Study Guide for Advanced Nursing Flashcards
1
Q
What is the Normal Pulse Oximetry range?
A
95 - 100%
2
Q
What are proper bronchotomy procedures?
A
- Pre-Procedure
- informed consent needed.
- Explain procedure to client.
- Must be NPO 6 to 8 hours before the procedure.
- Local or generalized anesthesia used.
- Receives atropine to dry secretions.
- Receives sedative or narcotic to depress vagus nerve.
- Post Procedure
- Assess for gag reflex.
- Keep NPO until the client has a gag reflex.
- Assess for dyspnea or bleeding.
- Keep an endotracheal tube at the bedside.
- Position client on his or her side.
- Give pain medication if necessary for soreness.
- After gag reflex returns, offer liquids and then advance to soft foods.
- Patient should rest for at least 24 hours
3
Q
What are proper Colostomy procedures?
A
- Be gentle, yet professional, about everything you do for the client.
- Carefully observe the condition of the new stoma.
- Cleanliness is important. Change everything that becomes soiled.
- Prevent infection.
- When changing an ileostomy appliance, check for undissolved tablets or capsules.
- Give special skin care around the stoma.
- After the gastrostomy or stoma has healed, clean it with soap and water.
- Do not use soap if it irritates the client’s skin.
- Do not use alcohol.
- If redness or a yeast-appearing growth appears, consult with the healthcare provider.
- An order to treat the area with an antifungal, such as nystatin (Mycostatin), powder may be given.
- A wafer of Stomahesive to peritube (around the tube) skin will protect it from drainage.
- Stomahesive paste may also be used.
- A drain tube attachment device (DTAD) can help to secure the tube.
- Encourage and teach the client to be independent as soon as possible:
- Teach how to remove and apply a new appliance, how to perform skin care around the stoma, and how and what to report about bowel changes.
- Allow the client to express feelings.
- Encourage questions and correct any misconceptions the client might have.
4
Q
What are proper G.I Series procedures?
A
- Pre-procedure
- Informed consent
- NPO after midnight before test
- Assess for allergies
- Problems with prior procedures
- Post Procedure
- NPO until gag reflex returns
- Avoid driving home after procedure
5
Q
What are proper Trach Care procedures?
A
- Identify the patient
- Determine the need for tracheostomy care. Premedicate patient as needed. Explain procedure. Gather necessary supplies.
- Explain procedure, perform hand hygiene
- Adjust bed to a comfortable working height. Lower side rail closest to you.
- Position patient. Conscious: Fowler’s. Unconscious: On his/her side facing you.
- Place towel or waterproof pad across patient’s chest.
- Turn suction to appropriate pressure:
Adult: 100-160 mm Hg
Child: 100-120 mm Hg
Infant: 80-100 mm Hg
Neonate: 60-80 mm Hg
Check pressure by occluding the end of the connecting tube with a gloved
hand. - Have resuscitation bag attached to oxygen within reach.
- Put on face shield or mask. Don gloves, suction tracheostomy if necessary.
- Remove soiled dressing and gloves.
- Open tracheostomy care kit and separate basins, touching only the edges.
If kit is not available, open three sterile basins. - Fill one basin 0.5” deep with hydrogen peroxide or half hydrogen
peroxide and half saline, based on facility protocol. - Fill the other 2 basins with 0.5” deep with saline
- Open sterile brush or pipe cleaners if they are not already available in the
cleaning kit. Open additional sterile gauze pad. - Put on disposable gloves.
- Stabilize the outer cannula and faceplate of the tracheostomy with one
hand. Rotate the lock on the inner cannula in a counterclockwise motion with
your other hand to release it. - Continue to hold the faceplate. Gently remove the inner and drop in the
hydrogen peroxide solution. Replace oxygen source if needed. - Remove gloves and discard.
- Don sterile gloves.
- Remove inner cannula from soaking solution. Moisten brush or pipe
cleaners in saline and insert into tube, using back and forth motion. - Agitate cannula in saline solution. Remove and tap against inner surface
of basin and place on sterile gauze pad. - Suction outer cannula if necessary.
- Stabilize the outer cannula and faceplate with the non dominant hand. 24. Replace inner cannula into outer cannula. Turn lock clockwise and check
that inner cannula is secure. Reapply oxygen source if necessary.
6
Q
What is the purpose of the equipment:
- Incentive spirometer
- Ventri mask
- Hyperbaric chamber
- Water seal drainage system
A
- Incentive spirometer
- The incentive spirometer , which forces the client to concentrate on inspirations while providing immediate feedback, aids deep breathing.
- Incentive spirometers are flow activated (flow generated) or volume activated (volume generated).
- The flow-activated incentive spirometer usually consists of one or more balls in a vertical tube.
- Because deep breaths (volume) are the objective, the length of time the client suspends the ball at the top of the tube determines the depth of the breath.
- Volume-activated devices come in many shapes, but because they measure volume directly, they make it easier for the client to understand when they have accomplished a deep breath.
- Ventri mask
- Of all the facial devices, the high-flow Venturi mask provides the most reliable and consistent oxygen enrichment.
- Because the Venturi mask has the ability to provide consistent, low levels of supplemental oxygen, it is often used for a client with chronic obstructive pulmonary disease ( COPD ).
- Venturi masks offer specific oxygen concentrations ranging from 24%–50% that match specific adapters for flow rates of 4, 6, or 8 LPM.
- By drawing room air in through its windows, the Venturi mask mixes a low flow of gas (oxygen) with a high flow of room air.
- The resulting effect is a high flow of gas to the client with a specific oxygen concentration.
- Hyperbaric chamber
- Some large facilities have a hyperbaric chamber, which simulates deep-sea diving by increasing atmospheric pressure.
- This method is called hyperbaric oxygenation ( HBO ) or high-pressure oxygenation.
- In the chamber, the person can take oxygen into the body in concentrations higher than is possible at normal atmospheric pressure.
- With the increased pressure, the client’s hemoglobin and other blood components can carry more oxygen.
- HBO is used to treat
- air or gas embolism
- carbon monoxide poisoning
- anaerobic infections (e.g., gas gangrene)
- administer some types of radiation therapy for cancer
- perform some surgeries (especially, heart surgery).
- It is also used to treat crush injuries or traumatic ischemias and enhance wound healing in necrotizing soft-tissue infections, compromised skin grafts and flaps, thermal burns, and chronic osteomyelitis.
- Water seal drainage system
- In this procedure, one or more catheters are inserted into the chest cavity.
- If more than one catheter is inserted, each may be connected to a separate suction setup, or they may all be joined and attached to one suction setup.
- The water-seal drainage system must remain closed (airtight) so that no air is allowed to enter the chest cavity; otherwise, the lungs collapse.
- By putting the drainage tubes under water, air is prevented from backing up into the chest.
- One widely used apparatus of disposable chest drainage systems is called the Pleur-Evac.
- When the chamber is full of blood, it is discarded and replaced with a new one; this is done only by a trained professional.
7
Q
What is the difference between hypoxia/hypoxemia?
A
- Hypoxemia:
- is low levels of oxygen in your blood.
- Hypoxia:
- low oxygen in your tissues
8
Q
What is some nursing education on hypoxia/hypoxemia?
A
9
Q
What are the different types of dressing applications and when do you use it?
A
- Sterile dressing
- Dry, sterile dressing
- A dry, sterile dressing is often ordered for a wound to protect it from contamination (also known as a dry-to-dry dressing ).
- This dressing is most often used for clean wounds healing by primary intention, such as surgical incisions.
- The materials used for this type of dressing include gauze (e.g., 2 × 2 or 4 × 4 gauze), Telfa pads, and larger abdominal ( ABD ) pads, also called Surgi-Pads.
- These materials collect drainage and protect the wound.
- The used dressing is removed to evaluate healing, and a new, dry dressing is applied.
- Wet to dry dressing or packing
- In some cases, mechanical debridement or cleansing of a wound can be accomplished by saturating a sterile dressing with normal saline or another sterile solution, placing the dressing on or packing it into the wound, and leaving it to dry.
- This is called a wet-to-dry dressing.
- Wet-to-dry dressings are not as commonly used as they were in the past, but still can be used for infected wounds healing by secondary intention.
- An infected wound has exudate composed of serum, tissue debris, and infectious material or pus.
- The wound will not heal unless these substances are removed.
- Debridement occurs as the dried dressing is removed; tissue debris and drainage that sticks to it also are removed.
- Follow the facility protocol to perform the wet-to-dry dressing change.
- Wet to wet dressing
- Wet-to-wet dressings are used on clean, open wounds or wounds that are granulating in.
- These dressings provide warmth and moisture, which aid the healing process and make the client more comfortable.
- Thick exudate also can be removed in this manner.
- Sterile saline or an antibiotic solution is used to saturate the dressing, and the dressing is not allowed to dry.
- These dressings are remoistened and/or replaced as ordered.
- Gel/Hydrocolloid dressings
- Some wound care products interact with moisture on the skin to produce a gel;
- this provides a moist healing environment.
- These dressings are most often used in shallow to moderate-depth wounds and when drainage is minimal.
- They aid in healing, while also sealing the wound against air and water.
- An example of this type of dressing is DuoDERM, a hydrocolloid dressing.
- DuoDERM is self-adhesive and remains in place for 3–7 days.
- It absorbs drainage into its matrix while protecting the wound.
- Other dressings, such as polyurethane dressings, are not self-adhesive and must be taped in place.
- Sometimes, dressings are also covered with a transparent dressing (film), such as Tegaderm or OpSite.
- Some wound care products interact with moisture on the skin to produce a gel;
- Stitches and staples
- Most incisions are closed with sutures (stitches) or staples.
- A common stitch pattern is called interrupted sutures ; each stitch is inserted and knotted separately.
- Suture/staple removal is generally performed 7–10 days after surgery.
- Careful inspection of the wound must be made to determine if enough healing has occurred to remove the staples or sutures safely.
- The nurse usually does not remove sutures or staples in the acute care facility, but may often do so in the clinic (following in-service training).
- A sterile “suture removal kit” is used.
- Sterile scissors are used to cut the suture close to the skin, while sterile tweezers firmly grip the knot.
- Then, the knot is pulled firmly, straight-up.
- Be sure to pull on the knot.
- Transparent dressings
- Apply transparent dressings to areas of friction (to prevent rubbing and facilitate observation without dressing removal).
- Dressings with open/closed drains
- One type of Open drain system the Penrose drain, is usually flat and is hollow.
- It wicks drainage out of a wound.
- A safety pin or other device is attached to the drain near its entrance to the skin, to prevent it from being pulled into the wound.
- A dressing or receptacle is placed over the open end of the drain, to catch drainage.
- The drain may be advanced (pulled out) a specified amount each day until it is completely removed.
- In this case, careful measurement of the drain length is necessary to make sure it is being advanced as ordered.
- Three common types of closed drainage systems are
- The Jackson–Pratt,
- The Hemovac, and
- The Davol.
- Using these devices, which provide gentle suction, can help deep or heavily draining wounds to heal faster.
- The Jackson–Pratt
- also called the grenade drain, allows drainage to collect in a bulb about the size of a large lemon.
- A plug is removed to empty the contents.
- To reestablish suction, the bulb is squeezed until the inside walls of the bulb touch and then the plug is replaced.
- As the bulb expands, it creates gentle suction.
- The Hemovac
- is used most often in a wound in which bloody drainage is expected after surgery.
- To establish suction, press on the top or both sides of the device, which is spring-loaded, and replace the plug.
- This creates suction as it slowly expands.
- The receptacle is emptied and the suction reactivated when it is full.
- The Davol
- is a drainage bottle with a rubber bulb on top.
- The bulb functions as a pump to inflate a balloon within the bottle.
- The balloon creates suction as it slowly deflates.
- The surgeon will usually place the specific type of suction device during surgery and order its postoperative management.
10
Q
What are precautions for applying dressings on a wound?
A
- Many types of dressings are used to treat wounds.
- The type of wound and its condition determine the type of dressing ordered and the frequency of dressing changes.
- The primary provider or wound care specialist orders the type and frequency for dressing changes.
- Always follow standard precautions for any wound care.
- The primary provider determines if debridement is appropriate or not.
- If any wound does not have adequate arterial blood flow to heal it, or if the wound contains stable, dry eschar and the circulation is questionable, current practice is to dry the wound and not debride.
- If a wound has adequate circulation to heal, it is usually kept moist and cleaned by debridement.
11
Q
What are the three types of suctioning we talked about in class and their purpose?
A
- Trach
- Oral
- Naso
12
Q
What are the procedures and equipment used for suctioning according to the skills packet?
A
- Identify patient and explain procedure
- Premedicate if necessary before suctioning on postoperative patients.
Perform respiratory assessment. - Perform hand hygiene.
- Adjust bed to a comfortable working height. Lower side rail closest to you.
- Position patient. Conscious: high fowler’s. Unconscious: On his/her side
facing you. Hyperoxygenate per facility protocol. - Place towel or waterproof pad across patient’s chest.
- Turn suction to appropriate pressure:
Adult: 100-160 mm Hg
Child: 100-120 mm Hg
Infant: 80-100 mm Hg
Neonate: 60-80 mm Hg
Check pressure by occluding the end of the connecting tube with a gloved
hand. - Have resuscitation bag attached to oxygen within reach.
- Open sterile suction package using aseptic technique. The open wrapper
becomes a sterile field to hold other supplies. Carefully remove the sterile
container, touching only the outside surface. Set it up on the work surface and
pour sterile saline into it. - Put on face shield or goggles and mask. Don sterile gloves
- With dominant hand pick up sterile catheter. With the non-dominant
hand pick up the connecting tubing and connect tubing with suction catheter. - Moisten tip of the catheter in the sterile saline. Occlude white Y-tube to
check suction. - Remove ventilator tube and with dominant hand gently insert catheter
into endotracheal/tracheostomy tube until resistance is met. Do not occlude
Y-port when inserting the catheter. - Apply suction by intermittently occluding the Y-port on the catheter with
the thumb of your non-dominant hand, and gently rotate catheter as it is
withdrawn. - Do not apply suction for more than 10 seconds at a time.
- Replace ventilator tubing immediately and oxygenate the patient.
- Flush catheter with saline. Repeat procedure as necessary and as
tolerated by the patient. (Total of 3 insertions for suctioning, with 30-60
seconds between each suction pass). Wrap the suction catheter around your
dominant hand between attempts. - When suctioning is completed, remove glove from dominant hand over
the coiled catheter, pulling it off inside out. Remove glove from non-dominant
hand and dispose of gloves, catheter and container with solution in the
appropriate receptacle. Remove face mask or goggles. 19. Turn off suction. Re-position patient for comfort, perform respiratory
assessment (evaluation). Lower bed, raise side rail, call light within reach. - Remove gloves, hand hygiene.
- Document care given, respiratory assessment, amount/color of sputum
obtained, patient tolerance to procedure. Report to MD/RN supervisor as
needed.
13
Q
What is the stages of death in correct order?
A
- Denial
- Anger
- Bargaining
- Depression
- Acceptance
- Detachment
14
Q
What is a water seal drainage system and what are nursing interventions?
A
- Water-Seal Chest Tube Drainage
- Technique for evacuating air or blood from the pleural cavity, which helps restore negative intrapleural pressure and re-inflate the lung.
- Nursing interventions:
- Assess lung sounds
- Ensure drainage system is placed below level of insertion.
- Tubing is non-obstructed.
- Encourage client to cough & deep breathe every 2 hours
- Never be separate tubing from system
- Clamps at bedside.
- Monitoring of chambers
- Collection
- Mark drainage level at end of each shift
- Water seal
- Tidaling of water, sterile h2o @ 2cm mark
- Suction control
- Regulate suction to produce gentle bubbling; add sterile water if evaporated
- Collection
15
Q
What is the placement and positioning of patient with breathing difficulty (Hypoxia)?
A
High Fowler’s position
