Reduction of Risk Potential Flashcards
chest physiotherapy contraindications
hemodynamic isntability increased intracranial pressure rib fracture vertebral fractures iinstability and recent hemoptysis - couhging up blood from your lungs
chest physiotherapy nursing considerations
auscultate breath sounds prior to performing the procedure to determine baseline resp status
perform pain assessment
place client in proper position
administer prescribed bronchodilator before chest physiotherapy
abdominal breathing
positioned on their back with their knees bent and hands placed on abdomen to create resistance
breathe from abdomen while keeping chest still
incentive spirometry
sit up if possible
exhale fully
place mouthpiece in mouth
take long, slow deep breath, raising the ball as high as possible
hold breath for 2-4 seconds before slowly exhaling
evaluate clients technique and record volume of air inspired
perofmr 5-10 breaths.sessions
- one session every hour while awake
nasal cannula
23 - 42%
1-6 L/min
face mask
40 - 60%
6- 8 L/min
partial rebreather mask
50- 75%
8 - 11L/min
nonrebreather mask
80 - 100%
12 L/min
this with flowmeter set at 15 liters will provide the highest FiO2 available
venturi mask
most accurate
24-40%
4-8L/min
tracheostomy collar
30-100%
8-10 L/min
oxygen hood
30 - 100%
8-10 L/min
oxygen teaching
oxygen is combustible
should start at low rate of 2-3 liters/min
to avoid oxygen toxicity:
evaluate what evel of inspired oxygen is sufficient to maintain an acceptable oxygen saturation
mechanical ventilator
if an alarm sounds while caring for a client on ventilator:
1. assess the client FIRST
if alarm continues to sounds and client develops distress:
- disconnect client from ventilator
- use manual resuscitation (ambu bag) to ventilate client
- call for help immediately
tracheostomy care complications
acute: bleeding infection aspiration air leak subcutaneous emphysema tube displacement
chronic:
altered body image
trachel necrosis
tracheal stenosis
fungal infections can develop under moist tracheostomy dressings
tracheostomy care
obturator should be available at ALL times
in acute care settings:
- care should be shared between the nurse and respiratory therapist
in the home setting:
- managed by client and family members or home health or visiting nurse
nursing considerations:
monitor stoma fro infection and excoration
perofrm trach care
make sure trach is secure but not too tight
place new, reaplcement trach kit at clients bedside
perform regular oral hygience
monitor resp status and SaO2
evaluate response to oxygen therapy
ensure nutritional needs are met
tracheostomy suctioning
when performing suctioning:
do NOT apply suction for longer than 10 seconds
hyperoxygenate prior to an immediate after suctioning
- BEFORE AND AFTER
what if chest tube water seal breaks
submerge in sterile water, or sterile saline
what if chest tube comes out
cover hole with gauzed hand
petroleum jelly or vaseline gauze dressing
3 sided sterile dressing
tape
what is chest tube bubbling
where:
water seal or suction control chamber
water seal:
intermittent: Good
continuous: BAD
- means that there is an air leak
suction control chamber:
intermittend: BAD
- means that the suction is not high enough
continuous: GOOD
notify the HCP if:
- bubbling in the water seal chamber conitnuous or worsens
- drainage from chest tube is greater than 100 ml/hr
- if drainage becomes bright red or the amount suddenly increases
*DONT MILK CHEST TUBE
Risk factors for DVT/VTE
reduced bloodflow increased venous pressure mechanical injury to vein -peripherally inserted venous catheter - IV drug use
increased blood vsicosity
acquired
nonpharmacologic interventions for VTE
early ambulation
prevention dehydration
smoking cessation
TED hose, compression stocking
intermittent or sequential compression devices
- only effective if applied correctly and when client wears them continuously
- should only be removed for bathing, skin inspection and ambulation
SCDs are contraindicated for clients with an existing DVT, but should be applied to the unaffected extremity
NG tube considerations
fasten the tube securely to the client, using an appropriate securement device
set the wall suction unti to the prescribed suction intensity
- 40 -60
- shoudl NOT go over 80
monitor the character and amount of aspirated GI contents
monitor the skin integrity around the tube and use protective padding under device
abdominal drains
Penrose drains
jackson pratt drain
t-tube
penrose drain
simplet latex drain that is freely laid inside the wound/surgical site
without sutures to hold it in place
drainage flow onto a auze dressing
open system
jackson pratt drainage and ahemovac
attached to a bulb-like (JP) or spring like (hemovac) container that applies suction when it is compressed
t-tube
placed in the comon bile duct of the gallbladder to allow for the passage of bile
abdominal drains nursing responsibilities
regular assessment/data collection
document color, consistency, and odor of the drainage
- with changes noted and reported to surgeon
monitoring the skin around the drain for damage and signs of infecting
types of enemas
oil retention
soapsuds
tap water
used to administer Kayexalate for treatment of hyperkalmiea
enema nursing considerations
should not administer if client had recent colon or rectal surgery, acute myocardial infarction or appendicitisw
should be used with caution for elderly clients because they are more at risk for hyperphosphatemia, perforation and sepsis
procedural sedation
also known as moderate or conscious sedation
common drugs for procedural sedation: - benzodiazepines (midazolam, diazepam) - fentanyl - propofol these are administered IV push
an RN may administer procedural sedation under a physicians supervision
nursing care procedural sedation
airway management
able to see life threatening dysrhythmias
ensure emergency resuscitation equipment
continuous ECg, capnography and pulse oximetry
drug reversal agents
-naloxone, fulmazenil
gauze
advantages: wicks away wound exudate does not interact with wounds comes in mayn sizes and lengths supplied as a roll
disadvantages: non adhesive non-occlusive fibers may shed or adhere to the wound absorbs topically applied medications like ointment or cream
dressings
premedicate the client with ana analgesic before a complex dressing change
if a drain is present, carefully remove wound dressing one layer at a time to avoid disloding the drain
FIRST post-operative dressing change is usually performed by the surgeon, not the nurse
casts management
monitor neuro status
elevate affected extremity on several pillows
apply ice for 24 hours
never relieve itching by inserting something into the cast immediately notify HCP if experiencing: - foul odor - drainage from a cast - changes in integrtiy of the cast
reassess for numbness, pain, impaired circulation
a cast may smell “sour” but not “foul”
traction management
bucks tractions, skeletal traction, cervical skeletal traction like a halo brace
- screws are surgically inserted directly into the bone
- allows for longer traction time and heavier weights
inspect traction equipment at least every 8-12 hours
weights should NOT be allowed to rest on the floor
implement pressure reduing measures
perform pin site care
notify HCP if severe pain from muscle spams
diligently monitor and treat clients pain
hemorrhage postop care
monitor amount and character drainage
monitor signs of hypovolemia and hypovolemic shock
atelectasis and penumonia post op care
monitor signs of: low O2 dyspnea adventitious breath sounds productive cough fever leukocytosis, tachyardia
venous thrombembolism post op care
monitor signs of:
calf pain
swelling
suddent onset of shortness of breath as indicative of pulmonary embolism
paralytic ileus post op
monitor for bowel sounds, abdominal distention and the passage of flatus or stool
cardiac enzymes
CK-MB Troponin C-reactive protein Liquid Profile.Panel BNP
CK-MB
detected in the blood within 3-5 hours post MI
Troponin
elevated 4-8 hours after heart attack
used to diagnose a heart attack and to assess the damage to the heart
c-reactive protein
protein produced by the liver
levels rise with inflammaiton throughout the body
may help determine the risk of future cardiac events who had a heart attack
can get with simple blood draw
liquid profile panel
should taking nothing but water by mouth 8-12 hours prior to blood draw
BNP
helps diagnose and evaluate clients for heart failure
use for prognosis and to monitor therapy of clients with HF
normal range: <100
angiogram cardiac catheterization
use to evaluate specific areas of the arterial system by injecting a dye through a catheter at the femoral or radial artery
dye makes coronary arteries visible on fluoroscopy
preoperatively:
evaluate history of allergy to iodine or radiopague dye
- if allergic, then premedicate for antihistamine
clients with impared renal functions are at an increased risk for futher renal damaged
- will receive large amounts of IV fluids to flush out the contast dye during procedure
acetylcysteine may be prescribed as a renal protectant
postoperatively:
clients who have catheter inserted in their groin will have a compression bandage on the insertion site
- must lie flat on their back for several hours post procedure
monitor catheter insertion site for bleeding or hematoma developmoent
distal pulses and vital signs are monitored for 7 hours:
- 4 times in 15 minute intervals
- 4 times in 30 minute intervals
- 4 times in hourly intervals
echocardiography
can be done at bedisde and performed by technician
used to evaluate structural defects and abnormalities of the heart valves, chambers and muscles
risk free and does not require specialized intervention before or after procedure
may be performed trans-esophgally TEE
nursing consideration for TEE
maintain NPO status during prescribed hours before TEE
monitor return of gag reflex post procedure
monitor for resp depression due to procedural sedation
offer throat lozenges for residual throat discomfort
cardiac stress test
clients walk on treadmill or ride stationary bicycle while connected to ECG monitoring
will exericse until predetermined heart rate is reached, 20 min have elapsed or if the clients starts to experience chest pain, fatigue, dyspnea, vertigo, or hypotension
cardiac stress test management
ensure that client adhere to pre-procedure diet restrictions:
- avoiding caffeine or caffeinated beverages
making sure client remains NPO or only eats a light meal
wear comfortable clothing and footwear
creatinine clearance
client eliminates in a 24 hour period
collection should be kept on ice during collection
glomerular filtration rate
amount of urine produced by the kidney/min
normal: 90-120
describes the stages of chronic kidney disease:
stage 1: GFR greater than 90 mL/min
stage 2: GFR 60- 89 ml/min
- mild CKD
stage 3: 30-59 ml/min
- moderate CKD
stage 4: 15 - 29 ml/min
- severe CKD
stage 5: less than 15 ml/min
- end stage kidney disease
cytoscopy
endoscopic procedure for direct visualization of the bladder and urethra
performed to dilate the urethra, place ureteral stents, resent and enlarged prostate gland
pre-procedure:
informed consent
completel bowel prep to empty the GI tract of any stool
ensure that client is NPO for prescribed time frame
post-procedure:
monitor character and volume of urine
check for abdominal distention, urinary frequency
urine is typically pink in color after the exam
if client expierneces worsening abdominal or pelvin pain post exam
- that can indicate urinary tract or bladder perforation
intravenous pyelogram
provides x ray of kidneys, ureters and bladder
bowel preparation is required
night before test, client may be NPO after midnight
before procedure:
determine iodine sensitivity
during injection, it is normal for clients to experience burning in the vein or a salty taste in their mouth
x-rays are taken at intervals after dye is injected
specimen collection
should go straight to the lab
do not allow specimen to sit at room temperature
paracentesis
needle aspiration of fluid from abdominal cavity used for examination and treatment of ascites
can be done at bedisde
in semi-fowlers position
instruct client to empty bladder BEFORE procedure to decrease the risk of accidnetal puncture
post procedure:
monitor worsening abdominal pain
abdominal rigidity and rebound tenderness
- these can be indicative of peritonitis
liver scan
evaluate size and shape of liver
radiopague dye is used during the exam
ask about previous allergies and previous iodine sensistivity
- must be monitored for anaphylaxis
those who are sensitive should use a aqueous of water based dye
will administer cleaning enema after the exam to remove barium and prevent impaction
x-rays may be repeated after all the barium has left the body
amylase
help and diagnose acute chronic pancreatitis
client will restrict food for 1-2 hours before the test and avoid opiates for 2 hours before the test
normal value: 23-85
ammonia
used to investigate changes in behavior and latered level of oconsciousness due to severe liver disease
use to support reye syndrome
refrain from smoking for several days prior to collection of sample
sputum analysis
used to determine if abnomral lung cells are present
identify cause of pulmonary infection
should be encouraged to take fluids the night before the test
if possible, collection should take place in morning
prior to test, client should rinse their mouth with water
- dont brush teeth, eat or use mouthwash before the test
acid fast bacillus smear and culture
used to dientify causative agent for TB
3 sputum samples are collected early in the morning on 3 different days
prior to test:
client can rinse their mouth with plain water, NOT mouthwash
difference between spit and sputum should be emphasized
sputum: mucus that you cough up from deep inside your lungs
spit: saliva
mantoux test
readings are taken 48-72 hours after injection
-positive result is injection isred and swollen
false positive may result if people have receive BCG vaccine
bronchoscopy
used to investigate source of bleeding in lungs, biopsy, remove secretion and foreign bodies
NPO at least 4 hours before the procedure and in most cases client will receive procedural sedation
may experience sore throat post test
remind client to sit or lie on their side
remain NPO until their gag reflex returns
pulmonary function test
measures the lungs capacity to hold air, move air in and out
exchange oxygen and carbon dioxide
refrain from smoking for 4 hours prior to test
may also be asked to withhold bronchodilator until after test
thoracentesis
fluid from pleural space is removed for diagnostic testing
will be asked to sit at the side of the bed and lean forward
local anestheticis used prior to needle insertion
may feel some pain as their lungs fill with air and expand against the chest wall
- may need to cough, feel light-headed and or short of breath during or after procedure
no more than 1,000mL should be removed at one time
monitor breath sound and vitals frequently
monitor for leakage of fluid at puncture site
- sterile dressing will be applied after the test and a chest X-ray may be ordered
CT scan of the brain
if contrast dye is used with scan, informed consent must be obtained
-painless but client ust remain immbolie during exam
this can cause anxiety and may be challenging for clients with dementia, delirium, claustrophobia
if contrast dye is used
- may experience flushed, warm face and/or metallic taste during injection
assess for allergic response to dye like rash, itching, angioedema, uritcaria
after CT scan, encourage client to intake fluids to pee out the contrast
MRI
must remove all metal
PET scan
provides 2-3D dimensional pictures of the brain
used to diagnose stroke, brain tumor, epilepsy, parkinsons and head injuries
clients inhales or is injected with radioactive substance and then is scanned
must lie still while gamma rays are detecting the body tissues
- may experience dizziness and headaches, during and after the test
lumbar puncture
appearance of CSF is normally colorless, clear and almost entirely free of colles
normal pressure: 50-180
lumbar puncture nursing considerations
informed consent
position client on one side in a fetal position with knee close tot heir chest or leaning forward while sitting
local anesthetic will be injected
- will feel a stinging sensation and pressure as theh spinal needle is inserted
instruct clients to lie flat for severl hour afterward
drink additional fluids
administer analgesics as needed
apply sterile dressing to the site
perform neuro-sensory assessment every 15-30 min until pt is stable
EEG
painless test that measures electricaly activity in the brain
can have bright or flashing light or noises
usually reclines in a chair or ona bed during the test and may take up to an hour
- if taken dring sleep, it can take around 3 hours
after test, nurse will remove electrode paste from scalp and hair
bone scan
involves the use of a radionucleide administered through IV and creates an image
radioactive material poses no threat because is readily deteriorates in the body
taken to nuclear medicine department 4-6 hours after injection
- procedure take around 30-60 in
- patient must lie still for accurate test results
no special care is required
radioisotope is excreted in stool and urine, but no preautions are required in handling the excreta
- remin client to increase fluid intake
DEXA scan
used to screen and diagnose osetoporosis
low dose X-rays are used to examine bone density at lower spine, hip and wrist
normal: <1 SD below normal
osetopenia: 1.0 - 2.5 SD below normal
osteoporosis: >2.5 SD below normal
oral glucose tolerance test
diagnosis of diabetes mellitus
client must fast for 12 hours prior to the test
during test, blood samples are drawn at set intervals after client drinks liquid containined concentrated glucose
test can take up to 3 hours
glucose levels are taken 2 hours after drinking the glucose
levels that are greater than 200 means positive
prostate specific antigen test
blood draw
should be done prior to digital rectal exam or biopsy
six weeks after manipulation of the prostate
human chorionic gonadotropin
used to confirm or monitor pregnancy
no special preparation is needed
negative: <5
positive: >25
colposcopy
recommended that client does not have vaginal intercourse, use tampons or take vaginal medications a day or 2 before the colposcopy
can use OTC analgesics prior to and after the procedure
cervical biopsy
no anesthesia is needed
may feel a cramping sensation during or after the test
should wait 3 days to have intercourse, douche or go swimming
breast biopsy
instruct to use OTC analgesics for post-procedural pain
- acetaminophen
- ibuprofen
