Nurs 242 Midterm Module 1-5 Flashcards
Goals for client with oxygenation and circulation problems:
- maintain patent airway
- improving comfort and ease of breathing
- maintaining or improving pu,monary ventilation and oxygenation
- maintaining or improving tissue perfusion
- improving ability to participate in physical activities
- preventing risk associated with oxygenation prbs: skin & tissue breakdown, syncope, acid-base imbalances,
Interventions of nurse to maintain normal respiration’s of clients include:
- positioning client to allow maximum chest expansion
- encouraging or providing frequent changes in position
- encourage ambulation
- measures that promote comfort, such as giving analgesic
- providing fluids and humidification
- encouraging deep breathing & coughing
what positions give patient maximum chest expansion when confined to a bed?
Semi-fowlers
High Fowlers
Dyspneic pts often sit in bed and lean over their overbed tables, usually with a pillow for support this is called
orthopenic position (an adaptation of high fowlers)
what are the further advantages for orthopenic position instead over high fowlers
because organs not pressing on diaphragm, client can press on lower part of chest against table to facilitate exhaling
Artificial airways are inserted to?
maintain air passage for client’s whose airway has or may become obstructed
oropharyngeal airways stimulate…
gag reflex and are used only for clients w altered levels of consciousness
To insert an oropharyngeal airway
- place client in supine or semi fowlers position
- hold lubricated airway by outer flange w distal end pointing UP
- open clients mouth and insert airway along top of mouth
- when distal end reaches soft palate at back of mouth, rotate airway 180 degrees DOWNWARD, slip past uvula to oral pharynx
- if not contradicted place pt in side lying position to allow secretions to drain out of mouth
- oropharynx may be suctioned as needed, by inserting suction along airway
- do not tape airway in place, remove when client begins to cough or gag
Nasopharyngeal airways are tolerated better by
alert clients
Hypoxia
insufficient 02 to meet metabolic demands of tissues and cells
Oxygen devices fall into 2 categories
High flow devices and Low flow devices
High flow devices
discourage en training room air, which dilutes inspired oxygen percentage
- venturi mask
- large volume nebulizer
- blender masks
Low flow devices
- nasal cannula
- various types of face masks
- tracheostomy bag
Saftey guidelines for oxygen
- know pts normal vital signs & pule oximetry values (SP02)
- be aware of environmental conditions
- Document pts smoking history
- know pts most recent hemoglobin value
- oxygen is medication
- provide education
Nasal Cannula flow rate
1-6L?min,
Higher flow rates dry airway mucosa & do not increase inspired oxygen concentration, do not use humidifiers for rates less then 4L/min
Simple oxygen face mask
for short term 02 therapy, fits loosley and delivers 02 concentration form 40% to 60%
Venturi mask
cone shaped high flow device w entrainment ports of various sizes at base of mask entrainment ports adjust to permit regulation of 02 form 24% to 60%, this mask useful because delivers more precise concentration of oxygen to pt
Incentive spirometer helps a pt
deep breathe
Incentive spirometer often used after
abdominal or thoracic surgery to reduce incidence of past operative pulmonary atelectasis
Incentive spirometer provides visual feedback to pts about
depth of their breaths
two types of incentive spirometer
flow oriented and volume oriented devices
flow oriented incentive spirometer
one or more plastic chambers w freely moving colored balls, As pt inhales slowly balls elevated to premarked area, pts goal to keep balls elevated for long as possible to maintain maximal sustained inhilation
volume oriented devices
pt must raise to predetermined volume by inhaling slowly
pts benefiting from incentive spirometery include
using it before surgery, especially for abdominal, cardiac or orthopedic surgery, pts w history of smoking pneumonia or chronic respiratory disease & pts w atelectasis
expected outcomes for incentive spirometry
- pt demonstrates correct use of IS
- pt achieves target volume & number of repetitions per hour
- pt has improved breath sounds
Incentive spirometer implementation:
- position pt in erect position (eg. high fowlers)
- instruct pt to exhale completey through mouth & put lips tightly around mouthpeice
- instruct pt take slow deep breath & maintain constant flow–like pulling through straw –when pt cannot inhale anymore maximal inspiration reached
- have pt hold breath for at least 3 seconds & then exhale normally
- remind pt to perform IS excercises 5-10 times followd by controlled coughing every hour while awake as directed by health care provider
airway size correct
when flange is held parallel to front teeth w ariway against pts cheek end curve reaches angle of jaw
expected outcomes for oral airway
- pts respiratory status improves – resps normal rate, easier removal of secretions, lack of gargling noise in throat w respiration
- pt not able to grind teeth or bite tubes
- pts tounge does not obstruct airway
family members can verbalize understanding of need for
oropharyngeal airways
do not continue inserting oral airway if pt begins to
gag
oral aiways seldom used in treatment of ariway obstruction in
infants and children, airway so narrow causes more harm then benefits
Asepsis
“without infection” implies absence of disease causing microorganisms
aspetic technique or sterile technique is used to
to decrease possibility of transferring microorganisms from one place to another
sterile technique
strictest possible measures to maintain sterility throughout procedure
aseptic technique
(clean technique) clean, absence of almost all but not all microorganisms, efforts made to reduce transfer of microorganisms
Principles and Practices of establishing & maintaining a sterile feild
- All objects used in a sterile feild must be sterile
- sterile objects become unsterile when touched by unsterile objects
- Sterile items that are out of vision or below waist of nurse are considered unsterile
- sterile objects can become unsterile by prolonged exposure to airborne dust containing microorganisms
- fluid flow in one direction of gravity
- moisture that passes through a sterile object draws microorganisms from unsterile surfaces above or below to sterile surface by capillary action
- skin is unsterile and cannot be sterilized
- conscientiousness, alertness and honesty are essential qualities in maintaining surgical asepesis
sterile feild
microorgamism free area
culture and sensitivity test for urine
culture identify if bacteria is present
sensitivity most effective antibiotic for treatment
collecting a clean voided urinal sample
- perform peri-care
- using surgical aspesis, open outer package of specimen kit
- open specimen container, maintaining sterility of inside specimen container & place cap w sterile inside up –do not touch inside of cap or container
Male urine sample
- hold penis w one hand, using circular motion & antiseptic towelette, clean meatus, moving from center to outside 3x w different towelettes, uncircumcised retract fore skin clean and keep retraced for voiding
- pt initiates urine stream stops then tarts again for you to collect 90 -120 ml of urine
Female urine sample
- spread labia minora w fingers of non dominant hand
- w dominant hand clean urethral area w antiseptic swab, move from front to back use fresh swab each time, clean 3x, while continuing to hold labia apart, pt initiates urine stream into toilet/bed pan after stream achieved pass container into stream
Collecting urine from indwelling catheter
- clamp catheter with rubber band for 10-15 min (urine cannot be obtained form drainage bag-unsterile)
- location of port is where catheter attaches to drainage bag
- clean port for 15 seconds w disinfectant swab & allow to dry
- attach needless luer-lok syringe to port
- withdraw 3ml for C&S or 20 ml for routine urinalysis
- transfer form syringe into clean urine container for routine urinalysis or sterile urine container for C&S
- unclamp catheter
- send specimen & completed requisiton to lab within 20 min, refrigerate specimen if delay cannot be avoided
Obtain cultures from pts before
antibiotics started, may interrupt growth of microorganisms, if pt receiving antibiotics notify lab & identify antibiotics pt receiving
Collection of specimen from nose & throat can cause
discomfort and gagging
important to collect throat culture before
mealtime or at least 1 hr after eating/drinking to decrease chance of inducing vomiting
pts clear understanding of specimen collection and technique minimizes
anxiety or discomfort
parenteral medications
administered in manner other than digestive tract
subcutaneous injection
injection into tissues just under dermis of skin
intramuscular injection
injection into body of a muscle
intradermal injection
injection into dermis just under epidermis
intravenous injection or infusion
injection into vein
muscle sites for intramuscular injections
- ventrogluteal
- vastus lateralis
- deltoid
Ventrogluteal inejecton site
- deep and situated away from major nerves & blood vessels
- easily identified by prominent bony landmarks
- preferred site for meds larger in volume, more viscous & irritating
- less painful than vastus lateralis
- recommended as pediatric IM injection site for children of all ages
Vastus Lateralis injection site
- absence of major nerves & blood vessels
- drug absorption rapid
- site used for immunizations in children
- recommended as pediatric IM injection site for infants up to 12 months of age
Deltoid injection site
- easily accessible, not well developed in most pts
- used for small volume of medication
- faster absorption rate
- may be used as vaccination site in adults, based on dev of muscle
- recommended as pediatric IM injections for children 18 mos and older
Angles of insertion
intramuscular: 90 degrees
subcutaneous: 45-90 degrees
intradermal: 15 degrees
to minimize pt discomfort when giving an injection
- use sharp, beveled needles, shortest length & smallest gauge
- change needle if med coats shaft
- position & flex pts limb to reduce muscular tension
- divert pts attn away from injection
- insert needle at proper angle, smoothly & quickly
- do not hesitate & slowly push needle into tissue
- inject med slowly but smoothly
- hold syringe steady once needle is in tissue to prevent tissue damage
- withdraw needle smoothly @ same angel used for insertion
- gently apply gauze pad to site, apply gentle pressure
- rotate injection site to prevent formation of indurations & abcesses
recommendations for prevention of needlestick injuries:
- avoid needles w effective needles systems or SESIP safety devices available
- do not recap needles after med admin
- plan safe handling & disposal of needles before beginning a procedure that requires use of needles
- immediately dispose needles INTO sharps container
- maintain sharps injury log
- report all needle stick & sharps related injuries immediately according to agency policies
- attend ed offerings regarding blood borne pathogens & follow infection prevention, including receive hep B vaccine
SESIP
is a sharp with engineered sharps injury protection
a device effective in preventing needlesticks
ex. blunt end cannula, a safety syringe equipped w plastic gaurd or sheath that slips over needle as it is withdrawn from skin
Avoid injecting large volume of fluid into tissues unusual to use syringe larger than __ for IM injection
5 ML syringe
3 parts to a needle
hub-fits into tip of syringe
shaft- connects to hub
bevel or slanted tip
needle hub, shaft & bevel must remain ___ at all times
sterile
the smaller the gauge the ____ of the needle diameter
larger
selection of gauge also depends on
viscosity of fluid to be injected
Ampules
contain single dose of injectable med in liquid form, coloured ring around neck indicates where ampule is prescores to be broken easily, filter needles must be used so no glass is drawn up, DO NOT administer med using filter needle
Vials
single/multi dose plastic/glass containers with a rubber seal @ top, multidose can be used several times for same pt, when using multi dose write date that vial opened on label
Hold syringe @ 90 degree angle to ensure correct volume & absence
of air bubbles
remove any remaining air by
tapping barrel to dislodge any air bubbles
for subcut injections meds absorbed more ___
slowly because of less blood vessels
give subcut meds in small doses
less than 2ml, that are isotonic, nonirritating, nonviscous & water soluble
Infants & children recommended up to ___ml in one site
0.5 Ml
assess for contradiction to subcut injection such as
circulatory shock or reduced local tissue perfusion
medications that require exact timing include
stat, first time or loading doses & one time doses
why pinch for subcut ?
needle penetrates tight skin more eaisly than loose skin. pinching elevates subcut tissue & desensitizes area
IM injection choice when 2 things are required
- a reasonably rapid systemic uptake of a drug (usually within 15 or 20 minutes)
- a realitivley prolonged action
Preventing infection during an injection
- prevent contamination of solution
- prevent needle contamination
- prepare skin
- reduce transfer of microorganisms
prevent contamination of solution (preventing infection during an injection)
ampules should not sit open & medication should be removed quickly
prevent needle contamination (preventing infection during an injection)
- avoid letting needle touch contaminated surface (eg. outer edges of ampule or vial, outer surface of needle cap, your hands, countertop or table surfaces)
- avoid touching length of plunger or inner part of barrel. Keep tip of syringe covered with cap or needle
Prepare skin (preventing infection during an injection)
-wash skin soiled w dirt, drainge or feces w soap & water. use friction & a circular motion while cleaning w antiseptic swab. swab from centre of site & move outward in 5cm (2 inch) radius
reduce transfer of microorganisms (preventing infection during an injection)
perform hand hygeine for minimum of 15 seconds
some paraenteral & oral medications supplied in powder from must be mixed w water or some other liquid before administration
reconstitution of solutions
Purpose of subcut butterfly injections
provide subcut meds– around the clock dosing
clients unable to take medications through other routes
parenteral route of choice for chronic pain
benefits of subcut butterfly
avoids multiple injections
avoids turning & repositioning client
allows better rest during the night
absorbs effectivley
simple & effective method of delivery which may be used in the hospital or home care setting
if client is at home, family members can be taught to give the injections via the butterfly
to prevent complications change the location of the butterfly at least
weekly
poor absorption of meds through subcut butterfly may reslut in breakthrough pain & can often be remedied by
changing the site
policy of subcut butterflys
- subcut administration of all medications will be provided under orders of a physician
- drug dose, concentration, volume & rate must be appropriate for subcut infusion
- infusion sites will be monitored with each infusion or every shift/vist if the site is not being used at regular intervals
if the concentration of a subcut butterfly medication is changed a
new site must be established
for subcut butterflys choose the concentration that would
allow smallest appropriate volume to be administered and allows for further titration
for inital dose of subcut butterfly med
add additional 0.4ml to prime the tubing
nurse preforming an interdermal injection feels resistance when injecting a medication what should nurse do?
inject medication during a interdermal injection feels resistance
how will a nurse mix medication that has been diluted in a vial
roll in palms
needle stick prevention
- sharps disposal containers
- may be used one handed
- colored red or labelled w bio hazardous symbols
for subcut butterflys amount administerd to one site
adults: 2ml
adolescent: 1.5-2ml
a single dose given by subcut butterfly should not exceed 2ml for Adults or 1.5-2ml for adolescents if so
a second site should be established and the dose split
medication amounts given by subcut butterfly greater than 1ml and administered frequently can make sites
boggy
what does a boggy site mean
causing poor absorption & necessitating more frequent site changes
preferred sites for subcut butterfly
- abdomen,
- infusion sited should also be away from
preferred sites for subcut butterfly
- abdomen(from below costal margins to the iliac crest away from waistline), Posteiror flank, subclavicular area, anterior aspects of thigh & upper arm
- infusion sited should also be away from bony prominences and large underlying muscles or nerves
- subclavicular site is preferred for children as is less painful and less restricting of movement. also preffered in elderly as other sites may have insufficent subcut tissue
label subcut butterfly site with
date, drug, & drug concentration used to prime on transparent dressing and inital
subcut butterfly injection site change
changed every 7 days and as needed. for end of life care pts routine change is not neccessary
change prn whenever leakeage, drainage, induration or redness is observed @ site
for following doses at subcut butterfly site
use same drug and same concentration as previous dose
IM injections have an increased risk of
injecting drugs directly into blood vessels
Subcut injection
Volume: 0.5-2ml Syringe size: 1-3ml gauge: 25-27G length:3/8-1/2 (usually 5/8) pinch or spread: pinch (or either) Angle: 45-90 degrees
IM injection
Volume: 2-5ml (but usually 3ml or less) syringe size: 2-3ml gauge: 18-25G Length: BMI 5/8 -1 1/2 Method: Z track & aspirate (expect w immunizations) angle: 90 degrees
ID injection
volume: 0.01-0.1 syringe size: 1ml gauge: 25-27G Length: 3/8 - 5/8 Method: use tb syringe, should form bleb angle: 5-15 degrees
IM injection requires_____ & ____ needle
longer & larger guage
factors that contribute to needle selection for IM injections
- med
- injection site
- pts weight & amount of adipose tissue
determine needle gauge by med to be administered
-admin immunizations & parenteral meds aqeous soulutions w a 20-25 guage needle
Viscous or oil based soln, w a 18-21 gauge needle
for small children (20-25 guage)
muscles is less sensitive to irritating &
viscous medication
rotate iM injection sites to decrease risk of
hypertrophy
emaciated or atrophied muscles absorb medication
poorly
what method is used for IM injections
Z track
Z track method
-prevents leakage of medication into subcut tissue, seals medication in muscle & minimizes irritation
Dorsogluteal injection site
not recommended as sciatic nevrve location, if needle hits sciatic nerve, pt may experince partial or permanant paralysis of leg
Ventroguleal site
- invovles gluteus minimus & maximus
- safe injection site for adults & children
Ventrogluteal site landmark
to locate, pt lie in either supine or lateral position, place heel of hand over greater trochanter of pts hip w wrist almost perpindicular to femur (thumbs to groin), point index finger to antierior superior illiac spine extend middle finger back along illiac crest form a v shaped triangle injection site @ center of triangle
to relax ventrogluteal site for injection
lie pt on their side or back, flexing knee & hip
Vasteus lateralis
- another injection site for adults
- preferred site for admin of immunizations to infants, toddlers & children
- muscle is thick & well developed
vasteus lateralis landmark
- located on anterior lateral aspect of thigh. it extends in a adult from hand breadth above knee to hand breadht below greater trochantar of femur
- use middle third of muscle for injection
to relax vasteus lateralis injection site
to help relax ask pt to lie flat w knee slightly flexed & foot extremely rotated or assume a sitting position
deltoid muscle site
- easily accesiible but muscle not well developed in many adults
- potential for injury because axillary, radial, brachial ulnar nerves & brachial artery lie in upper arm
- site for small med volumes
- for admin of routine immunizations in toddlers, older children & adults or when sites inaccesible because of dressings or casts
to relax deltoid muscle site
ask pt to relax arm @ sie by supporting pts arm & flexing elbow
to landmark deltoid muscle injection site
palpate lower edge of acromin process forms base of a traingle in line with midpoint of lateral aspect of upper arm. injection site is in center triangle about 3-5cm below acromin process
