test 9 Flashcards
post op nurse helps pt cough by
hugging pillow, splinting.
bright red drainage
Sanguineous
6 hour post op nurse priorities
- assess pain level
- check dressing for drainage
- check vitals
- offer fluids
wound healing needs further teaching if
i only have to drink 500mL fluid
exclude foods high in vitamin B
change sterile dressing steps
explain procedure to pt administer pain meds 30 mins before wash hands apply clean gloves remove old dressing note drainage remove gloves wash hands sterile gloves and field new dressing
wet to dry dressings should…
dry by next shift
absorb drainage
what type debridement is wet to dry dressing?
mechanical
when not to use transparent dressings
deep wounds
puncture with bleeding
large cut near hairline
heavy exudate
when to check pt w resp problems and abd binder
change in respirations
problem mDyspnea
common bandage to anchor dressing
figure 8
circular
3 reasons smoking inhibits wound healing
decreases tissue oxygenation
decreases functional HGB
interferes with normal cell function.
clear watery drainage
Serous
Call HCP for how much drainage?
300mL
dehiscence seen in what stage
Reconstruction/proliferative
montgomery straps used for
wounds with heavy drainage
allergy alert for arteriogram
iodine/shellfish
when collect post void residual
10 minutes after last void
type stool sample taken to lab immediately
ova and parasites
black and tarry stools mean
upper GI bleed
collect sterile urine culture
clamp below port for 15-30 mins before
disinfect port
withdrawl 3mL urine
transfer to sterile container
main complaint low BGL
headache
why most substances enter the intracellular compartment
so they can carry out functions in body
process of Lasix
Osmosis
advantages of transparent dressing
adheres well to intact skin
breathable
see skin
priorities for wound evisceration
check VS
assess wound
cover wound with wet sterile dressing (0.9% NS)
Call DR
Normal pH
7.35-7.45
what electrolyte imbalance causes fluid retention
Hypernatremia
RR 46, CO2-28, pH-7.5
Respiratory alkilosis
what acid base imbalance is low HCO3
metabolic acidosis
wound healing by secondary intention
granulation
wound edges are not approximated
metabolic acidosis
lungs UP high CO2
Down pH
metabolic alkalosis
Low CO2
HIgh pH
metabolic alkalosis
HIGH pH
HIGH HCO3
metabolic acidosis
LOW pH
LOW HCO3
CO2 range
35-45
HCO3
22-26
