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90 Cards in this Set
- Front
- Back
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6 goals of taking a health history
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1. Gather information – text and subtext
(Provides the subjective database) 2. Identify actual and potential health problems 3. Negotiate management 4. Contract for: Positive behavioral change Disease prevention 5. Support emotional and spiritual needs 6. Identify teaching and referral needs |
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7 elements of traditional medical history (in order)
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Always starts with a general survey (skill 2-1)
CC - Chief Complaint, in pt’s own words HPC/HPI - History of Present Concern/illness PMH - Past Medical History FH - Family History SH - Social or Lifestyle History ROS - Review of Systems |
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how do you write the chief complaint (cc)?
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CC – a. In quotation marks in pts words.
b. duration. Usually only 2 lines. Details go in HPI. |
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the 4 main elements of the HPI
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1. DETAILS OF CURRENT PROBLEM
- Chronologic sequence of events - Symptom evaluation mnemonics (COLD ERA) 2. PREVIOUS TREATMENT FOR PROBLEM - Surgery, hospitalizations, medications, alternative therapies 3. IMPACT OF PROBLEM ON LIFESTYLE – esp. important for nursing. (get back to previous level of function) 4. STATE OF HEALTH BEFORE PROBLEM |
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12 elements of PMH
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General health and strength
Emotional status Allergies Medications (OTC, Rx, BCP, Herbs, Vit) Childhood illnesses Major adult illnesses Immunizations Surgery Serious injury and resulting disability Pregnancies/deliveries Transfusions Recent screening tests |
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does the HPI only relate to the CC?
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Yup.
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briefly describe the family history
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Concerned with genetic risk or the interaction of genetic and environmental factors
Often done with a genogram or pedigree |
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describe common genogram symbols
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what does A&W refer to in genograms?
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alive and well
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8 elements of SH (social history)
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Personal status (married?)
Occupation Habits Sexual history Home conditions Military record Religious preference Cultural influences on health care |
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what comprises the Review of Systems according to Brenda's slide?
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CV
Resp (Abd) complete ROS would be general, skin/breast, eye/ear/nose/mouth/throat, CV, resp, GI, GU, neuro/psych, musculoskeletal, immunologic/allergic/endocrine/lymphatic |
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cuffs of endotracheal tubes should never be inflated to more than....
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30 mmhg. just squishibly soft
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what do nurses do wrt ETTs?
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just suction and observe.
move to other side of the mouth, retape. mark exit of tube from mouth with indelible marker. |
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4 uses for a tracheostomy
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Replace an ET tube
Mechanical ventilation (trach. or endotrach. tube) Bypass an obstruction Remove secretions |
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important thing to remember for trach tape replacement
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Never take off the old tape before the new tape is on. New tape first, then remove old tape. (risk of coughing out trach).
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what is the function of the inner cannula of the trach?
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Inner cannula collects crust and secretions that suction could not. Inner cannula is removed and cleaned (permanent) or disposed of.
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3 things that are variable between trach types
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cuff/ no cuff
number of cannula (single/double). for double, inner cannula can be disposible or perm, fenestrated or not |
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is the trachea or the espohagus more ventral?
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trachea!
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what's the purpose of a trach cuff?
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to decrease the risk of aspiration
Gastric reflux pools on top of cuff, prevents reflux from entering lungs. |
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trach cuff inflation guidelines
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Inflated by physician’s order. If you don’t have an order to keep it inflated at all times, we don’t keep it inflated.
Inflated cuff can disrupt swallowing (press on esophagus). Sometimes deflate the cuff before eating. Make sure you suction first (pooled secretions), and deflate it slowly (avoid coughing fit). |
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describe fenestrated trachs.
what do you have to do to allow it to serve its intended purpose? |
Fenestrated
Allows patient to speak. For the pt. to speak, you have to remove inner cannula and cap the outer cannula. Outer cannula has openings, Inner cannula is usually solid |
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suctioning guidelines for a fenestrated trach
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Suctioning: make sure the inner cannula is IN when you do this so the suctioning tube does not get caught in the window.
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how often is trach suctioning done?
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Suctioning is usu done q shift or q 12h depending on unit.
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4 common complications in trach care.
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Complications: hypoxia, tissue damage, infection. Vasovagal reaction can happen here – sudden bradycardia and BP drops.
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2 things that compromise the mucociliary elevator
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smoking
heavy secretions |
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what can you NEVER NEVER do to make a trach dressing
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cut a 4X4 gauze. this is dangerous because of lint inhalation.
you CAN fold 2 4X4s and layer them at 90 deg angle, |
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suctioning length guidelines for oropharyngeal, nasopharyngeal, trach, and ETT.
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Oropharyngeal (3-4 inches)
Nasopharyngeal (6-7 inches) Endotracheal (1 cm below length of tube) Tracheostomy (1 cm below length of tube) |
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can you go from oropharyngeal suction to nasopharyngeal sunctioning?
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NOPE.
you can do from NP to OP suctioning, though. working your way down is okay. |
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pre-suctioning assessment
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Lung sounds
Oxygen saturation levels Respiratory rate and depth Nasal flaring, retractions, grunting Effectiveness of cough Hx deviated septum, nasal polyps, epistaxis, nasal injury or swelling Assess need for pre-medication |
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general suctioning guidelines.
vacuum pressure? |
Procedural guides
Pre-test suction Hyperoxygenate per facility Ambu Deep breaths 3 passes, 10-15 seconds each 30 sec – 1 min between passes Suction set at 100-150mmHg |
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what are 5 things you document for suctioning?
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Time of suctioning
Pre and post assessment data Reason for suctioning Route used Characteristics & amount of secretions |
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the 2 common sputum lab tests and the amount of time it takes the lab to complete them.
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Gram stain (30 min)
C&S (48-72h for final reading) |
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2 items of sputum culture cup teaching
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don’t touch the inside of the cup
don't put it down. |
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briefly describe chest tubes
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Used to drain the pleural space
Sutured in place with an airtight dressing Attached to a drainage system |
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what is a "significant negative"?
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“Significant negative” – you are definitively saying that there is not a specific complication or characteristic (e.g., no bubbles in the water seal chamber).
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what do you need to change a CDU? how do you do it?
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ER equipment: 2 Kelly clamps, new drainage system, and sterile water
Never clamp except to change CDU |
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nursing care considerations of the patient with a CDU.
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Encourage deep breaths and use of IS
Presence of subcutaneous emphysema (crunchiness) (significant negative) Monitor output every shift and with general survey How should the patient appear if the CDU is functioning properly? Resting comfortably. |
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6 elements of a nursing general survey of the CDU patient
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Occlusive dressing
All connections taped (foam tape) No dependent loops and kinks Collection device upright and below level of tube insertion Water seal chamber tidaling Suction chamber bubbling and set to correct level of suction |
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what do you document for the CDU patient?
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Site of CT
Amount and type of drainage Bubbling and tidaling Subcutaneous emphysema Type & integrity of dressing Level of pain Pain relief measures |
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describe nursing function in CT removal.
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Assess breath sounds, RR, oxygen saturation, and pain
Pre-medicate patient Assist the physician, instruct pt. to perform valsalva maneuver. Site secured with an occlusive dressing Expect a CXR to be ordered* Document: Assessment findings Status of insertion site CT output Type of dressing |
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describe secondary intention wounds.
in what direction do they heal? |
High infection potential, take a longer time to heal, scar a lot.
Heal from the bottom up and the sides in. |
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what is the contraction effect?
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Contraction effect – new tissue at edges rolls in slowly.
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what are we assessing the wound for?
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Drainage (color, amt), odor, retraction effect?, maceration or irritation of surrounding tissue, check for tunneling (with Q-tips). with a fistula, q tip will keep going without stopping.
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describe a penrose drain. how do you clean this? what kinds of wounds is this used for?
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a penrose is a flat tube that is not sutured in place. usually has a safety pin through the top. used for primary intention wounds (e.g., stab).
clean this by going in a circular motion around the base. |
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what are the different kinds of JP drains? sutures?
when do you empty them? |
50mL and 100 mL. yes, they are sutured in place.
empty these when they are 1/2 full. clean gloves are fine for emptying. |
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describe a hemovac drain. when do you empty this?
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Negative pressure
Often thru a stab wound Sutured in place Expect a large amount of drainage empty this when 1/2 full to maintain suction. |
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describe vacuum assisted closure units.
what kinds of wounds are these used on? how often are they emptied? |
Vacuum-assisted closure (VAC)
Uses Applies negative pressure Fenestrated tube embedded in foam Occlusive dressing tegaderm must be nice and tight. used on secondary intention wounds (e.g., decubitus ulcers) Soft necrotic tissue is okay for vacuum drainage. * emptied every 2-3 days |
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what are some special considerations for VAC? (pt.s you would have to be especially careful with?)
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have to be careful with pt.s on anticoagulants, pt.s with exposed veins or arteries (will suck blood out), fistulas (will create abscess), anaerobic infections, hard necrotic tissue (can’t heal necrotic tissue), malignant wounds (these don’t heal).
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3 healing benefits of VAC
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Sucking action 1) increases blood flow to wound 2) increases retraction 3) decreases bacterial cell counts.
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4 methods of wound debridment
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Mechanical (whirlpool, wet to dry dressings)
Enzymatic Autolytic (body’s own immune response – duoderm or tegaderm) Surgical (scalpel – nurses and physicians) |
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why is NS an especially good irrigant?
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it has the same osmolarity as blood.
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best syringe/needle combo for irrigation?
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Best for irrigation: 30 cc syringe with an 18 gauge needle.
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what can macerated tissue cause?
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rashes and skin breakdown.
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what assessments do we do with pt.s using PCDs?
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Assessment:
CSM every 8 hours Skin integrity |
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contraindications for PCDs
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DVT
PAD (peripheral arterial disease). Severe edema (compressing cells, painful, can contribute to skin breakdown) Cellulitis Skin graft Infected extremity |
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what is cellulitis?
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A spreading bacterial infection of the skin and subcutaneous tissues, usually caused by streptococcal or staphylococcal infections in adults (and occasionally by Haemophilus species in children).
It may occur following damage to skin from an insect bite, an excoriation, or other wound. The extremities, esp. the lower legs, are the most common sites. Adjacent soft tissue may be involved. Affected skin becomes inflamed: red, swollen, warm to the touch, and tender. Spread of infection up lymphatic channels may occur |
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what is the difference between infiltration and extravasation?
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A serious complication is the inadvertent administration of a solution or medication into the tissue surrounding the IV catheter--when it is a nonvesicant solution or medication, it is called infiltration; when it is a vesicant medication (capable of forming a blister or causing tissue destruction), it is called extravasation.
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the 3 main types of vascular access devices
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peripheral venous catheters
midline catheters central venous access devices |
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how often should peripheral venous catheter insertion sites be moved?
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every 72 to 96 hours
(unless a child, in which case it can be left until a complication develops) |
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what meds would be inappropriate for peripheral vascular catheters?
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TPN, vesicant chemotherapy, or drugs classified as irritants.
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types of CVADs
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PICCs (peripherally inserted central catheter)
Nontunneled percutaneous central venous catheters Tunneled central venous catheters Implanted ports |
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how often are PICCs replaced?
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only if the catheter is no longer patent or if the site looks infected.
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indications for PICCs
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extended IV antibiotics (2-6 weeks), PN, chemo, continuous narcotic infusions, vesicants, hyperosmolar solutions, blood components, vasopressors and anticoagulants, long-term rehydration.
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areas you want to avoid when placing an IV catheter.
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dominant arm (better not to)
Areas of flexion (don’t) Areas of edema (don’t) Boney prominences (nope) Same side as surgical procedures (don’t) Same side venipuncture –e.g., blood draw (don’t) Same side BP assessments (don’t) |
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describe midline catheter
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Midline cath – 3-8 inches. Considered peripheral because it does not go into the vena cava.
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can you draw blood for peripheral lines?
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nope.
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what is a CLABSI?
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CLABSI – central line assoc blood stream infection.
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describe positional IV problems
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“positional IV” – when pt moves their arm, it can go faster. Gravity drips. Not good for CHF pts., etc.
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what's a good way to check for IV obstruction in an elderly person?
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take the bag down and look for backflush. Less chance of collapsing a vein this way.
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what's the typical gauge for peripheral lines?
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20 gauge
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cannot do a blood transfusion with smaller than a _______
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18 gauge needle. (i.e., not with 20, 22, 24, etc.)
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nursing action if a hard stick is anticipated?
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If hard stick anticipated: 10-15 minutes of moist heat can vasodilate.
also stroking blood down arm can help. |
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what are syringe pump infusions good for?
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strict I/O
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care for a saline lock
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Flushing guidelines (usu 3mL normal saline before IV, 3mL afterwards, flush after 8 h even if not in use to retain patency)
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IV tubing change frequency
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Change tubing q72h***
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Iv dressing change frequency
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Change dressing q24h***
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how frequently do we change the IV solution?
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Change solution q24h***
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what are IV things we should be monitoring every hour?
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Fluid type
Rate Patient response Dressing integrity |
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4 things that can affect flow rate in a gravity bag.
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Height of solution
Position of extremity Tubing obstruction IV patency |
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5 signs of fluid overload
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Signs of fluid overload: breath sounds (crackles), hypertension, air hunger, anxiety, edema (late).
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what is speed shock and what are the s/s?
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speed shock is the body's reaction to a substance being injected too rapidly into the circulatory system.
s/s: pounding headache, fainting, rapid pulse rate, apprehension, chills, back pains, dyspnea. |
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formula for regulating flow rate
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gtt/min = [(vol in mL) X drop factor (gtt/mL)] / time in minutes
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3 possible at-site complications of IVT
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Infiltration
Phlebitis Thrombus |
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3 possible systemic complications of IVT
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fluid overload
sepsis air embolism |
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signs of fluid overload
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Signs of fluid overload: breath sounds (crackles), hypertension, air hunger, anxiety, edema (late).
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describe the infiltration scale, 0-4
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0 = No symptoms
1 = edema < 1”; cool; blanched 2 = edema 1-6”; cool; blanched 3 = gross edema >6”; cool; blanched; mild/mod pain/ possible numbness 4 = pitting edema; skin tight, leaking, bruised; mod/severe pain |
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describe the phlebitis scale, 0-4
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Phlebitis scale
0 = no symptoms 1 = erythema; possible pain 2 = erythema, edema, pain 3 = same as 2 w/ palpable venous cord 4 = same as 3 w/ palpable venous cord >1”; purulent drainage |
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what is the hallmark sign of phlebitis?
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palpable cord
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is phlebitis reportable?
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simple phlebitis is not reportable. signs of infection are reportable, however.
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the 4 common IV drop factors
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10
15 20 60 (mindrip - pedi and seniors) not good for large volumes of fluid |
