PCC 2 Finals |Parker |Fall 2023 Flashcards
1
Q
Deprivation lead to
A
- Changes within the CNS, such as hallucinations
- Changes in cognitive such as ability to concentrate and focus
- Changes in emotions such as fear and anxiety
2
Q
What does BED stand for wound care?
A
Bacterial
Exudate
Debridement
3
Q
Sensory overload signs
A
Agitation and anxiety
- Constant beeping
- Bright lights
-Loud people
4
Q
Treatment for sensory overload
A
►Dim the lights
►Allow only a certain amount of people come in or none at all
► Cluster care
► Don’t room with another person
►Educate patient on what the beeping sounds are
► Tell them to use call light if need anything
► Educate and involve them in their recovery process
5
Q
Sensory Depravation Treatment
A
Keep mind engaged
► Turn on TV
► Have visitors
► play games with other patients (nursing homes)
► Colorful walls with paintings
► Pet therapy (Can help all impairments)
6
Q
Visually impaired room safety
A
Keep things the same in the room. Don’t be constantly moving furniture around. Educate the patient where everything is or reacclimate them if things are moved.
► Make sure there is no trip hazards
7
Q
Visually impaired feeding
A
Clock method (want to encourage functional independence)
8
Q
How to talk to hearing impaired
A
► Greet them by name then listen and wait.
► Stand in front of them
► Be at their level
► Speak as loud as they need you to. Start at an average volume and then see how loud they need you to be. Do not just go in and start screaming at them.
► Use adaptive mask if they lip read
► Ask for a sign language interpreter prn
► Avoid covering mouth while speaking
►Speak clearly and at a reasonable volume speak slowly
► Try lowering pitch before increasing volume to be heard
► Rephrase rather than repeat
► Cut out background noise
► ASK what can be done
► Write out things that are not understood
9
Q
Ostomy Education
A
► Small amount of blood after the operation is normal
► Might not stay the same size. Might be swollen and then shrink (up to 1/3 of size in 3 months)
► Measure the stoma to cut the correct size
10
Q
How to know if client accepts education for Ostomy
A
They are going to look at it and ask question (readiness to learn)
11
Q
Ileostomy Diet
A
Ileostomy lumen is smaller and get clogged easier:
► Lots of water
► Avoid fibrous food like celery
► Avoid seeds
► Avoid alcohol (high gas product)
► Avoid carbonated (high gas product)
► avoid cabbage (high gas product)
12
Q
What are the benefits for colostomy irrigation?
A
► Increase independence
► Increase the quality of life
► need stoma cap and can’t depend on it working well b/c it takes weeks to months to train and makes sure there are no difficulties with the stoma
13
Q
Caput Medusae
A
People with liver disease cause it
► Hypervascularity
14
Q
What is the biggest risk to a patient with Caput Medusae
A
Bleeding
► Prevent by being gentle and apply a soft pouching system (use Vaseline instead of adhesive)
15
Q
Ostomy Complications
A
► Necrosis - most common post-op
► Candidiasis - yeast infection due to excess moisture (make sure the site is dry and use antifungal powder and not cream
► Stripping injury - if we are too rough pulling off
► Prolapsed stoma: stoma outside body (don’t leave the pt. Monitor for s/s of shock, cover with moist towel, call PCP to prepare OR
► Dermatitis
► Stoma retraction
► Stoma stenosis
► Skin irritation and burns from stomach acid
► Caput Medusa: hypervascularity on pt with liver disease
16
Q
Effluent
A
Drainage of the stoma
17
Q
Ileostomy Output
A
Liquid and pasty
► Never going to have normal formed stool
18
Q
Colonoscopy
A
Normal bowel movement. At first pasty after operation, but it will eventually become formed.
19
Q
Stoma necrosis
A
Stoma is dying
► Most common in first 3-5 days
Common Cause:
► Tension mesentery
► excessive dissection of mesentery
► obesity or edema (puts pressure on blood supply)
Need to determine level of necrosis using test tube. If it extends to fascia level it indicates a surgical emergency.
20
Q
Irritant dermatitis
A
Skin is irritated from leakage or adhesive
► Poor pouch seal (leakage)
► Incorrect skin barrier size
► poor stoma construction
21
Q
Candidiasis
A
Cause by constant contact with moisture
Risk:
►Compromised host (immuno-sufficent, DM, etc)
► medication (antibiotics, cancer, chemotherapy, steroids)
To prevent:
► Completely dry skin before putting on new appliance
► Antifungal powder
► porous tape
► pouch cover
► Evaluate barrier
22
Q
Stoma retraction
A
Pulling back of a stoma below skin level
Intervention
► Ostomy belts must lie straight in horizontal direction (puts pressure around to squeeze back out)
23
Q
Stoma stenosis
A
Lumen has collapsed
►Harder for stool to pass through
24
Q
Stoma hernia
A
Additional bowel has come through the muscle wall but not through the skin
25
Prolapsed stoma
Bowels come out
► Use one piece pouch system
► Change when it is most retracted
► Don't try to push it back in
► Reduce with cool packs and lying on back
26
How to prevent skin complications from ostomies
► Make sure cleansed it appropriately
► Completely dry
► Not aggressively pull on adhesive
27
If someone with an ileostomy says they haven't had a bowel movement in a few days what should we tell them?
It's an emergency
► Occlusion or severe dehydration
► Never give them an laxative
28
Why do we use the Z track method
Minimize local skin irritation by sealing the medication in the muscle tissue
29
Z track method
Used for IM injection. Put a new needle on the syringe after preparing the medicaiton so no solution remains on the outside of the needle shaft
KNOW YOUR LANDMARKS
►Then select a IM site, preferably in a large, deep muscle such as the ventrolateral
►Place the ulnar side of the nondominant hand just below the site and pull the overlying skin and sq tissue apx 2-3 cm laterally or downward. Hold the skin in this position until you administer the injection
►After preparing the site with the antiseptic swab, inject the needle deep into the muscle
►Grasp the barrel of the syringe with the thumb and index finger of the nondominant hand and slowly inject the medication if there is no blood return on aspiration
30
6 Rights of medicaiton
► Right medication
► Right dose
► Right patient
► Right route
► Right time
► Right Documentation
31
Right medication
Check the label 3 times to verify the medication, strength and dose
► No matter how the nurse receives a medication order, they should compare the prescriber's orders with the MAR
32
Oral Route
► Easiest and most desirable route
Enteral and small-bore feeding
► Verify tube location
► Use liquids when possible
► If medication is to be given on an empty stomach, allow at least 30 min before or after eating
33
Topical medication
Medication are applied locally, uslly to the skin, but also to the mucous membranes.
34
Inhalation route
Medication into the airway; alveolar-capillary network absorbs medication rapidly.
MDIs:
► Use spacer
35
Optic instillation
► Put inside the conjunctival sac
► Avoid cornea
► Avoid eyelids with droppers of tubes to decrease the risk of infection
► Use only on the affected eye
► Never share medications
► Wait 5 min between meds
36
Nasal instillation
Pt use alternating sinus to receive spray, drops, or tampons.
► With dropper, don't let it touch nose bc it is sterile
► Keep sprays to one person, clean applicator afterwards
37
Ear instillation
► Because internal ear structure are temperature sensitive, you will need to instill eardrops at room temperature to prevent vertigo, dizziness, or nausea
► Make sure eardrum is not ruptured
► Don't occlude or block the ear canal
38
Parenteral Route
Administration by injection into the body tissues
► Invasive procedures needing aseptic techniques
► Risk of infection occurs after a needle pierces the skin. The effects develop rapidly, depending on rater of medication absorption
► Closely observe a patients response to parental medication
39
Types of medication orders
► Standing or routine
► PRN
► Single
► STAT
► Now
► Prescription
40
Standing or Routine
Carried out until the prescriber cancels it by another order
41
PRN
Given when the pt needs it
42
Process of mixing insulin
► Inspect
► Roll
► Air in NPH
► Air in Rapid
► Draw up clear
► Draw up cloudy
43
Types of injection
► Intradermal
► SQ
► Intramuscular
► IV
44
IM injections
► Preferred and safest site for all adults, children and infants
► Recommended for 2 mL or higher
► 90°
► Adults 2-5mL | Children and older adults up to 2 mL | Small children and infants: up to 1 mL | Smaller infants: up to 0.5 mL
Landmarks
►Ventrogluteal: Place palm of the you hand over the greater trochanter, perpendicular to the femur. Point the thumb towards the groin and the index finger toward the anterior superior iliac supine; extend the middle finger back along the iliac crest toward the buttock. The index finger, the middle finger, and iliac crest forma V-shape. Inject at the center of the triangle.
► Vastus lateralis: Located on the anterior lateral aspect of the thigh, and extends in an adult from a hand breadth above the knee to a hand breadth below the greater trochanter of the femur.
► Deltoid: Use for small medication (< 2mL); located 3-5 cm below the acronym process.
45
SQ Injection
► Location include the upper arm and the anterior and lateral parts of the thigh, buttocks, and abdomen.
► Rotate sites
► 45°-90°
46
Intradermal
►Used for skin testing (TB, allergies)
► 5°-15°
► Make sure blep forms
47
Medication Safety: 3 Checks
►When pulling the medication out
► Before going in the room
► At ADM
► Asking patient about it before giving it
48
Medication disposal
► Dispose of sharps in marked containers
► Use puncture and leak proof containers
► Never force needles into receptacle (2/3 full is max)
► Never place used needles into wastebaskets, your pockets, or client's tray or bedside.
Disposal of controlled medication:
► 2 Nurse comfirmation
► Make sure medication goes into the appropriate container, and not with sharps (pt or other people can still dig it out)
49
Medication error reporting
When an error occurs, the patient's safety and well-being are the top priorities.
►First assess and examine the pt condition, and notify the care provider asap.
►Once the pt is stable, report incident to the appropriate person in the agency. YOU are responsible for preparing and filling an occurrence or incident report as soon as possible after the error occurs. The error is not report in the medical record.
50
Part of syringe
Tip, barrel, and plunger
51
Parts of the needle
Hub, bevel, shaft, gauge number
52
Parts of Catheter
► Balloon port
► Urine drainage port
► Sampling port
► Balloon
► Bladder opening
► bifurcation (Y)
53
Pt who can get a catheter
► Acute urinary retention
► Acute bladder obstruction
► Improve life care
► Strict prolonged immobilization
► Urologic surgeries
54
Prevent CAUTI
► Sterile technique for insertion
Client teaching:
►Don't raise bag above the bladder
►Keep bag on immovable part of bed
► Use aseptic technique
► Maintain a closed system
► Leave it in for the least time possible
► Hand hygiene
► Empty bag if half full
55
Urinary Specimen Collection
► Clean Catch "mid-stream": Use for C&S. Cleanse the area, start flow of urine then stop, collect the rest of the pee.
► Random specimen: Use for UA and microscopic analysis. No special procedure.
► First morning specimen ( 8 hour collection): Used for Pregnancy test. Urine concentrated in the morning. Contains higher level of cellular element and analysis such as protein and hormones.
► Timed collection specimen (24 hours collection): Obtain a big collection container and a pan of ice. Discard first void b/c you don't know how long it's been there. Place "24 hours" sign. Make sure start time is visible. Pour ALL voided urine in container in ice.
If one void is discarded START OVER.
56
Bolus feeding
Given in all in at once
► By gravity
► Open System
► Over 30 - 1 hr
► Sit Up
57
Continuous feeding
►Closed System (Change every 24-48 hrs)
►Always on a pump
►At least 30 degrees raised
58
Preparation for enteral feeding
Prior
► Check the expiration date and integrity of the container
►Ensure the formula is at room temperature
► Connect tubing of administration set to container or hanging system. Use aseptic technique to avoid contamination of system
► Label bag
► Open roller clamp on tubing and fill tubing (prime tubing) with formula. Close roller clamp and cap end of tubing.
►Label "Tube feeding only"
►Hang bag
► For intermittent or bolus feeding, have syringe ready and room temperature formula.
Place client in high-fowler position or elevate had of bead at least 30 degrees
► Verify tube placement
► Document pH measurement prior to feeding
Initiate feeding
► Advance the rate of concentration of of feeding gradually
► Following intermittent infusion or every 4 hrs with continuous, flush tube with 30 mL water
►When client receiving intermittent tube feeding, cap or clamp the proximal end of the feeding tube
► Rinse bag and tubing with warm water before adding formula, every 8 hours and whenever feeding are interrupted
59
Medication administration through tube feeding
►Flush tube at least 15 mL of sterile water using 60 mL syringe
► Draw up meds in 60 mL syringe
► Push meds or allow gravity
► Administer each med seperately followed by a flush of 15-30 mL
► After all meds are administered, flush with at least 30-60 mL
► Restart feeding when appropriate
►Document MAR
Evaluate responce
60
MRI safety
Don't wear anything made of metal and make sure you don't have any metal implants
61
REM cycles
Rapid Eye Movement
►Vivid dreaming
►Begins apprx 90 min after stage 1
► Variable VS
►Absent skeletal muscle tone
► Increased gastric secretions
► Vivid dreaming
► Difficult to arouse
62
Ways to promote sleep
► Assess for a problem first, treat if necessary
► Do as much outside
► Reschedule long term treatments to awake hours if possible
► Visitation hours/can't stay the night in ICU
► Good sleep environment (Dark/cool/quite)
► Less exposure of technology light before bed
63
Evaluating/Factors of sleep
►Always subjective based on client report
►You can't tell if they are asleep or not
Factors to improve sleep
►Lifestyle change
►Environmental change
►Stress management
►Symptom management
►Education
64
Sleep Apnea
►During sleep, airway is occluded and breathing stops
► Diagnosed with Sleep Study (STOPBANG to see if they should do a sleep study)
► Treated with CPAP (Continuous positive airway pressure)
► Snoring
► Excessive daytime sleeping
65
Insomnia
Treat first with life style modification
Use medication as last resort
66
Narcolepsy
Uncontrolled falling asleep
► Worsens with strong emotion
► Cataplexy (paralyzed and can't catch themselves so increased fall risk)
► Sleep paralysis
67
What type of medication can you give to someone with pneumonia
Expectorant; do not give cough suppressants b/c you need to cough up the phlegm
68
Community Acquired Pneumonia (CAP)
Less than 3 days at healthcare facility
Risk factors:
► Older adults
►Little kids
► Never received pneumonia vaccine
or not within last 6 years
► Did not receive flu vaccine
► Has a chronic condition or other existing comorbidity
► Recent exposure to respiratory infection (viral or influenza)
► Alcohol or tobacco use of exposed to high levels of second hand smoke
69
Healthcare Acquired Pneumonia (HCAP)
Have to be in healthcare facility for more than 3 days
Risk factors:
► Older adult
► Chronic lung disease
► Presence of Gp bacteria colonization of the mouth, throat, or stomach
► Recent aspiration event
►Presence of endotracheal, tracheostomy, or nasogastric tubes
►Poor nutritional status
►Immunocompromised
► Increase gastric pH
►Current on mechanical ventilation
Bacteria are more resistant so treatment is more intense.
70
Prioritizing care of pneumonia
► Adm oxygen therapy
► Obtain sputum culture
► Administer antibiotics
►Administer an antipyretic medication
71
S/S of pneumonia
►Cough, fever, shaking, chills, SOB, headache, diaphoresis, loss of appetite, low energy, and fatigue, confusion, hypoxemia
72
Droplet Precation
Mask, googles, face shield, patient should wear face mask when leaving the rom
Ex: Pneumonia
73
Airborne Precation
N95, googles, negative pressure room
EX: TB, covid, disseminated shingles
74
Teaching for Pneumonia
► Use incentive spirometer; avoid atelectasis
► Teach cough and breathing techniques q 2 hr
► Encourage adequate fluid intake unless contraindicated
► Tell clients to take their full session of antibiotics
► Teach client and family the risk factors of pneumonia and how to prevent it
75
Oxygen safety
► Oxygen adjusted with health care provider's orders
►Oxygen in Use sign
► O2 should be 10 feet away from any open flames.
►No synthetic fibers
►Use cotton bed linens and clothes bc it won't create static)
No smoking close by
► Secure O2 cylinders
► Check all electrical equipment should be grounded
►Make sure there is enough O2 in tank when transferring clients
►Don't use petroleum based Chapstick or Vaseline
76
What is an incentive spirometer trying to prevent
Atelectasis and pneumonia
77
What is atelectasis
Collapsed lung: incomplete expansion of alveoli causing fluid build up in the lungs
►Air can't get where it needs to be
►Prevent with chest physiotherapy
►Incentive spirometer
78
Biots respiration
Shallow respiration interrupted by apnea
►Brain sensory is not able to control the breathing
79
Cheyne-Stokes Respiration
Waxing and waning of respirations from very deep to very shallow and temporary apnea.
►Seeing in cardiac damage and dying patients.
►Gradual increase in breath then gradual decrease
80
Kussmauls Respiration
Deep breath in and max out rapidly
►A form of hyperventilation due to metabolic acidosis
►Seen in diabetic ketoacidoses
81
Late sign of hypoxia
Cyanosis
82
Early signs of hypoxia
Restlessness, irritability, apprehension, tachycardia, anxiety, light headedness, shallow respiration, and dyspnea
83
What increases a pt chance of pressure ulcer?
Immobility, moisture, incontinence, shear and friction injury
84
Stage 1 pressure injury
Skin is red but nonblanchable
85
Stage 2 pressure injury
Redness, skin is visible damage. Damage to the dermis but no subq visible
86
Stage 3 pressure injury
Skin is visibly damaged, full loss of skin tissue. May see subq and epibole. Bone, tendon, and muscle are not visible.
87
Stage 4 pressure injury
Full loss of the skin and bone, muscle, and ligament are visible
88
Unstageable pressure injury
Eschar is covering a full-thickness injury
►Can't assess the actual depth of the wound b/c the slough or eschar is covering it
89
What would you use if you needed to add moisture to a wound?
hydrocolloid
hydrogel
90
What would you use on a highly infected wound?
Ag (Silver)
91
What dressing would you use for a wound with very high output?
Alginate
Foam
92
Dressing to stay balanced
Tegaderm
normal saline
93
Cleaning woud
► Clean from least contaminated to most
►When irrigating, allow the solution to flow from the least to the most contaminated area
94
Diet for wound care
High Protein
►Chicken, tofu, beans, beef, eggs, soy, peanut butter, dairy products (yogurt, cheese)
95
Wound Vac
►Vacuum-Assisted Closure
►A device that assists in wound closure by applying localized negative pressure to draw edges of a wound together
►Can be worn 24 hours to 5 days depending on the wound
►Rule of thumb: if the wound vac is inactive (off) for an hour, the whole dressing needs to be changed.
►Use on nonhealing (hard healing wounds - deep abdominal wounds, feet and ankle wounds); for areas with limited blood supply.
96
Suture removal
►Don't pull pull sutures under the skin
► Wear gloves and hand hygiene
97
Serous Drainage
►Clear and watery fluid
► Normal
98
Serousanguinous
► Pink to pale red and contains a mix of serous fluid and sanguineous (red, bloody fluid)
► Normal
99
Sanguineous drainage
► Red bloody drainage
► Not normal
100
Purulent Drainage
►Thick green, yellow, or brown drainage
►Sign of infection
101
Measuring wound
► Lenght, width, and depth (sides as well)
102
Hyperkalemia S/S
MURDER: Muscle weakness, urinary output, respiratory failure, decreased cardiac contractility, early muscle twitches and cramps, rhythm changes (tall T waves, prolonged PR intervals) - dysrhythmias.
103
Hypokalemia
7 L’s: Lethal cardiac dysrhythmias, lethargic, low respiration, lots of urine, leg cramps, limp muscles, low BP and HR
104
Hypocalcemia
CRAMPS: Convulsion, reflexes hyperactive, arrhythmias (prolonged QT intervals), muscle spasms, positive trousseau’s and chvostek’s, sensation of tingling/numbness (paresthesia)
►Chvostek test: Touch the facial nerve and watch for twitching
► Trousseau: Tight blood pressure cuff and watch for carpal spasm
105
Hypercalcemia
WEAK: Weakness of muscles, EKG changes, absent reflexes, kidney stone formation
106
Hyponatremia
SALT LOSS: Seizures and stupor, abd cramping, lethargic, tendon reflexes diminish, Loss of urine and appetite, orthostatic hypotension and overactive bowel sounds, shallow respiration, spasm of muscles, decrease sense of thirst and inability to express thirst.
107
Hypernatremia
FRIED: Fatigue, Restlessness, Increase reflexes, Extreme thirst, Decreased urine output
108
Hypomagnesemia:
TWITCH: Trousseau and Chvostek, weakness, increased deep tendon reflex, torsade de pointes/tetany, calcium and potassium levels low, hypertension, muscle cramps.
109
Hypermagnesemia
LETHARGIC: lethargic, EKG changes, Tendon reflexes absent/diminished, hypotension, arrhythmias (bradycardia, heart blocks, red and hot face) GI issues, impaired breathing, confusion.
110
Potassium Rich Food
White potatoes
bananas
dark leafy greens
111
Sodium diet
Avoid:
►Processed foods
►Canned foods
► Fast foods
112
Magnesium Rich Foods
Nuts, whole grains, seeds, fatty fishes, dark chocolate
113
Calcium rich food
Milk, dairy, tofu, broccoli, soy milk, rice milk
114
Chvostek sign
spasm of facial muscles after tapping the upper jaw
-a positive test indicated hypocalcemia
115
Trousseaus sign
Use a blood pressure cuff and keep it on for up to 5 min. The fingers squeeze together and the hand goes inwards (muscle ischemia)
-positive test indicates hypocalcemia
116
FVD S/S
►PE s/s are the most accurate indicator of fluid volume changes
►S/S: Acute weight loss, CV change (HR increase and BP decrease (compensation) - orthostatic hypotension, increased respiration, dry mucous membrane, decreased and concentrated urine output, increased Hct (in low fluid looks elevated bc it looks like there is more solutes), sunken eyeballs, flat neck veins, decrease skin turgor, sticky mucous membranes in oral cavity, cool skin
►Weight should be measured at the same time, same clothes, same scale
117
FVO S/S
Edema, distended neck veins, distended peripheral veins, crackling in lungs, SOB, slow emptying peripheral veins, elevated CVP, PAWP, PAP, polyuria (if renal is normal), ascites and/or pleural effusion if severe excess, decreased BUN, high BP, full bounding pulse, tachypnea
118
FVD and FVO care planning/nursing intervention
►Fall prevention (both), monitor for Peripheral edema (FVO), skin care (both), skin turgor (FVD - skin is a poor indicator of fluid status, though), third spacing assessment and intervention (move the fluid), renal impairment
►Early and Old Age, renal function
119
Central line
Terminates in a great vessel
► if it is given in an IV the vein will blow due to the high concentration
120
Why does a TPN need a pump?
Needs to be an accurate rate
►Given too fast: hyperglycemia and fluid overload
► Given too slow: hypoglycemia and we aren't meeting the bodies requirements
121
Why does TPN administration require 2 RN nurses to verify and what are the safety precautions?
Because the TPN is patient specific and it is considered a high risk medication
►It is based on their body chemistry, electrolyte status, nutritional needs, fluid and volume status
►Sterility procedure for all central line related maintenance. Insertion, changes of tubing,, cleaning dressing are all sterile procedures
►If TPN is not here on time, administer D10
Change line every 24 hours
122
Hyperglycemia S/S
Polyuria, polydipsia, polyphagia, HA, lethargy
123
Hypoglycemia S/S
Tired, groggy, confused/LOC, diaphoresis (sweating), shakiness
Sudden discontinuation of TPN can cause hypoglycemia, so it should be tapered off by replacing it with 10% dextrose.
124
Complication with infusion
Infection
►Increase WBC, redness, pain
125
Lipids
We administer lipid to help metabolize vitamins, essentially fatty acids (extra calories)
►Peripheral parenteral nutrition is often used for lipids because they are considered isotonic
►Do not give if it looks separated, speckled, spots, chunks (doesn’t look like milk)
126
IV site selection
►Avoid areas of flexion
►In general, start distally in hand and progress proximally to preserve peripheral access. Low and go up
►Some therapies, such as vesicants, should not be infused through a hand, wrist, or antecubital vein if at all possible.
►Consider individual situations (I.E. arm restraints, one arm restrictions, crutches, wheelchairs)
►Not in an arm statutes post lymph node dissection
►Not in an arm with an arterio-venous fistula (AVF)
127
Phlebitis vs Infiltration vs Extravasation
►Phlebitis: warm, red, painful, streaking swelling
►Infiltration: Cold, pale, no pain, puffy, painless. Sing of infection
►Extravasation: Leaking of vesicant drugs such as various antineoplastic drugs into surrounding tissue which can produce severe tissue damage or necrosis
128
Phlebitis Scale
0
No Symptome
1
Erythema at the access site, with or without pain
2
Pain at the access site, with erythema
3
Pain at the access site, with erythema
Streak formation
A palpable venous cord
4
Pain at the access site, with erythema
Streak formation
A palpable venous cord > 2.54 cm in length
Purulent drainage
129
Isotonic Fluids
►Dextrose 5% in water (D5W) - start as isotonic
►0.9 Sodium chloride (NaCl) - NS (can be used with blood transfusion)
►Lactated Ringer’s (LR) (caution with renal failure and liver failure pt).
Content: Lactate, potassium, salt, and water
Bad liver: can’t process lactate
Bad renal: can’t process extra potassium
130
Hypotonic Fluids
Cell grow
0.45 Sodium Chloride (½ NS)
131
Hypertonic
Cell shrink
►3% NaCl
►Dextrose 5% in ½ normal saline
►Dextrose 5% in normal saline
►Dextrose 10% in water
132
What is speed shock and what are the s/s?
► Occurs with bolus injections of IV fluids with medications or when “pushing” meds rapidly
►s/s: Facial flushing, irregular pulse, severe headache, hypotension, progress to loss of consciousness, and cardiac arrest
► Prevention: Slow down rate, give at recommended rate
►Intervention: Clamp IV; notify MD; O2; monitor VS frequently
133
Lines duration
►Peripheral IV: Less than 1 week
►Midline: 1-4 weeks
►Central line: more than 4 weeks
134
Delegation
► AP
Basic care
Ambulating
Turning
Bath
I&O
Mouth care
Toileting
Linen changes
Feeding (but not to aspirate pt)
VS (stable)
Weights
►LPN
ALL AP duties
Gather assessment (listen lung, bowel, heart sound)
Glucose check
Foley care
Wound care
Ostomy care
Can give medication
No IV or blood meds
►RN
Admission assessment
TAPE (do not delegate)
Teaching, assessing, planning, evaluating
135
How often does TPN and its lines get change out?
►24 hours
►The dressing on central lines get changed once a week
136
Scales, intensity, quality
►Pain Scales
Numeric
Faces (wong baker)
FLACC (used for nonverbal patients)
►Intensity
Severe, mild, etc
Also numeric value
►Quality
Sharp, dull
137
Myths about pain
►Clients who abuse substances overreact to discomforts
►Administering analgesics regularly leads to drug addiction
►The amount of tissue damage in an injury accurately indicates pain intensity
►Health care personnel are the best authorities on the nature of a client’s pain
►Chronic pain is all psychological
►Clients who cannot speak do not feel pain
138
Tolerance, addiction, dependence
►Tolerance
When a person’s physical response to a substance, such as a drug or alcohol, lessens over time. Therefore, it takes a higher dose of the substance to reach the same effect as when they were first used.
►Addiction
Addiction is a disease, whereas dependence and tolerance are not. Addiction, or substance use disorder, is when a person continues using drugs or alcohol and cannot stop using them despite the negative impacts it causes in all aspects of their life: at school, at work, or at home
►Dependence
When a person stops using a drug their body experiences physical withdrawal and psychological changes
139
ABCDE of pain management
A = Ask about pain regularly; assess systematically
B = Believe the client & family about reports of pain & what relieves it
C = Choose pain control options appropriate for the client, family & setting
D = Deliver interventions in a timely, logical & coordinated fashion
E = Empower clients & families; enable them to control their course to the greatest extent possible
140
Reversal Agents
►Naloxone (Narcan)
Opioids (dilaudid, morphine, fentanyl)
IV Dantrolene
►Malignant Hyperthermia
S/S: Tachycardia, tachypnea, hypercarbia, dysrhythmia
►Flumazenil
Benzos
141
Types (levels) of anesthesia
►General
Loss of all sensations and consciousness
Breathing for them
►Regional
Loss of sensation in an area of the body
Dental surgeries, sutures
►Local
Loss of sensation at a site
Epidural
►Conscious sedation/moderate sedation
Used for procedures that do not require complete anesthesia
Independently maintains a patent airway
142
Role of circulating RN
A circulating nurse ensures the safety of the client.
143
Complications: (Paralytic ileus, DVT, post-op PNA)
►Paralytic ileus
Since anesthesia puts everything to sleep we might be worried about paralytic ileus
Interventions: listen to bowel sounds x4 - 5 min in each quadrants
Make them start walking around
►DVT
Pt might get unilateral swelling red or painful to touch
Apply SCDs (stockings or elastic stockings), reposition q2h and ambulate regularly, anticoagulants, monitor.
►Post-op PNA
Accumulation of mucous secretion in bronchi
Incentive spirometer, early ambulation
144
Why get informed consent
To protect patient through a legally binding document and they can decline or revoke at anytime
145
Who is supposed to get the consent form signed?
►the surgeon
as nurses we just make sure that signed document is in the charts
146
Who can't sign an informed consent?
►minor
►under the influence of drug or alcohol
►cognitively impaired
►language barrier (get a medical interpreter)
147
Can a person that can't read or write provide consent?
Yes, give it verbally, have a witness, have them pt. sign or speak consent and then have another RN sign next to it saying it is the pt. signature
148
Classifications of surgery - Seriousness
►Major: extensive reconstruction; can pose risk to well being
Coronary artery bypass, lung resection, colon resection
►Minor: Minimal alteration in body parts; minimal risk to well being
Tooth extraction and facial plastic surgery
149
What should you do if a patient revokes consent after signing?
Ask why
Have surgeon explain
Notify provider
Document refusal
150
Classifications of surgery - Urgency
►Elective: pt choice
►Urgent: necessary for pt health, not emergent. Such as tumor removal, gallbladder removal
►Emergency: Immediate to save life or preserve body part. Such as ruptured appendix, internal hemorrhage, traumatic amputation
151
Classifications of surgery - Purposes
►Diagnostic:
trying to figure out what’s going on
Biopsy and -scopy
►Ablative (ectomy):
excision of diseased body part
Amputation, appendix, or gallbladder removal
►Palliative
Debridement, resection of nerve roots
►Reconstructive/restorative:
Restores function to traumatized or malfunctioning tissues
►Scar revision
►Organ procurement/transplant
Kidney, heart, or liver transplant
►Constructive
restore lost function
Repair of cleft palate
►Cosmetic: improves personal appearance
Rhinoplasty
152
Using adrete tool
For testing purposes, since PACU discharge criteria requires a minimum of 8
153
Malignant Hyperthermia
Malignant hyperthermia: a life-threatening risk with inhalation of anesthesia
►S/S:
Tachycardia, tachypnea, hypercarbia, dysrhythmias
►Risk factors
Previous experience with surgery
Hx of heatstroke in pt or family
Known muscular abnormalities
CPK level may be elevated
Key assessment: family hx of unexplained death under general anesthesia
►DX preoperatively with a muscle biopsy
►Prophylactic dantrolene for MH susceptible patients
►Antidote:
100% oxygen, dantrolene, and cooling blanket
Intervention: Stop surgery
154
Stages: hypotensive, normal range, hypertension, hypertensive crisis
►Normal range: <120/<80
►Stage 1 HTN: 130-139/80-89
►Stage 2 HTN: ≥140/≥90
►Hypotensive: SBP <90
►Hypertensive crisis: Super high blood pressure
155
HTN Medication Education
►Same time, don’t skip dose, avoid sodium, diet dependent on diuretics
►Potassium-sparing diuretics: Triamterene, spironolactone, amiloride, and eplerenone
►Potassium rich food: bananas, white potatoes, spinach, salt substitutes
156
HTN modifiable and non-modifiable factors
►Non-modifiable
Age, gender, family history, and genetics
►Modifiable
Weight, lifestyle changes (exercise and smoking), and dietary changes
157
158
Before sending patient to OR what things do we need to remove
-MAKE UP
-NAIL POLISH
-jewelry
-hearing aids
-dentures
-glasses
-contacts
-piercings
-make sure surgical marking is in the right spot
159
IV potassium Teaching
Don push it
Dilute it and run it slowly
Cannot run with other lines
Central line
Needs Pump
160
Ostomy General Care
Dressing change
-Be gentle so no to irritate
-Use warm water
-Dry thoroughly
-Do not use alcohol anything
-If infection or bleeding, call the wound care nurse
