased workload
58
Bruits (what are they and what do they indicate?)
blowing sound of turbulent blood flow from atherosclerotic plaque
increased risk for TIA/stroke
59
What 3 positions can you auscultate the heart in? When are murmurs and friction rub best heard?
Sitting up, left side-lying, HOB slightly raised to 30-45 degrees
Murmurs and friction rub best heard when sitting and leaned forward
60
What is the main sign of a valve problem and which valves are most often affected?
Murmur
| Mitral and aortic
61
What are the two causes of valvular heart disease and explain them?
1. Stenotic/stiff- valve-opening problem; narrowing and decreasing blood flow
2. Insufficiency- valve-closing problem; incomplete closing results in backflow
62
List different arteries
```
Temporal- head
Carotid- neck
Brachial- upper arm
Ulnar- forearm
Radial- wrist
Femoral- groin
Popliteal- knee
Posterior tibialis- lower leg
Dorsal pedis- foot
```
63
During systole, are the muscle fibers contracting or dilating? What about in diastole?
```
Systole = recoil/contract
Diastole = stretch/dilation
```
64
What is ischemia?
Decreased O2 delivery to tissues
65
Does peripheral artery disease affect arteries of the heart?
No, only the periphery
66
List and explain the 3 causes of pitting edema
1. Cellulitis/DVT - acute swelling <72 h
2. Acute compartment syndrome - from trauma, fracture, or CCB rx
3. Chronic - renal/liver disease
67
Stages of Pitting Edema (+1-4)
+1 mild pitting, slight indentation, no perceptible swelling
+2 moderate, indent subsides quickly
+3 deep pitting, short-lasting indent, looks swollen
+4 very deep, long-lasting indent, grossly swollen/distorted
68
What population are murmurs normal in?
Children
69
Grades of Murmurs (I-VI)
```
I. Barely audible with stethoscope
II. Quiet but audible
III. Moderately loud (like S1/S2)
IV. Loud w/ thrill
V. Very loud, palpable thrill
VI. Audible w/o stethoscope and palpable/visible thrill
```
70
PAD vs. PVD (think: causes, skin, temp, circulation, hair, swelling, necrosis, pain, and healing)
PAD: caused by athero. plaque; skin is shiny and pale with dependent rubor; temp cool; >3 sec cap refill and weak thready pulse; no hair on area; no edema; necrosis likely; sharp stabbing pain and claudication; non-healing wounds
PVD: caused by valvular insufficiency or stenosis; skin is brown and pruritus; temp is warm; cap refill <3 sec and strong pulse; hair present; edema present; no necrosis; achy cramping pain (1st sign!)
71
Claudication
Achy pain during activity fro increased O2 demands
72
12 Lead ECG (purpose, electrodes, skin prep, pt position)
Measures electrical activity of the heart (timing and strength)
10 electrodes (6 on chest, 4 on limbs)
Skin is warm, dry, clean
Patient is supine with HOB slightly raised
73
What assessment is most important to determine sign of declining?
LOC and mentation
74
Levels of Consciousness (and definitions)
(think: CLOSE)
1. Full conscious- alert, attentive, responds promptly and obeys direction
2. Lethargic- drowsy but awaken to stimulation, follows commands but slow and inattentive
3. Obtunded- difficult to arouse, responds with few words, needs constant stimulation to follow commands or will fall back asleep
4. Stuporous- arouses to constant and vigorous stimulation (typically painful), may respond with moan or attempt to withdraw from stimulus, does not follow commands
5. Comatose- no verbal or motor responses (possible reflexes)
75
Mentation (what is is it and how do you assess it?)
```
Someone's awareness
Ask general questions that are not yes/no
What is your name?
Where are you?
What year is it?
Why are you here?
```
76
LOC tools for special populations (stroke, dementia, head injury, unresponsive)
stroke - NIHSS
dementia- MMSE
head injury- Glasgow (GCS)
unresponsive- FOUR (brainstem reflexes)
77
What are the 3 aspects of the GCS and what score indicates coma?
1. Eye opening
2. Motor response
3. Verbal response
Score 8-11, <8 = coma
78
How many questions are part of the MMSE, what does it test, and what score indicates severe dementia?
30 Qs
Cognitive skills only
<9 = severe
79
How do you test and score (1-5) muscle strength?
Squeeze fingers, flex and extend hand/feet against nurses hand, lift leg against nurses hand, lift leg against gravity
```
5/5 = full strength
4/5 = weakness w/ resistance
3/5 = overcomes gravity only
2/5 = moves limb w/o gravity
1/5 = no activation of muscle
```
80
What two tests assess for motor dysfunction?
1. Strength
| 2. Cerebellar fxn
81
What does a cerebella function test assess for and how? Who can be tested?
Assesses for coordination, fine motor movement, and balance
Must be alert and responsive to verbal stimuli
Balance- assess gait with initial interaction, heel-toe walk (tandem gait), and rhombergs test
Coordination- rapid alternating movements, finger to nose, heel down shin
82
Spastic hemiparesis (hemiplegic) gait
drags one side of body
83
Spastic diplegia (scissoring or diplegic) gait
abnormally narrow base dragging legs (ex. cerebral palsy)
84
Cerebellar ataxia gait
similar to alcoholics walk, wide base, swaggering
85
Steppage gait (neuropathic)
pts with foot drop take abnormally high steps to avoid dragging foot
86
Dystrophic (waddling) gait
weakness of pelvis (+Trendelburg) causes drop in hip to appear like waddling (ex. muscular dystrophy)
87
Sensory ataxia gait
pt slams foot to ground to receive proprioception (stomping)
88
Parkinsonian gait
slow, little steps with stooped head
89
What are the two deep tendon reflexes we might assess and how would you grade them (0-4+)?
Patellar and bicep
```
0 = absent (diminished)
2+ = normal
4+ = CLONUS, dorsiflex foot back and observe for tap tap tap
```
90
What are the 3 steps to assess for sensation?
1. Assess for sensation with light touch from foot to face (distal to proximal)
2. Test superficial pain with safety pin (can they tell the difference between sharp and dull?)
3. Test proprioception by moving fingers up or down (can they tell you the position?)
91
Steneognosis
Pt can recognize an object with their eyes closed
92
Graphesthesia
recognize letters or # drawn on palm
93
How do you assess superficial reflexes? What is normal and abnormal?
Stroke lateral aspect of sole of foot
Normal = plantar flexion
Abnormal = bubinski; toes fan out (upper motor neuron disorder)
94
What are the 2 meningeal signs?
Kernigs- knee and hip flexed to 90 degrees and then pain in knee when knee is extended
Brudzinski- lie supine and flex neck, pain in neck and/or knees and hips flex
95
What is posturing and describe the 2 types (think feet, hips, elbows, arms, wrists)?
Withdrawal response from painful stimuli while in a coma
1. Decorticate- plantar flexion, hips internally rotated, elbows flexed, wrists flexed, arms adducted
2. Decerebrate- plantar flexion, arms adducted, elbows extended, wrists flexed, forearm pronated
96
What are the purposes of an IV?
```
Fluids/e-
Parental nutrition
Medications
Blood products
Contrast dyes
```
97
Name the 3 types of IV solutions, examples for each, and what they do
Isotonic: NS 0.9% expands volume, dilutes meds, keeps vein open; LR fluid resuscitation
Hypotonic: D5W metabolizes glucose and hydrates cells
Hypertonic: D5 1/2 NS Na/volume replacement, dehydrate cells
98
Who should never receive D5W?
Infants and those with head injury
99
How should you administer a hypertonic solution?
SLOWWWWLY
| monitor BP, HR, lung sounds, serum Na, and urine
100
Considerations for IV placement
Timing
General health (consider substance abuse)
Solution/meds px
What poses the least risk
101
What are the aspects of an IV order and what are things to consider before admin?
Date/time and signature of HCP
Type of solution
Amount prescribed (infusion rate may not be given)
Consider if the order is the most recent, pts e- values, compatibility, and safe rate of infusion
102
Peripheral IVs (who inserts them, where are they placed, what can be given via PIV, considerations, contraindications)
Most common IV
RN can insert them
Places in hand or forearm
Used for fluids, meds, blood
More comfortable because of auto-retracting needle
Not appropriate for TPN, pH <5 or >9, osmolality >600
103
What needle color corresponds to what gauge and what are they most commonly used for?
Magma- 14g trauma
Grey- 16g major surgery, lg volume infus, unstable
Green- 18g lg volume infus, multiple/rapid trans
Pink-20g meds, fluids, trans
Blue- 22g small veins, chemo, NO trans
Yellow- 24g fragile, small veins
104
What are considerations for primary lines? (what are the variations?)
Vented or nonvented
How many lumens (1, 2, or 3)
Macro or micro drip (diameter of drop chamber) Continuous or bolus
105
Which types of lines need to be flushed and what method is used?
Intermittent (non-continuous)
2-3 ml saline q8h or each use
Push pause method (pos pressure)
106
What position should someone be in for a venipuncture and why?
supine with head slightly elevated and arm supported
| prevent vasovagal rxn
107
What areas should be avoided during a venipuncture?
Areas below phlebitis or sclerosed veins
Same limb as an infiltration, mastectomy, edema, clot, shunt, or fistula
Inflammation, bruising, or skin breakdown
108
How to perform venipucture
```
Use non-dominant hand if possible
Have patient supine with head slightly elevated
Turnicut 5-6" above puncture site
Dilate vein
Cleanse with chlorahexadine and dry
Pull skin taught and stabilize vein
Bevel up
Insert 10-30 degrees
```
109
How do you dilate a vein and which population may need this most often?
Stroke down distally
Light tap
Warm, moist heat
Pump fist lower than heart
Elderly and dehydrated
110
What are things to monitor after IV placement?
Tolerance and complications of IV
Dressing and skin integrity around IV
IOs
111
How do you prevent infection during and after IV placement?
```
Hand hygiene before and after
Change site q3-4d
Aseptic technique
Change primary tubing q4d
Change secondary tubing q1d
Change fluids q1d
Change dressing q1d
Discontinue ASAP
Avoid writing directly on bag
Wipe all ports with aseptic wipe before use
```
112
What are the 3 local complications of an IV?
Infiltration
Phlebitis
Extravasation
113
What is infiltration?
Leaking of IV fluid into surrounding tissue
114
Describe the stages of infiltration (0-4)
```
0 = no s/s
1 = edema <1", cool, pale
2 = edema 1-6", cool, pale
3 = gross edema >6", cool, pale, pain, numbing
4 = gross edema >6", pitting, skin tight, leaking, bruising, mod/sev pain
```
115
How do you treat infiltration?
```
Warm compress for normal/alkaline; cool for acidic
Elevate extremity
Check pulse and cap refill
Remove catheter and restart elsewhere
Continue to recheck site
Document
```
116
What is phlebitis and what are possible causes?
Inflammation of vein from bacteria, physical, or chemical irritant
Possible causes: wrong catheter size, increased osmolarity, alkaline/acidic solution, prolonged use
117
Describe the stages of phlebitis (0-4)
```
0 = no symptoms
1 = erythema, possible pain
2 = erythema, edema, pain
3 = "", streaks formation, palpable venous cord
4 = "". venous cord > 1", purulent drainage
```
118
How do you treat phlebitis?
Remove catheter at 1st s/s and restart on other arm
Warm compress
Document and treat
119
What is extravasation?
leaking of vesicant fluid into surrounding tissue
120
What is vesicant fluid?
Medication that can cause blistering or necrosis of tissue
121
How do you treat extravasation?
```
Immediately stop infusion
Aspirate meds from port
Elevate
Notify MD ASAP
Call pharmacy for antedote
Apply ice for 15-20 min (warm for vinka alkaloid)
Document in med record and safety report
```
122
Where do you document that extravasation has occured?
Med record and safety report
123
What are the 4 systemic complications of an IV?
Fluid overload
Speed shock
Sepsis
Air embolism
124
What are symptoms of fluid overload?
dyspnea, increased BP/HR/RR, crackles, JVD, edema
125
What are symptoms of speed shock?
dizzy, chest tightness, flushed, pounding HA, chills
126
What are symptoms of sepsis?
red, tender IV site, fever, malaise, VS changes
127
What are signs of an air embolism?
RD, decreased HR, increased BP, cyanosis, decreased LOC
128
What is a central venous access device (CVAD), how are they placed, and what are the types?
IV insertion with terminal end in SVC
Placement confirmed by radiology
Short term- non-tunneled, PICC
Long term- tunneled, implantable
129
What are the uses for a CVAD?
```
long term therapy
poor peripheral access
hypertonic, vesicant, or extreme pH
TPN (need isolated line)
chemo
```
130
Describe a non-tunneled percutaneous catheter CVAD (where are they inserted and by who, length of time, lumens, how do they stay in place, and considerations?)
```
Inserted most often in subclavian but also jugular or femoral
Inserted by MD
3-10d
1-3 lumens
Sutured in place
High risk for CLABSI or pneumothorax
Patient in Trendelenburg doing Valsalva
```
131
Describe a PICC CVAD (where are they inserted and by who, length of time, how do they stay in place, and considerations?)
```
Insert in AC fossa of upper arm
Insert by certified nurse
Weeks to months (possibly year)
Secured by wound closure strip
Good for all ages, may need frequent flushing, decreased risk for complications
```
132
Describe a tunneled CVAD (where are they inserted, length of time, how do they stay in place, and considerations?)
Inserted 3-6" into SQ of subclavian or jugular
Long term
Dacron cuff seals internal cath to keep in place and prevent infx
Easily maintained at home, less visible, more moveable
133
Describe an implanted port CVAD (where are they inserted, lumens, length of time, and considerations?)
Implanted into SQ in upper chest from chest, abd, or forearm
Multiple lumens
Long term (access with noncore needle can remain 7d)
Reservoir under skin
Great for young kids and adults that swim
Minimal daily care
134
How to flush a CVAD
>10ml syringe
3-5 ml saline
3 ml heparin
q7d if not in use
After placement, before/after use at same ROF
Push pause method
Use 2x more solution than capacity of cath
135
CVAD dressing changes (PPE, types of dressings, other considerations)
PPE: mask, gown, gloves, and pt in mask
Occlusive gauze/tape if site oozing or wet and change q8h or semi-permeable membrane if dry to allow for visualization and replace q7d or if damaged
Anticrobial scrub 30 sec, 2" radius, and allow to dry
Change caps
Change tubing (TPN q1d)
136
Complications of CVAD
```
CLABSI
Pneumo/hemothorax
Air embolism
thrombosis
Catheter migration
```
137
How do you treat a pneumo/hemothorax from a CVAD?
```
O2
VS monitoring
Pressure over entry site
Remove catheter
Possible chest tube
```
138
How do you treat a thrombosis from a CVAD?
Move IV and apply warm compress
| Do NOT massage
139
Name and describe the 3 types of med incompatibilities
1. Physical- drugs mix and become unsafe (form precipitate)
2. Chemical- drugs mix and integrity or potency is changes
3. Therapeutic- drugs mix and result in undesirable response
140
5 Rights to Med Admin
1. Patient
2. Med
3. Time
4. Dose
5. Route
141
How to add a piggyback
```
Mix 50-100 ml bag
Connect to port most proximal to primary bag
Back prime
Lower primary bag
Set rate on primary bag
```
142
How to administer an IV push
Clamp tubing above distal port to prevent backflow
Aspirate for blood
Flush with saline
Administer med slowly at appropriate rate of infusion
Observe pt for response to med
Flush again with saline at same rate of infusion for med to prevent bolus
143
What are the verifications you need to check with new blood sent for a transfusion?
```
Document along with another nurse
Right patient
Right label
ABO compatibility
Expiration
```
144
What equipment is needed for a blood transfusion and why?
Y-set filter (primary bag for NS and another lumen for blood)
145
How do you infuse blood? When might you discontinue it?
Turn saline off when blood is hung
Consider pump or gravity drip
Infuse at 2-5ml/min and take VS for 1st 15 min
Discontinue at first signs of problem
146
How long do you have to hang blood after receiving it from the bank? In what time frame do you have to use it?
Blood must be hung w/in 30 min of receiving it
| Blood must be used w/in 4h
147
What are the 3 types of infusion rxns?
Allergic
Febrile
Hemolytic
148
What is an allergic transfusion rxn? When might you see it?
Seen usually within first 15 min
| Allergy symptoms from runny nose and wheezing to shock, cardiac distress, hives
149
How do you treat an allergic transfusion rxn?
Pause infusion and run NS
Admin CPR if needed
Anticipate steroid and antihistamine use
Maintain BP
150
What is a febrile transfusion rxn? What are s/s associated with it? When might you see this?
```
Response to leukocytes or platelets (possibly prevent with leukocyte reduced blood)
Fever (rise of 1 degree)
Chills
HA
Tach
Nonproductive cough
```
Seen immediately or w/in 1-2h
151
How do you treat a febrile transfusion rxn?
Discontinue transfusion and run NS
Notify HCP
Monitor VS
Admin antipyretic
152
What is a hemolytic transfusion rxn? What are the s/s?
```
The transfusion activates the coagulation response resulting in vasomotor instability, CV collapse, or DIC
Hemoglobinuria
Bleeding
Apprehension
Lumbar, flank, or chest pain
Fever (w or w/o chills)
Tach
Decreased BP
```
153
What is the most serious transfusion rxn?
Hemolytic
154
How do you treat a hemolytic transfusion rxn?
Stop transfusion and disconnect tubing
Admin NS only
Get help
Monitor for shock and dialysis
155
Factors affecting skin integrity
Moisture
Dryness
Circulation
Nutrition
156
What are the 4 wound variations?
1. Intentional or unintentional
2. Acute or chronic
3. Partial thickness or full thickness
4. Open or closed
157
Unintentional wounds vs. intentional wounds
Unintentional- not done under control (highest risk for infx) - ex. gunshot
Intentional- done under control and aseptic - ex. surgery
158
Open vs closed wounds
Open- exposed tissue at base of wound
| Closed- damage to tissue w/o exposure (i.e. bruise)
159
Acute vs chronic wounds
Acute- close efficiently
| Chronic- not efficient at healing (weeks to months to yrs)
160
Partial vs full thickness wounds
Partial- depth to dermis/epidermis
| Full- depth beyond dermal layers
161
List the 4 types of acute wounds and which one is most prone to infx
Avulsions
Abrasions
Lacerations
Punctures
162
How can you prevent skin tears?
```
Adequate nutrition and hydration
Moisturize at least 2x/day
Minimize bathing
Use neutral pH cleanser
Proper safety and transfering to minimize friction
Falls precautions
```
163
List and describe the 2 ways that wounds heal
Regeneration- shallow wounds are replaced by healthy tissue (recover 100% of fxn and 80% of tensile strength)
Scar formation- deep wound cannot regenerate so fibrous scare tissue forms (loss of fxn)
164
Venous stasis ulcers vs. decubitus ulcers (think: other names, causes, and prevention)
VSU- aka leg egg ulcer; caused by venous insufficiency and blood pools in legs; pressure results in ulcer
DU- aka bed sores; caused by pressure over bony prominence; prevented by postural changes
165
What are the 4 phases of wound healing?
1. Hemostasis (bleeding stops)
2. Inflammatory (WBCs neutrophils >> macrophages)
3. Proliferation (connective tissue, angiogenesis, and scarring)
4. Maturation (collagen remodeling, scarring, and strengthening)
166
Name and describe the 2 types of necrosis
Slough- yellow, moist, stringy, loose
| Eschar- black, leathery, dry, thick
167
Principles of Surgical Asepsis
Keep sterile items above waist
Never turn your back to sterile field
Avoid drips/moisture on field
Outer 1" of sterile field is considered contaminated
Lip bottles of solution (2 ml)
Avoid laughing, talking, sneezing over field
Consider that fluids flow towards gravity
168
Systemic factors that affect healing
```
Age
Nutrition
Circulation
Health status
Immunosuppression
Medications
Adherence to tx
```
169
Primary vs. Secondary vs. Tertiary Wound Healing (which is the most common?)
Primary- intentional w/ sutures, staples, glue, or strips
approximated edges, little tissue lost, fastest
Secondary- most common; extensive tissue loss, non-approximated edges, heals inside to out, increased risk for infx
Tertiary- delayed healing and scar formation
170
How do you remove sutures?
NEVER pull outside of suture through underlying tissue
First and last suture are last to be removed
Begin by pulling out every other and replacing with steristrip
171
What is the purpose of applying heat to a wound?
What types of heat applications are there?
How long can you apply heat?
Vasodilation, increased O2/blood/nutrients, increased waste removal and drainage, decreased pain/aching/inflammation
Moist heat = more penetrating b/c better conductor
Dry heat = stays at temp longer but needs higher temps
Limit time to 20-30 minutes or rebound could occur
172
What is the purpose of applying cold to a wound?
| How long can you apply cold?
Vasoconstriction, decreased pain by numbing, prevent swelling, stop bleeding, cool fever
Limit to 20 min or rebound
173
How to relieve edema
```
elevate above heart
sodium restrictions
ambulation/activity
compression
massage
```
174
How do you record drainage characteristics?
Scant, moderate, or heavy
Serous- normal, clear, watery
Serosangenous- normal, pink, serum and blood
Sangenous- abnormal, red, blood
Purulent- abnormal, infection, yellow/green, odor
175
What are 4 wound bed terms? Can you match colors associated with each term?
Necrotic- black
Sloughy- yellow, grey
Eschar- black
Granulation- red, pink
176
What does the Braden Scale assess for and how is it scaled?
Risk for pressure ulcers
| Scored 6-23 (lower the score, higher the risk)
177
What are 5 wound complications?
```
Infection
Hemorrhage
Dehiscence (can lead to evisceration)
Evisceration
Fistula
```
178
How can you promote wound healing?
```
Remove exudate/clean w/ drains, vac, irrigation
Debridement to remove dead tissue
Pack wound loosely
Nutrition (high PRO and fluids)
Keep wound moist and peri-wound dry
```
179
4 Principle of Choosing Dressings
1. Dry or desiccant
2. Need for absorption
3. Necrotic
4. Infection
180
Dry Gauze Properties
Absorptive
Can be impregnated
Good for low exudate
Can stick to heavy exudate
181
Transparent Dressing Properties
Allows O2 exchange w/o bacterial contamination
Moist healing >> can lead to maceration
Autolytic debridement
No absorption
Used for necrotic tissue or superficial tears
182
Hydrogel Dressing Properties
High water content promotes epithelialization
Autolytic debridement
Do NOT use for dry, gangrene, or ischemic wounds
183
Antimicrobial Dressing Properties
Prevent infx
184
Hydrocolloid Dressing Properties
```
Gel w/ some absorption
Moist environment
Autolytic debridement
Protects against contamination
Change q7d
Cushioned- good for bony prominences
```
185
Alginate Dressing Properties
Absorb LARGE amounts of exudate
Maintains moisture
Establishes hemostasis
Does not adhere to wound - contact with wound activates gel
186
Foam Dressing Properties
VERY absorptive
Moist environment
Self-adherent
Cushioned- good for bony prominences
187
How to clean a wound
```
Only clean when indicated (infx, necrosis, contamin)
Use new gauze with each wipe
Wipe inside to outside, top to bottom (clean to dirty)
Use clean pad to collect drainage
NS used to irrigate
Dry peri-area
Report drainage or necrosis
Assess and treat for pain before/after
```
188
What are the 2 types of saline moistened dressings?
wet to dry (nonselective debridement)
| wet to moist- done aseptically
189
How to obtain a wound culture and what is the goal?
Clean wound
Roll swab in wound for maximal contact
Different swab for different areas
Goal: identify if there is infx
190
What is the purpose of irrigating a wound?
When do you irrigate a wound?
What solutions or equipment do you need?
PPE?
Most effective method of cleaning wound
Do at initial assessment and with every dressing change
Use NS and 35ml syringe w/ 19g to deliver 8psi (4-18psi)
PPE: gown, gloves, mask, goggles
Do until solution runs clear
191
List the 4 wound drainage instruments
1. Penrose
2. Jackson Pratt (JP drain)
3. Hemovac
4. Vacuum assisted closure (VAC)
192
Describe a penrose drain
```
Open drain- aseptic
No secured- safety pin on end
Passive drainage
Pin is pulled out a little each day as drainage minimizes
Clean in circular motion
```
193
Describe a jackson pratt drain
Implanted surgically and sutured in place
Squeeze tube for negative pressure
Empty drain when 1/2 full
Holds 50-100ml (most effective at measuring)
Located along side wound
194
Describe hemovac drain
```
Similar to JP
Surgically placed and sutured
Negative pressure system
Empty when 1/2 full
Holds 400-800ml
```
195
Describe the vacuum assisted closure drain (VAC)
Secondary intention
Negative pressure system
Reduced risk for infx
Suction decreases edema and improves circulation and angiogenesis
Fenestrated tube imbedded in foam for even pressure
Occlusive dressing prevents air from entering
$$$
196
List the 5 types of debridement
1. Mechanical
2. Autolytic
3. Enzymatic
4. Surgical
5. Biological
197
Describe the pros and cons of mechanical debridement
PROS: simple, $, promotes healing
CONS: non-selective, risk of infx, painful
198
Describe the pros and cons of autolytic debridement
PROS: selective (body's own response), for stage 2/3, not painful
CONS: not for stage 4, takes days to weeks, constant monitoring, and possibility of anaerobic growth
Need semi or occlusive dressing
199
Describe the pros and cons of enzymatic debridement
PROS: selective, useful for necrosis or eschar, faster than autolytic
CONS: can burn, need rx
200
Describe the pros and cons of surgical debridement
PROS: selective, good for large wounds with lots of necrosis, good control/fast, speeds healing process
CONS: painful, $$$
201
Describe the pros and cons of biological debridement
PROS: selective
CONS: can be gross and painful
202
Who should or shouldnt use pneumatic compression devices?
Those who are immobile who need to decreased risk for edema, blood pooling, and DVT should use PCD
Someone with a current DVT should not
203
What is the most common HCAI?
CAUTIs
204
How to prevent CAUTIs
```
Hand hygiene
Shortest needed time
Assess cath 2x/day and remove ASAP
Prevent obstruction/kinds
Empty collections frequently and attach new bag
Dont use when not indicated
Educate staff
```
205
What is the purpose of a bladder scan? How do you read the results?
Calculates amount of urine in bladder to prevent necessary catheterization by calculating post-void residual >100ml
Non-invasive, painless
Average results from 3 scans
206
When can you use a catheter?
Urinary retention or obstruction
Accurate measurements for critically ill
Perioperative
Assistance for wound healing with stage 3/4 perianal or sacral wound
Hospice/palliative care
Require immobilization from trauma/surgery
207
What are the 4 types of catheters?
1. Suprapubic
2. Indwelling
3. Intermittent/straight cath
4. Purewick or condom cath
208
Is clean or aseptic technique used with a straight cath?
@ home - clean
| @ hospital - aspetic
209
Causes of urinary retention
Urethral obstruction
Nerve problems
Meds
Weak bladder
210
What are the differences between single, double, and triple lumen caths?
single lumen = straight cath, urine only
double lumen = urine and saline (cuff)
triple lumen = urine, saline (cuff), meds
211
What kind of catheter may be used for someone with an obstruction like BPH?
Coude-tipped
212
How do you prepare your patient for catheterization?
```
Ask about allergies- iodine or latex
Female - dorsal recumbant or side lying
Men - supine
Provide privacy
Choose appropriate size (14-16Fr with 5-10 ml balloon)
```
213
What are the 3 types of urine drainage bags and why are they used?
1. Standard bag- large capacity, empty q8h
2. Urine meter- strict IO
3. Leg bag- discreet but small capacity
214
How do you insert a catheter in a female?
Position dorsal recumbant or side lying
Clean labia down each side and then down middle meatus >> keep labia separated
Insert catheter until urine return and then continue in another 2-3"
215
How do you insert a catheter in a male?
Position in supine
Clean from tip of penis down the head >> keep foreskin retracted
Insert catheter until urine returns and then insert all the way up to Y
216
What are the two ways you can take a urine sample?
Clean catch and cath system (NEVER from bag, clamp tubing and take from port)
217
What is the purpose of irrigating a closed catheter system?
To observe for any blockages
218
How do you irrigate a closed system?
Kink tube to irrigate bladder
Instill 30-60ml or room temp solution slowly
Subtract irrigant from IO
219
What is the purpose of continuous irrigation for a catheter?
Flush clots and debris from catheter and bladder
Instill meds into bladder
Restore patency of cath
220
What is a stoma?
The visible, communicating end of the bowl after resectioning
221
List the 3 types of ostomies
1. Colostomy
2. Ileostomy
3. Urinostomy
222
What is a colostomy?
What is the difference between an end, a loop, and a double barrel colostomy?
Where can a colostomy be placed and what does the drainage look like for each?
Part of LI is removed or bypassed (temporary or permanent)
End = damaged section removed, permanent
Loop = remove obstruction, two openings in one stoma, temporary
Double barrel = two separate stomas, temporary
```
Ascending = liquid
Transverse = liquid, semi-formed
Descending = semi-formed
Sigmoid = formed
```
223
What is an ileostomy and what are teachings associated with having one?
Permanent bypass of the LI
Smaller in diameter than colostomy
Thin, watery >>> thick, yellow/brown (very acidic)
Educate on increased fluid intake
Empty pouch when 1/3-1/2 full
Skin care
Low residue diet
224
How do you know you have a ileostomy obstruction and what do you do?
```
No output for >6h
Drink tea
Knees to chest
Warm towel on abdomen
If swollen, use pouch with smaller hole
```
225
What are 4 types of incontinent urinary diversions?
1. Urostomy
2. Ileal conduit- most common
3. Transureterostomy- most prone to complications
4. Ureterostomy
226
What should a stoma look like?
Shiny, red, and wet
227
How do you change an ostomy bag?
Push on skin rather than pull on adhesion to remove
Measure stoma with guide and trace on back of stoma pouch
Cut opening 1/8" wider to prevent constriction
228
What is the purpose of an NG tube?
```
Enteral nutrition
Lavage
Decompression
Compression
Diagnose problems with GI motility
Aspirate contents for analysis
Admin radiographic contract media
```
229
What does it mean to lavage the stomach?
irrigate the stomach to remove toxins or treat hyper/hypothermia
Contraindicated for poison >> activated charcoal
230
What does it mean to decompress the stomach?
removes gas/fluid for those that are NPO, have a bowel obstruction, or paralytic ileus >>> continue until peristalsis resumes
231
What should you do if PO meds are needed but you have decompression going through their NG tube?
Stop the suction and resume once meds are absorbed
232
What is the purpose of compression?
Stop GI bleeding when endoscopy is not available
233
What size NG tube is used for adults? Neonates? Peds?
Neonates 4-8F
Peds 6-14F
Adults 12-18F
234
What are the 4 types of NG tubes?
Single lumen
Double lumen (Salem sump)- most common
Dobhoff
Sengstaken/Blakemore
235
What is a single lumen NG tube? What is it used for?
NG tube with small drainage holes at end
Small holes can get blocked
Can only use suction on low, intermittent to prevent erosion of gastric mucosa
236
What is a salem-sump NG tube? What is it used for?
The most common NG tube
Can do continuous suction because of pigtail vent
Used for irrigation and tube feeding
237
What is the purpose of the pig tail?
Creates a vent that prevents adherence to gastric mucosa and prevent reflux
238
What are things you should know about a pig tail?
Always keep it above waist and NEVER clamp is
239
What NG tube is most often used for tube feeding and why?
Dobhoff tube- has one big hole at end instead of tiny holes
| Inserted into jejunum or duodenum
240
What NG tubes are most common for treating GI bleeds? How is it inserted?
Blakemore- triple lumen, one reserved for GI suction
Recommend endotrach intubation to promote airway
Distall balloon in stomach
Proximal balloon in esophagus
241
What NG tubes can be used for intermittent suctioning? Continuous suctioning?
Intermittent- single lumen or salem-sump
Continuous- salem sump ONLY
242
What should you assess prior to inserting an NG tube?
Nares patency and see which one is more open
Must have gag reflex present
Suction must be working and ready
243
What position should a patient be in when being suctioned?
high fowlers
244
What PPE is needed for suctioning?
Gloves
245
How do you measure an NG tube?
tip of nose to earlobe to xyphoid
246
How do you insert an NG tube?
Have the patient deep breath
| Have patient tilt chin to chest and slowly drink water
247
How do you assess placement of NG tube?
CXR for first use
| Then...aspirate GI content or test pH 0-5
248
How do you irrigate an NG tube?
q4h
verify placement and markings
use 60ml syringe
disconnect distal tube from suction
irrigate with 20-30 ml of tap, saline, or sterile saline
irrigate pig tail with 20 ml of air to reestablish buffer
document amount to subtract from IO
249
How do you remove an NG tube?
verify order
intermittently clamp to assess for N/V or distention
PPE: gloves
inject 10ml fluid/air
remove tape from nose and unpin from johnnie
place towel across lap and emesis bin redy
take deep breath and hold
withdraw slowly until at esophagus
250
When are artificial airways used?
Loss of consciousness or obstruction (or risk of)
251
Is clean or sterile technique used to insert an artificial airway?
```
Clean = oral airway
Sterile = everything else
```
252
What are the 5 types of artificial airways?
```
Oralpharyngeal
Nasopharyngeal
Endotracheal
Laryngeal mask
Tracheostomy
```
253
Who can get an oropharyngeal airway and how do you measure it?
Someone with low LOC because this airway stimulates the gag reflex
Prevents obstruction or secretions from blocking the airway
Measure corner of mouth to angle of jaw under ear
254
Who can get a nasopharyngeal airway and how do you measure it?
Someone with an obstruction or secretions that block airway (or risk of)
Measure nose to angle of jaw under ear
255
How is an endotrach airway inserted (from where to where) and how long can it stay in?
Inserted by a laryngoscope in mouth or nose and ends where the trachea bifurcates to lungs
Short term <14 days (unless weaning)
256
Who can insert a laryngeal mask and why is it benefiticial?
EMTs can insert it and its good for those that are not skilled in airways and decreases distention and risk for aspiration
257
What is a tracheostomy used for? How long is it used? What are the 3 different variations?
Used for mechanical ventilation, secretions, or obstruction of airway
Used long term >14 days
Cuffed or uncuffed
Fenestrated or nonfenestrated
Single or double lumen
258
What are the differences between a cuffed trach and an uncuffed trach?
Cuffed- airtight seal, direct air flow (especially needed for mechanical vent), prevents aspiration, increased risk for necrosis
Uncuffed- can still speak, for adults and ped with no aspiration risk or risk for mechanical vent
259
How do you deflate a cuffed trach and when might you deflate the cuff?
Suction 1st
Deflate slowly during peak inspiration
Deflate before meals
260
How can you allow a person to speak with a fenestrated trach?
Remove the inner cannula
Deflate cuff
Cover opening of trach
261
How does the nurse confirm placement of a trach?
Auscultate chest
Bilateral chest rise
Check location of tube ta teeth
Capnography (purple = O2, yellow = CO2)
262
What should the nurse do after trach insertion and confirmed placement?
Assess respiratory q2h
Assess nasal/oral mucosa
Reposition q2h (side lying or semi-fowler)
Monitor cuff pressure to prevent necrosis
Move oral tube to other side of mouth q8h
Provide oral care q4h
Provide bite block
Communicate frequently
Provide humidification
263
How do you change a trach or ET tube? (how many people and PPE)
Secure w/ 2 people (one to hold and one to tie)- if only 1 person, attach new ties first and then release the old one
PPE: mask, gown, gloves, goggles
264
What emergency equipment is needed for a trach?
```
Obturator
Suction
O2
2 tubes (1 smaller)
BVM (reuscitation)
```
265
What do you do if the patient is accidentally decannulated?
Call for help but dont leave pt
Replace tube or use obturator
Possible mechanical ventilation
266
When should you use suctioning on someone?
When they lost the ability to swallow or their cough is not effective at mobilizing secretions
267
What is the purpose of suctioning a patient?
Remove secretions and maintain gas exchange
268
Closed vs open suctioning (risks, # of uses, sterility)
Closed- attached to vent, decreased risk of hypoxia (attached to MV) and infx, reusable sterile cath for 24h, need PPE but not sterile gloves
Open- risk for infx, hypoxia, and vagal stimulation, one time use with each cath, need for sterile gloves
269
How do you suction a patient?
Pre-test suction
Only suction on way out
Hyperoxygenate before (deep breath or O2)
3 passes, 10-15 sec, 30-60 sec break between
Suction between 100-120 mmHg
270
What is the first sign of hypoxia?
Restlessness
271
What is the purpose of a chest tube thoracotomy and where is it inserted?
Inserted into pleural space to remove and prevent air, fluid, or blood from re-entering and promote lung re-expansion
272
What is the difference between a pneumothorax, hemothorax, and pleural effusion and where are each found in the lungs?
```
Pneumo = air, apex
Hemo = blood, base
Pleural = fluid, base
```
273
What do you need prior to chest tube insertion?
Informed consent
274
Why might you use a larger or smaller tube for a chest tube?
Small tube = air
| Large tube = blood/fluid
275
How do you confirm chest tube placement?
CXR
276
What are the 3 chambers of a CDU?
1. Water seal
2. Collection chamber
3. Suction chamber
277
Water Seal Chamber (what is it, how does it work, what should you assess?)
Negative pressure system where a straw remains under 2 cm of water to create "seal" and prevent fluid or air from returning to pleural space
Assess for tidaling (increased volume with insp and decreased volume for exp- opposite for MV)
Assess for gentle intermittent bubbling (continuous = air leak)
278
Collection Chamber (how does it work, how to assess, health promotion)
Fluid drainage system that should be kept below chest level
Assess drainage q1h for 1st 24h then q8h
Encourage positional changes, coughing, deep breathing
279
Suction Chamber (when is it used, types, assessments)
Used to help pull secretions when fluid is thick
Wet or dry
Wet- regulated by ht of water (-20cm) and connected to suction on wall- assess for gentle bubbling and evaporation
Dry- no water, bellow with dial
280
Emergency chest tube equipment
```
2 kelly clamps
1 vaseline gauze
1 4x4 gauze
250 ml normal saline
new CDU
```
281
Where should a CDU be placed?
Below level of chest
282
What is a tension pneumothorax?
When air enters the pleural space with each breath and gets trapped >> increases pressure and can result in lung collapse
283
How can you prevent a tension pneumothorax?
NEVER clamp tubing on chest tube (prevents air escape)
| NEVER strip or milk the chest tube (creates neg pressure)
