N388 Unit 3 Flashcards
Cyanosis
bluish/grayish discoloration of skin/mucous membranes
Q’s: Have you ever noticed (or anyone told you) that your skin is pale or bluish?
Dyspnea
difficulty breathing, labored breathing
Edema
Accumulation of fluid
Q’s: Do you have any swelling of your feet and legs? Onset, time of day, how much, does it going away
Grading scale for pitting edema
Nocturia
increased urination at night; wakes people to pee
Q’s: Do you awaken at night with the sudden urgent need to urinate? how long has this been occurring?
Orthopnea
can’t breathe lying flat, needs to sit up
Q’s: how many pillows do you sleep on?
Tachyn[ea
increased respiration
Presenting Problems: cardiovascular
Chest pain Cough Cyanosis Dyspnea Edema Fatigue Nocturia Orthopnea
associated symptoms: diaphoresis, nausea, dyspnea
Diaphoresis
Cold sweat
Cough
Frequency, duration, positional, productive, hemoptysis
hemoptysis
coughing up blood, quantity, # of tissues
productive cough
sputum produced? color, amount
Rales/crackles:
fine or coarse, often heard on inspiration
Rhonci
coarse, often heard on exhalation
Babbly brook, noisy sound of fluid, mucus in airway
Wheezes
high pitched sounds heard on inspiration or exhalation or both
Factors affecting oxygenation
Age, environment, lifestyle, health status, medications, stress
Pulmonary Focused Assessment
Subjective
Difficulty breathing? Shortness of breath? Constant? Duration? Position? Does shortness of breath interfere with activities of daily living?
Do you have a cough? Frequency, duration, positional, productive, hemoptysis
Objective
Vital signs & Pulse oximetry
Inspection (can they speak in full sentence, work of muscles)
General survey: work of breathing, obvious distress, speak in full sentences, respiratory rate, accessory muscle use, nasal flaring in infants,
Auscultation: Adventitious breath sounds
atelactasis
Collapsed alveoli
Who is at risk? Clients who: smoke respiratory disease obesity post-surgery hospitalized
need for oxygenation
Collapsed alveoli (atelectasis), Damaged alveoli, shallow breathing, positioning, immobility
Position interventions for breathing
Orthopneic
Tripod
Changing positions
Mobility
Deep breathing
Abdominal breathing
Pursed lip breathing
Coughing
Huff coughing
Breathing interventions
Position
Deep breathing
Incentive spirometer
Incentive spirometer
Position and breath Seal lips around mouthpiece Take slow and steady breath Hold for 3 seconds Breathe out normally 10 times an hour (i.e., during commercial breaks)
Positive pressure machines
CPAP: Continuous Positive Airway Pressure
BiPAP: Bilevel Positive Airway Pressure
Why positive pressure? Putting pressure in will prevent
collapse
Why supplemental oxygen
Treat hypoxia <92%
Causes of hypoxia
Anxiety, confusion, restlessness
Oxygen as medication
Need order to…
Starting oxygen
Titrating
Delivery device
Setting up oxygen
LPM = liters/minute
FiO2 = fraction of inspired
Consider humidification @ > 4LPM
Don’t delegate to NAP
oxygen devices
Nasal cannula Simple face mask Non-rebreather mask Partial rebreather mask Venturi mask Face tents
Face tents
Humidification
Not too tight or confining
4-8 L/min
30-50% FiO2
Nasal cannula
Common Comfortable Prongs face back/down 1-6 L/min flow rate 24-44% FiO2 Home oxygen
Simple face mask
Common in PACU 5-8 L/min flow rate 40-60% FiO2 Mixing at side ports Short term use
Non-rebreather mask
Common in PACU 5-8 L/min flow rate 40-60% FiO2 Mixing at side ports Short term use
Partial rebreather mask
High levels of O2 delivery
6-10 L/min
40-60% FiO2
Rebreath ⅓ of expired air
Weaning oxygen device
Remember right device
As oxygenation improves
Consider weaning the delivery device
Things to consider with needles
Giving less than 1 ml? Use a tuberculin or 1 mL syringe
Giving an IM injection? YOu need a longer needle- based on musculature/body size
Vials
Liquid medication
Dry powder- reconstituted with diluent
Do not shake- Bubbles
Before drawing up med alcohol swab for 15 seconds
For multi-dose vials: date, time, initial
Ampules Glass Filter needle needle to give and needle to inject!! Safety Tap top of ampule
Needle safety
No recapping of USED needles
Slide into cap and top it after
Needles
Hollow
Size: length in inches
The longer the needle the farther it goes
Gauge: diameter
The larger the gauge the smaller the needle (Ex:16-25 = largest to smallest)
Oxygen safety
Beware of other fire sources Electrical equipment Heat sources 3-5 ft away Avoid petroleum based products on face Tubing
Types of Injections
Skin (Intradermal- ID)- i.e., TB test
Subcutaneous (SC) - below skin but not muscle
Muscle (Intramuscular, IM)
Intravenous (IV)
Injection risks
Fibrosis, nerve/bone/blood damage, abscess, tissue necrosis, muscle contraction, gangrene, pain
Intradermal Injections
Small volume - TB syringe Small needle size 25-27 gauge Length: ¼ to ⅝ inch long Bevel up- 5-15 degree angle Location: smooth flat area of skin, forearm, areas of back Uses: PPD, allergy and other skin tests Bleb forms (looks like blister)
Subcutaneous Injections
*rotate sites Below skin, deeper levels of tissues Recommended in abdomen only - insulin, heparin & enoxaparin 45 to 90 degree angle Syringe appropriate to amount Size: 25 gauge (or smaller 27, 29) Length: ⅜ to ⅝ inch long A lot of body? Can do SQ
Ventrogluteal
Preferred site for adults
Gluteus medius muscle
Deep and away from major nerves and blood vessels
1-3 mL/injection for average, well-nourished adult
90 degrees
Size: 21-22 gauge
Length 1.5 inches
Vastus lateralis
Preferred in children Muscle is thick and well developed Middle third of muscle .5-2mL volume 90 degrees Adult: Size: 21-22 gauge Length: 1-1.5 inches PEDS: Size 22-25 gauge Length: ⅝ to 1 inch
IM sites
deltoid
ventrogluteal
vastus leteralis
Nurses role in IM administration
Look at patient: size, muscles, subcutaneous tissue Medication: volume, viscosity Determine: Syringe size Needle gauge Needle length Location for injection Technique/angle of injection
Special IM techniques
Z track
Seals medicine in muscle tissue
Prevents irritation and discoloration of subcutaneous tissue
Air lock
Less irritating with needle withdrawal
Only a few meds
GU System Focused
Presenting problems:
Bleeding, change in skin integrity (ulcers, erythema), discharge, dysmenorrhea, dyspareunia, erectile dysfunction, hematuria, incontinence, LMP, pain, prolapse, retention, UTI
Subjective
Sexual history
Objective
Inspection of the GU system
Urine (color, quantity)
Urinary retention: inspect and palpate at symphysis pubis, bladder scan
GI System Focused
Presenting problems
Ascites, anorexia, constipation, dehydration, diarrhea, distension, dysphagia, flatus, emesis/vomitus, hemorrhoids, hernia, incontinence (fecal), jaundice, nausea, pain, vomiting
Subjective
Diet prefences/24 hours recall
H/W/BMI
Bowel patterns
Objective Physical assessment of abdomen and GI system I, P, P, A Acute problems: objective data Bowel sounds Flatus Vital signs I and O Skin turgor and mucous membranes Physical assessment of GI system and abdomen
Other GI related terms
Food security/insecurity (SDOH)
Enteral nutrition
Parenteral nutrition - delivered through central lines
Medical nutrition therapy - use of diet to soothe medical issue
NPO vs. fasting
NPO- strict, dysphagia, OR/GI issue
Fasting- usually can have water, may be for a test
Sexual history
Is this an expectation of the nurse in this setting?
Importance of sexual health to overall health
Legitimate part of a health assessment
Consider cultural influences and modify questions and approach as needed
5 P’s of Sexual History
Partners (do you have sex with men/women/both)
Practices (do you have oral/vaginal/anal sex?)
Protection from STI (monogamous, serial monogamous)
Past history of STIs
Prevention of pregnancy
PLILSSIT model for sexual history
Permission
Limited information
Specific suggestions
Intensive therapy
Minors consent
Governed by state law and thus, variable!
Nurses’ duty to know laws of stat where care is delivered
Strategies to reduce CAUTI
Properly secure catheter to minimize movement
Maintain closed system
Keep catheter and collecting tube free from kinking
Keep urine collecting bag below the level of the bladder and off the floor
Empty the urine collecting bag regularly
Biofilm
complex group of microorganisms that functions within a slimy gel coating on medical devices
Guidelines for preventing CAUTI
Insert under strict aseptic technique
Hand hygiene when touching any component of urinary system
Secure indwelling catheter
Use Soap & Water
Wounds are
Wound is a disruption in the normal structure and function of the skin and underlying soft tissue and can be related to a variety of etiologies; they are continuous throughout the lifespan, intentional vs. unintentional, open vs closed, acute vs. chronic
Wound assessment & documentation
Overall appearance Color Drainage Size Depth Undermining and/or tunneling Swelling Pain *Use clock for describing
Factors influencing wound healing
Age, diet, obesity, chronic diseases, smoking, tissue perfusion, medications, wound stress
Pressure Injury
is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device;
the injury can present as intact skin or an open ulcer and may be painful
The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear
Braden scale
Used for predicting pressure sore risk - 18 and below = @ risk
Device Related Pressure Injuries
result from a medical device creating localized tissue compensation
Key interventions:
Secure with minimal pressure against underlying tissue
Use soft dressings or foam around rigid edges
If possible, remove/reposition device daily and assess skin underneath
pressure ulcer prevention/nurse intervention
Reposition
Every 2 hours while in bed/every 1 hour while in char
Use pillows or wedges
Use static air boots and/or cushions
Perform routine and PRN skin care Routine peri-care May require condom cath or fecal management device Moisture barrier ointment or paste Assess skin folds for moisture
Decrease friction and shear
Use lifting devices to move patients
Keep head of bed at greater than 30 degrees
Nutrition
Encourage a protein- rich diet and hydration
Consult dietitian
Mobility
Encourage frequent movement/ambulation
Consult physical and occupational therapy
