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
draw regular insulin then NPH, bc you dont want to contaminate the ____ insulin
regular
inject air into ___ then regular insulin then pull from regular then pull from NPH
NPH
NPH is a _____ acting and cloudy insulin(dont put cloudy into clear)
intermediate
regular insulin is ___ acting
short
HH is the best way to prevent spread of _____
infection
hanging IV steps
Prime tubing, place into pump, connect to patient and close clamp close to patient, set information into pump, start pump, open clamp close to patient. Keep in mind sites that remain sterile
what is sterile on the IV stuff
hub connected to the pt and spike into bag
how full should a drip chamber be?
HALF
hang the PB (secondary) ____ than the primary IV fluid
think higher or lower
higher
nurse can do what with iV’s?
assess IV site for swelling/redness, hanging them, and control of pump
nurse can do what with iV’s?
flow set of pump
CNA’s can do what with iV’s?
let the nurse know if pt is complaining abt the IV site
the sites of skin breakdown are the ___ and mucosa
nare
what are the steps of inserting a NG tube?
inspect nares for patency
use more patent nare thru nose blow to insert tube
test gag reflex
pt in high fowlers and towel across chest
measure tube from tip of nose to tip of ear then to xiphoid process
mark tube with tape
lube tip of tube
put tube in nostril and put to post pharynx
pt tilt head forward and drink water in process
tape tube to nose and use xray to ensure in right place
anchor the tube to gown and clamp end of tube or attach to suction
put waste in trash and ensure comfort and document
when dealing with a NG tube, if you face resistance when inserting, _____ tube to the nasoharynx
withdraw
when dealing with a NG tube, if no nares are patent, ____ provider
notify
when dealing with a NG tube, the pt needs to breathe thru mouth and _____ constantly
swallow
when dealing with a NG tube, to reduce discomfort, examine each __ for patency and skin breakdown
nare
how do you cleanse an ostomy site
warm water to wipe the skin around
put a put a pt in ____fowlers position when doing ostomy care
semi
empty a ostomy pouch Q 3-__ days
7
asses what with an ostomy
abdomen, color and size
asses what with an ostomy
what color, was there blood and the amt when emptying
asses what with an ostomy
the redness, swelling or breakdown
asses what with an ostomy
the psychosocial impact with TC
assessing a stoma after surgery…it will be swollen and ___
enlarged
assessing a stoma after surgery…you check for color, tugor, and ____
edema
assessing a stoma after surgery…you check for signs of injury like ____
bleeding
assessing a stoma you want to see what coloring?
pink to red and moist
assessing a stoma you dont want to see purple, black, brown, dark red, grey, and ____
pale
assessing a stoma you want to see the stoma swelling ____ with time, gradually shrinking over the first few months
subdue
assessing a stoma you can measure when it is _____ size and shape
consistent
assessing a stoma how often is called for?
daily once
when you wash a stoma gently, it should ____
bleed
___ output can harm the skin around the ____ and can cause irritation and infection
stoma
the ___ barrier or adhesive helps prevent and manage peristomal skin damage
skin
_____are essential for protecting the peristomal area while supporting the skin
gentle removal of adhesives
clean with water alone when caring for ___
ostomy
keep the skin dry to ensure a good adhesive seal and to reduce the risk for ___
infection
on pouch replacement days, how do you shower?
with pouch off and apply the clean system after area is pat and dried
when bathing with the pouch system on, they should dry the ____ barrier and the pouching system bf dressing
skin
a stool from your LI will ____ to formed
soft
stool from your SI will be ____
liquid
what stage of a pressure ulcer is this?
skin unbroken, no skin removed, redness, Non-blanchable erythema, The skin feel warm to touch
one
epidermis and dermis broken, blister like;Partial thickness skin loss involving epidermis, dermis, or both. The lesion is superficial and presents clinically as an abrasion or shallow center. is what stage pressure ulcer
2
undermining beginning(epidermis and dermis layers tissue is tearing away);Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. Deep crater with or without undermining of adjacent tissue is what stage pressure ulcer
3
undermining, tunneling(need to measure it);Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. This is the most severe pressure ulcer formation and is most difficult to treat…what stage pressure ulcer?
4
immobilization and cog deficit are instrinsic factors that are RF for what?
wound healing
age is a major role in wound healing and so does reduced ___ sensation
skin
_______ is a intrinsic RF for wound healing
immunosuppressed
poor ____ levels are an instrinsic RF for wound healing
think CO2 or O2
oxygen
meds and radiation and chemo are ___ RF for wound healing
extrinsic
stress and the brain are ____ RF for wound healing
extrinsic
trauma, infection, and damage to tissues are ____ RF for wound healing
extrinsic
the braden scale assess ___ number of factors
6
friction and shear are assessed in the ___ scale
braden
nutrition and mobility are assessed in the ___ scale
braden
activity and moisture are assess in the ____ scale
braden
sensory perception is assessed in the Braden ___
scale
the braden scale measures the ____ ulcer risk
pressure
there are five factors affecting the pressure ulcers ____ factors
think intrinsic or extrinsic
extrinsic
friction and shearing force are extrinsic factors(EF) that cause
pressure ulcers
moisture, pressure, and humidity are EF that cause
pressure ulcers
rubbing on surfaces has to do with friction or moisture?
friction
occurs when the skin is rubbed over a surface and the epithelial tissue is irritated or injured, such as when a patient is dragged across bed linens….has onto do with pressure or friction?
friction
lift them and not drag them(will tear tissue);occurs when the skin itself stays in place while subcutaneous tissues shift…this has to do with shear force or moisture?
shear force
with ___ we want to prevent breakdown
think moisture or pressure
moisture
a CNA can sit pt on cushion to prevent breakdown ass with ___
ulcers
a CNA can do special beds for best rest pts ass with ____
ulcers
a CNA can do prevention strategies like ___ a pt Q2 hours to prevent ulcers
turning
any doubt with sterility is ___ longer sterile
no or stil
no
check sterile packages for ___ for punctures, tears, discoloration, or moisture. check the exp date as well
integrity
check the table for cleanliness, moisture, and if its near air flow in what technique
sterile
anticipate the number and variety of supplies needed for procedure in what technique
sterile
a ___ field is est immediately bf the procedure
sterile
the edges of a ___ field or container are considered to be contaminated…outer one in is nonsterile
sterile
edges of ____ containers become exposed to air after they are opened, and thus contaminated
sterile
dont talk, reach over or have airflow over your _____ field
sterile
when a ___ surface comes in contact with a wet, contaminated surface, the _____ field/object is no longer ______
sterile
primary intentions that are closed ____ heal
surgically
primary intentions are sutures, with touching edges, and ___ edges
clean
primary intentions are closed with stiches and stapes and ___ and stripes
tape
primary intentions dont let the body ___ and dont form granulation tissue
contract
gradual formation of scar tissue allows the wound to close slowly is primary or secondary intention
primary
wound edges dont touch is primary or secondary intention
secondary intention
the wound heals by formation of granulation tissue is primary or secondary intention?
secondary
there is wound contraction and epithelialization with ____ intention
secondary
open wounds and irregular edges are _____ intention
secondary
larger wounds have a greater loss of tissue and contamination and are ass with _____ intentions
secondary
complications of wound healing are hemorrhage and ______
think I
infection
complications of wound healing are dehiscence and ______
think e
evisceration
organs come thru the opening are
evisceration
opening of edges of surgical wound with partial or total separation of wound layers
dehiscence
serous is the ___ common wound drainage, it is golden, clear, and water plasma
most
sangineous drainage is ____ blood, and active bleeding
bright red
serous-sangineous drainage is _____, red, watery and a mix
pale
purulent drainage is glow in the dark, ____, yellow, pale green, white drainage, and indicates infection
think consistency
thick
hemovac is a ____ drain system
closed
hemovac is a suction device that has a disc shaped reservoir for ____ drainage
collecting
hemovac has a pouring spout for ____ the collection reservoir and the system needs to be compressed bf replacing the spout
emptying
to empty the hemovac, ___ the stopper and pour the drainage out, squeeze the drain flat and replace the stopper
open
dry dressings are a guaze pad that is ____ to wound by rolled tape or bandaid
secured
simple, nonexpensive, widely available are what kind of dressing
dry
these dressings work well for wounds with little exudate
dry
these dressings can stick to the wound and expose the wound
dry
these dressings can be removed by pouring ____ _____ over the area to moisten
normal saline
these dressings can be applied in sterile and clean envirionment
dry
surgical wounds and VAD are _____applications
sterile
_____ dressings reduce the risk of infection and cross contamination
sterile
wounds that need debridement will get what dressing?
wet to dry
To create this type of dressing, place a saline-soaked gauze within a wound after wringing out excess and unfolding. As the dressing dries, it pulls exudate out of the wound…what kind of dressinf?
wet to dry
The disadvantages of ____ dressings are that they are nonselective with debridement
wet to dry
_________– dressings are time-consuming to apply and are generally painful to remove.
wet to dry
Surrounding wound edges can become macerated because of the moisture contained in the dressing, and that can lead to enlargement of the wound’s diameter with what dressing?
wet to dry
cross contamination is a problem with what dressing?
wet to dry
when changing what dressing, do you premedicate for pain and leave dressing dry even when it is sticky?
wet to dry
what dressing is beneficial for: 24 yr old with open and infected wound from spider bite & 30 yr old with cyst removed and has necrotic tissue in crater type wound
wet to dry
____woven gauze dressings are most often used for abrasions and postoperative incisions when minimal drainage is anticipated
dry
_____ dressings are often used for helping to heal full-thickness wounds that look like craters
moist
_______dressings are best used with necrotic, infected wounds requiring debridement
moist to dry
what site in IM do you use for kids, an epipen and where the arm ends?
VL
primary intentions are like a paper cut…true or fasle?
true
secondary intentions are ass with trauma and the edges do or dont match with healing.
dont
the primary reason for wet to dry dressings are to ___ healing and to pull out eschar tissue
promote
CLEAN GLOVES IN A CENTRAL LINE DRESSING WHEN?
WHEN TAKING OFF OLD DRESSING AND PREPARING MATERIALS AND AFTER NEW DRESSING IS SEALED
WHEN REMOVING AN OLD CENTRAL LINE DRESSING, WHY DO YOU USE A MASK?
SO THERE IS NO CONTAMINATION AND NO BREATHING OVER THE FIELD
TO MINIMIZE THE RISK OF DISLODGING A URINARY CATH, YOU _____ THE DRESSING OR TAPE OR GUAZE IN THE DIRECITON OF THE CATH INSERTION
REMOVE
TO MINIMIZE THE RISK OF DISLODGING A URINARY CATH, TAKE STERILE WATER SYRINGE OFF TO KEEP THE BALLOON ______
INFLATED
WHEN MIXING INSULIN, INJECT AIR INTO NPH THEN INTO REGULAR THEN PULL FROM ____ THEN NPH
REGULAR
THE SITE OF SKIN BREAKDOWN WITH AN NG TUBE ARE ____ AND MUCOSA
NARE
YOU WANT TO TILT THE HEAD ___ WHEN PUTTING IN A NG TUBE
FORWARD
MEASURE THE WAFTER __ LARGER THAN THE STOMA
1/8IN
MORE ___ MORE POSIBILITY TO DEVELOP AN ULCER
PRESSURE
A CNA CAN DO ___ STRATEGIES WITH PRESSURE ULCERS
PREVENTION
ONE STITCH BREAKS WITH DEHESENCE OR EVISCERATION?
DEHESENCE
WHOLE INCISION/WOUND BREAKS UP AND IS AN EMERGENCY AND IS WHAT?
THINK E OR D
EVISCERATION
WHAT IS THE REASON FOR A WET TO DRY DRESSING?
PROMOTE HEALING AND CIRCULATION BY OPENING CAPILLARIES
