p 1 Flashcards
when doing central line changing, put mask on pt and then remove pillow from ___
head
when doing central line changing, put pt head away from the __
site
when doing central line changing, put everything at bedside to maintain
sterility
when doing central line changing, why does the pt put a mask on?
prevent contamination and increase site access
when doing central line changing, you want to follow these steps
- HH, do general intro, why are you here?, raise bed, pt wears mask, remove pillow and turn head, open dressing kit to put mask on
- apply clean gloves
- assess the old line and site
- pull off the old dressing toward while stabilizing the catheter(make sure to not touch skin, catheter or site)
- dispose of old dressing and gloves
- wash hands
- prepare the sterile field
- drop biopatch onto sterile field and don sterile gloves
- use chloraprep to cleanse site for 30 seconds…then air dry for 2 min
- Apply bio patch color side up
- Put bandaid to site and secure IV tubing to chest with loop from insertion site to prevent pulling on sutures or dressing
- Throw stuff away. take gloves off And do HH and take masks off. Label dressing with date, time, and JW
- Lower bed down and teach pt what to report.
- say call light in reach
- Verbalize documentation of procedure with date, time and description of insertion site and length of catheter exposed, drainage, difficulties to process and pt response.
When doing a Foley catheter follow these steps
- Drape pt, put clean gloves to clean area
- HH, then open kit and put clean gloves on, put drape shiny side down by pts area, remove gloves and do HH
- Don sterile gloves, spray antiseptic on cotton balls and put lube into tray. Set top tray aside. Take blue sheath off catheter and attach sterile syringe to tube and lube tip of catheter and put back in tray.
- Put trays together again and put between legs.
- With nondominant hand, retract labia to expose urethral meat us. Cleanse labia with cotton balls(side near you then far then middle). Remove top tray and throw out. Insert tube into meatus until see urine then 1-2 more in. When in body, use left hand to release from labia to hold catheter while inflating with sterile water. Tug on cath to seed in bladder neck.
- Remove sterile gloves and do HH
- Don clean gloves and take cath to inner thigh leaving slack to move. Put drainage bag to place on bed frame hook lower than body. Do peri care to clean if excess iodine and dry area.
- Throw things away. Lower bed. HH. State date, time, size cath, quantity, color and clarity of urine, difficulties in process and pt response.
a CNA can…
think glucose, VS, and report/tell of what
take glucose, get VS, tell nurse of problems then the nurse can check it out retake signs
a CNA can…
think notice what and tell who
notice changes when caring for the pt in dressings and notify the nurse
a CNA can…
think assist in what and ___ fever
assist in postitioning the pt during insertion and care and report fever
a CNA can…
think _____ line pulled out and site is damp or dry
report to the nurse if the catheter line has been pulled out further than inserted originally and tell the nurse if the site is damp
a nurse can…
think m,a,d
give meds and assess and determine
a nurse can…
think assess for ___ and care or not care for site
assess site for infection and care for site
a nurse can…
think ____ the cath and do or not do dressing change
insert the catheter and perform dressing changes
when removing an old central line dressing…
think what kind of gloves, who gets a mask and what we remove
use clean gloves, mask for N and pt, and remove plastic but not catheter
when removing a central line dressing…
think where does the finger go?, what happens with the pts face and do they wear a mask?
pull sides off and put finger on central line and keep mask on pt and face turned
why do we label new dressing?
to know the time and who put it on and when it should be changed
when changing a central line dressing, when do you wear clean gloves?
preparing materials and after new dressing is sealed
when changing a central dressing, when do you wear sterile gloves?
while changing dressing
steps for a foley catheter are…
- general intro and raise bed
- drape pt and don clean gloves and do peri care…take off gloves and do HH, open package, don CG and drape under butt(shiny down), remove CG and HH.
- don SG and spill iodine and lube…remove top tray and set beside the bottom one
- on bottom tray, lube the cath and attach sterile water to cath
- bring trays to drape by pt. retract labia and use iodine to clean it(out to middle)
- discard top tray. insert cath until urine is seen. then go 2 more in. hold cath by area and push water to inflate balloon. put cath to seed in bladder neck.
- remove SG and HH. don CG and put cath on inside thigh and bag below bed. peri care to remove iodine, cleanse and dry peri area.
- dispose of things and lower bed. HH, teach abt follow up.
- docu time, date, cath size, quantity, color and clarity of urine and pt response and difficulties
why do we allow the chlora prep to air dry?
promotes maximum bactericidal effectiveness
why a clear bandaid?
protects cath insertion site and min risk of infection
why a clear bandaid?
clear visualization for cath site and in between dressing changes
with a cath, report…..
pain or swelling and fever
with a cath, report….
chills, bleeding, and cough/wheeze/SOB
with a cath report….
gurgles from cath, falls out of place(damage) or weird HR
with a cath report…
movement trouble or stiffness
why do we do peri care after cath insertion?
to decrease skin irritation
why does the drainage bag go below bladder?
prevent UTI
why do we check allergies to: iodine, tape, latex, & antiseptic?
reduce injury
look for kinks in tubing to _____ infectoin
prevent
if pt is in dorsal position and uncomfy, lay on ____ with upper leg flexed at knee and hip
side
a ___ can direct light to perineal area
NAP(not nurse)
we remove dressing and tape in direction of cath insertion to _____
minimize risk of dislodging
with the ____ _____ use it 10 times Q hour
incentive spirometer
with the ___ ___, sit upright and not when in pain or cant breathe
incentive spirometer
with the ___ ____, you inspire and breath slow
incentive spirometer
with the _,docu MAR, name and med concentration in IVPB, vol infused, the start and stop time of administration, and venous access device type and location
IV
with med injection safety, you don’t keep sharp points and you keep: plunger, hub of syringe, and needle all _____
sterile
you dont want to lay the needle down if it is _____
uncapped
with ___, rotate sites, aspirate, and use ETOH swab on site
IM injections
the __ is less vascular than muscle, so meds are absorbed slower
SC
for SC injections, you want to aim for ____areas that are easy for the pt to reach for self administration
larger
use the upper outer arm, ___, and thigh for SC injection
abdomen
you can use the scapula and upper ventrodorsal gluteal area for ___ injection
SC
for insulin(SC), ____ injection sites within each location and site…it prevents tissue damage
rotate
pinch loose fatty skin and insert at 45-90 degree for normal person and __ for obese person for SC injection
90
for thin person, do a __ injection in the abdomen
SC
you do or dont need to aspirate with a SC injection
dont
do no more than ___ mL for SC injection for normal size
2
Once the needle is inserted, release the pinch and use this hand to stabilize the syringe while administering the medication slowly with your dominant hand. After injecting all of the medication, remove the needle quickly at the same angle at which you inserted it. Cover the site with dry gauze immediately and apply gentle pressure. Do not massage the site.
are directions for a __ injection
SC
after a SC shot, ____ reduces uncomfyness
guaze
use thigh or back of arm preferred for ___ shots
SC
if forearm and back cant be used for ID, use what sites…SC or IM?
SC
use the inner forearm and upper back and lower abdomen(if fat) for ____
ID shots
you need to feel resistance with ID shots, if none, ____ the needle
withdraw
if a ID flu shot, use 1 ml and what muscle?
deltoid
if a pt is on bedrest, use what for the ID shot
back
with a TB test, if it pos., you’ll see a flat, ____ area 5 MM or greater in diameter
red
you need to see the bulge of the needle thru the skin with ___ shots
ID
a NAP/nonnurse can tell the pt _____
to report itchy and dysnpnea
use a 90 degree angle with ____
IM
use ____ motion for IM
darting
aspirate with ____ shots
IM
lack of blood shows IM shot went into the ___
muscle
Inject the medication slowly and smoothly, then hold the needle in place for 10 seconds to allow the medication to disperse. Withdraw the needle quickly at the same angle at which you inserted it. Cover the site with dry gauze immediately and apply gentle pressure. Do not massage the site. pull back on plunger after inserting needle to minimize injury. rotate injection sites as well
are instructions for what kind of shot?
IM
you see the vastus lateralus, ventrogluteal, and deltoid for __ landmarks
IM
landmarks are the greater trochanter and knee…you want to insert needle middle
IM
Insert the needle into the middle third of the muscle at least one hand width below the greater trochanter and one hand width above the knee in the anterolateral aspect of the leg. are instruction for
vastus lateralus
Landmarks for the ______ muscle are the head of the greater trochanter and the anterior superior iliac spine. Place the heel or the palm of your hand on the head of the greater trochanter with your thumb pointing toward the patient’s abdomen. Extend your index finger up to the anterior superior iliac spine then spread your other fingers back along the iliac crest. Insert the needle in the “V” formed between your index and third fingers. are the instructions for
ventrogluteal
what is the most common IM site
ventrogluteal
Landmarks for the ____ muscle are the acromion process and the axillary line. Insert the needle at a point two to three finger widths (1 to 2 inches) below the acromion process, above the axillary line in the middle of the triangular-shaped _____ muscle in the midline of the lateral aspect of the arm. Carefully locate the deltoid muscle using the anatomical landmarks. There is potential for injury due to proximity to the brachial artery and the radial nerve
deltoid
ID needle are ___ G
25-27
ID needle are ____ and use 1 mL
3/8 - 5/8
OR 1/2 to 5/8
SC needles are ____ G
25-27/25-31
SC needles are ____in and 1-3 mL
3/8 - 5/8
IM needles are ____ G
20-25 G
IM needles are __in for the deltoid
1-1.5
if SC at a 45 deg angle use a ___ in needle
5/8
if SC at a 90 deg, use a ___ in needle
1/2
most common SC needle size are ___ G and 3/8 in long
25
insert an ID needle 1/8 into skin and observe for ____ and the appearance of a wheal
blanching
massage or dont massage a ID shot site
dont
if there is no wheal formation or there is bleeding, the ___ shot was done wrong
ID
18- to 25- gauge, ⅝- to 1-inch needle for oil-based or viscous solutions. Use a 22- to 27-gauge, ⅝- to 1-inch needle for aqueous solutions. For infants, give up to 1 mL with a 1-inch needle; for small infants, give up to 0.5 mL with a ⅝-inch needle. This is one of the preferred sites for infants. are for what IM spot?
VL
18- to 25-gauge, 1½-inch needle for oil-based or viscous solutions. Use a 22- to 27- gauge, 1½-inch needle for aqueous solutions. For infants, give up to 1 mL with a ½- to 1-inch, 21- to 25-gauge needle; for small infants, give up to 0.5 mL with a ⅝-inch, 21- to 25-gauge needle. For toddlers, give up to 2 mL with a 1-inch, 21- to 25-gauge needle. For children age 3 and older, give up to 2 to 3 mL with a ½- to 1-inch, 21- to 25-gauge needle. For adolescents, give up to 2 mL with a 1- to 1½-inch, 21- to 25-gauge needle. are for what IM site?
VG
parenteral routes are invasive, ____, IVs, IM
injections
nonperenteral routes are ointments, EC capsule, and ____
suppositories
when mixing insulin, ___ vials in hand
roll
when mixing insulin, draw up longer acting insulin first or second?
first
when mixing insulin, do or dont push insulin back into longer acting vial?
dont
