Set 8 Flashcards
The nurse should culture a wound _________ starting antibiotic treatment
Before
What part of the wound should be swabbed?
VIABLE tissue (NOT slough or Eschar)
PPE for wound irrigation
Gown, gloves, and eye protection
For wound irrigation, the nurse should use a ___ mL piston syringe and a ___ gauge catheter or needle
35; 19
Sterile dressing change wound care key points
- Use clean gloves (off the wall) to remove old dressing, THEN set up sterile field and apply sterile gloves
- With moistened gauze, clean from the wound and then away to prevent introduction of new bacteria (the wound itself is considered sterile)
Guideline for removing staples
Remove every other staple (allows nurse to see if wound is dehiscing)
Removing sutures guidelines
- use STERILE suture removal kit
- grasp the knot of suture with forceps and gently lift
- make cut on suture below knot, close to the skin, and pull
A Penrose drain is an example of
An open drain
Wound drain that drains freely and deposits fluid onto the surface of the skin or a dressing
Open drain
Examples of closed drains for wounds
JP drain, hemovac, anything set to suction
Closed drains function through
Negative pressure (via suction or negative pressure created through the closed system)
Diabetic foot care
- wear professionally fit shoes
- inspect feet DAILY in a mirror
- apply moisturizer to feet, but NOT between the toes
- wear cotton, NOT synthetic socks
- cut toenails straight across, do NOT round the edges
- do NOT use heating pads on feet
- do NOT soak feet; check temp of shower water with wrist or elbow
What are three different types of solution osmolarity?
Hypertonic, isotonic, hypotonic
Solution with a higher tonicity of the fluid than the body
Hypertonic
__________ solutions cause fluid to move out of cells, shriveling them
Hypertonic
__________ fluids have the same tonicity as the body’s fluid
Isotonic
Examples of isotonic fluids
NS, LR
__________ solutions are lower in tonicity than the fluid in the body
Hypotonic
_________ solutions cause fluid to move inside the cells leading to swelling and possible bursting/lysis
Hypotonic
Examples of hypertonic fluids
D10W, 3% sodium chloride, 5% sodium chloride
Examples of hypotonic fluids
1/2NS, 0.45%NS, 0.225%NS
Any fluid put into the body including drinks, IV fluids, IV flushed, liquid medications, gastric lavage, bladder irrigation, etc.
Intake
Any fluid that comes out of the body including urine, emesis, blood, wound drainage, chest tube drainage, etc.
Output
__________ losses can be measured (ex: urine, blood)
Sensible
__________ losses are things that cannot really be measured like water lost through respiration and the sweat that comes out of skin
Insensible
When calculating I&Os, ice chips are recorded as
Half their volume (ex: 100 mL of ice = 50 mL of water)
S/S of fluid volume deficit
- Hypotension
- Tachycardia
- Weak, thready pulse
Labs associated with fluid volume deficit
Elevated: Hct, blood osmolality, BUN, urine specific gravity, urine osmolality
Treatment for fluid volume deficit
IV fluids, usually isotonic
S/S of fluid volume overload
- weight gain
- edema
- tachycardia
- hypertension
- dyspnea, crackles in lungs
- JVD
- bounding pulses
Labs associated with fluid volume overload
Decreased: Hct, Hgb, serum osmolality, urine specific gravity (dilute everything)
Treatment for fluid volume overload
Diuretics, paracentesis
Weight gain to report to provider
1-2 lbs in 24 hr
OR
3 lb in a week
Calcium normal range
9-10.5 mEq/L
What are some of the causes for Hypercalcemia?
Prolonged immobility, hyperparathyroidism
What are some of the causes for hypocalcemia?
Hypoparathyroidism, decreased vitamin D intake, diarrhea
Positive Chvostek and Trousseau’s signs indicate
Hypocalcemia
Magnesium normal range
1.5-2.5 mEq/L
Deep tendon reflexes are __________ with hypermagnesemia and __________ with hypomagnesemia
Decreased; increased
A patient with hypomagnesemia is at risk for
Seizures
Potassium normal range
3.5-5 mEq/L
What does the nurse need to assess in a patient with a potassium imbalance?
Cardiovascular function
Sodium normal range
135-145 mEq/L
What should the nurse assess in patients with sodium imbalances?
Neurological status
Patients with hyponatremia are at risk for
Seizures
Normal pH
7.35-7.45
pH less than 7.35
Acidosis
PH above 7.45
Alkalosis
Normal PCO2
35-45
The higher the CO2, the more _________. The lower the CO2, the more _________.
Acidic; basic (opposite of pH and bicarbonate)
Normal HCO3
21-28
Acid base imbalance characterized by pH greater than 7.45 and PaCO2 less than 35
Respiratory alkalosis
Major cause of respiratory alkalosis
Hyperventilation (r/t anxiety, pain, neurological disorder or injury)
Acid base imbalance characterized by pH less than 7.35 and PaCO2 greater than 45
Respiratory acidosis
Causes of respiratory acidosis
Air trapping disease (COPD), oversedation (anesthesia, opioids, Benzos, mechanical ventilation)
Treatment for respiratory alkalosis
Calm the patient down, have patient breathe into cupped hands or paper bag to rebreathe CO2 to increase amount in blood
Treatment for respiratory acidosis
Encourage patient to breathe more frequently, adjust ventilator settings, sternal rub to arouse patient if over sedated, administering antidote for overdose (flumazenil, naloxone)
Acid base imbalance characterized by pH greater than 7.45 and HCO3 greater than 28
Metabolic alkalosis
Causes of metabolic alkalosis
Antacid overdose, vomiting, excessive GI suctioning (such as by NGT)
Acid base imbalance characterized by pH less than 7.35 and HCO3 less than 21
Metabolic acidosis
Metabolic acidosis is common in patients with
DKA, kidney failure, excessive diarrhea
Treatment for metabolic acidosis
Depends on cause: Antiemetics (if d/t vomiting), stop antacids, insulin for DKA
